Gupta AS

Women with complaints of pruritus vulvae, vulval pain, change in skin texture or color and any vulval lesions many a times consult a gynecologist rather than a dermatologist. Gynecologist has to be aware of the various epithelial and non epithelial lesions of the vulva and should be able to differentiate the normal variations from the abnormal lesions and benign from the malignant conditions. Some of these may represent systemic disease processes involving various mucocutaneous areas or they may be localized to the vulva. Reaching a clinical diagnosis needs good history taking, physical examination that includes the study of the morphology of the lesions and when required laboratory investigations.
The detailed history should elicit the onset, duration and progress of the lesions, symptoms associated with the lesion like itching, bleeding, discharge, and pain. Symptoms related to systemic involvement also need to be elicited like fever, joint pains, weight loss, etc. History should elicit sexually transmitted diseases, diabetes, or thyroid disorders, iron deficiency anemia, any history of urinary or fecal incontinence, use of various toiletries and personal care products. History of autoimmune disorders should be elicited in cases of suspected lichen planus with erosion's and lichen sclerosis. Specific attention should be directed towards examination of other mucosal surfaces like the naso-oral cavity, anal mucosa and vagina.  
The examination under good illumination and position should focus on morphology of the lesions. This includes using a noun to define the lesion like macule, papule, pustule, vesicle, plaque, patch, bulla, cyst, edema, erosion, excoriation, fissure, rash and ulcer. An adjective is used to describe each of these nouns like color (red, white, blue, brown, black, skin colored), margins (well demarcated, sharp, blurred, or poorly demarcated with a gradual change from the normal to the abnormal area), surface (rough or smooth is described after palpation), and shape or configuration of the lesion. Roughness of the surface is due to the formation of a crust or scale that occurs due to break in the epithelium and subsequent increase in the proliferative activity of the epithelium. Secondary changes like excoriation, lichenification, fissure, edema of the lesion should be documented. The number, site and formation of groups should also be studied. Further more these lesions may be polymorphic wherein the presentation may occur in more than one way as in Molluscum contagiousm. Examination of regional lymph nodes should not be forgotten. Colposcopy can be done to aid clinical examination and identify the area for taking the biopsy in suspected cases of genital warts, hyperkeratosis, HSIL or malignancy, or failure of treatment but is not required in all cases which can be clinically diagnosed especially vulval dermatoses.
Vulval disorders that are benign include vulvar atrophy, non neoplastic epithelial disorders, tumors, cysts. Benign tumors are not frequently seen on the vulva. These would include fibroma, lipoma, angiomyxoma, fibromyoma, hemangiomas, bartholins cysts. These would be managed surgically.
I hope the readers find the cases in the August issue of our journal interesting and gain some insight on reading the various aspects of these cases. This issue has one unusual case report of a keloid on the vulva which I hope the readers would like.