Plasma Cell Vulvitis: A Classification Into Two Clinical Phenotypes

OBJECTIVE

The etiology of plasma cell vulvitis (PCV) is debated. The authors aimed to test the hypothesis that PCV could be divided into 2 clinical phenotypes.

METHODS

Patients with a clinico-pathological diagnosis of PCV and with available vulvar photos seen in a vulvar clinic were retrospectively studied. The cases of PCV were divided into 2 groups: non-lichen-associated (primary PCV) and lichen-associated (secondary PCV). The 2 groups were compared in terms of age, menopausal status, location of the PCV, and 12 histologic parameters (Fisher exact test, p < .05).

RESULTS

Thirty-five patients (20 primary and 15 secondary PCV) were included. The 2 groups did not differ in terms of age (mean, 65; range, 50-85) or menopausal status. Primary PCV was located exclusively on the vestibule for 19/20 patients, whereas secondary PCV was extravestibular for 14 of 15 patients, either exclusively (2) or both extravestibular and vestibular (12). One patient with secondary PCV had solely vestibular involvement. Five histological features were observed significantly more often in case of secondary PCV: epidermal atrophy, parakeratosis, dermal and epidermal neutrophils, and dermal eosinophils.

CONCLUSIONS

Plasma cell vulvitis can be divided clinically into 2 phenotypes. Primary non-lichen-associated PCV is restricted to the vestibule and could be the vulvar counterpart of atrophic vaginitis. Secondary lichen-associated PCV is both extravestibular and vestibular, and its clinical and histological features should be looked for outside the PCV areas. This division of PCV into 2 clinical phenotypes could have therapeutic implications.

Nocturnal Vulval Pain in Girls-A Subset of Vulvodynia?

OBJECTIVES

The aims of the authors' case series were to outline the clinical features of prepubertal nocturnal vulval pain syndrome and to look at management and outcomes.

METHODS

Clinical details of prepubertal girls experiencing episodes of nocturnal vulval pain with no identifiable cause were recorded and analyzed. Parents completed a questionnaire to look at outcomes.

RESULTS

Eight girls with age at onset of symptoms between 3.5 and 8 years (mean 4.4 years) were included. Each patient described intermittent episodes of vulval pain lasting between 20 minutes and 5 hours, starting 1-4 hours after falling asleep. They were crying and rubbing or holding the vulva with no obvious cause seen. Many were not fully awake and 75% had no recollection of the events. Management focused on reassurance alone. The questionnaire showed that 83% had full resolution of symptoms with a mean duration of 5.7 years.

CONCLUSIONS

Prepubertal nocturnal vulval pain syndrome may be a subset of vulvodynia (generalized, spontaneous, intermittent) to be included in the clinical spectrum of night terrors. Recognizing the clinical key features should aid prompt diagnosis and reassurance of the parents.

Vulvar pseudotumoral acyclovir-resistant herpes in an HIV-negative, non-immunosuppressed patient: A therapeutic challenge

Background

Vulvar pseudotumoral herpes infections have been reported in HIV-positive patients. A 32-year-old HIV-negative woman presented with a 6-month history of a vulvar pseudotumor that had been unresponsive to oral acyclovir and valacyclovir, as well as topical imiquimod.

Objective

This study aimed to evaluate the therapeutic efficacy of a multidrug regimen for vulvar pseudotumor herpes infection in an HIV-negative patient.

Methods

Histology revealed multinucleated giant cells, consistent with a herpes infection. The patient's herpes simplex virus type 2 was resistant to acyclovir. Immunomodulatory agents (thalidomide and topical imiquimod) were started.

Results

The lesion enlarged after 6 weeks of treatment. Topical cidofovir 1% gel was added. There was gradual decrease in the pseudotumor size. After 7 months, the Pseudotumor had resolved.

Conclusion

This is the first reported case of vulvar pseudotumoral herpes in an immunocompetent, HIV-negative patient. Oral thalidomide, in association with topical imiquimod and topical cidofovir, was effective in treating acyclovir-resistant pseudotumoral herpes of the vulva.

Vulvar Fordyce adenitis: A cohort of 45 women

BACKGROUND

Recurrent episodes of painful papules and nodules, mostly located on the labia minora, have been reported under the denominations of vulvar sebaceous adenitis (14 published cases) and vulvar acne (16 published cases).

OBJECTIVES

The primary aim of this study was to delve further into the clinical and pathological features of this condition. The secondary aim was to collect therapeutic data.

METHODS

In this retrospective cohort study, files and photographs of patients with papules or nodules on the labia minora or the inner labia majora were extracted from a vulvar clinic database. Clinical, pathological and therapeutic data were analysed.

RESULTS

Forty-five women were included from 2002 to 2018. The median age at the time of diagnosis was 36 years (range: 16-60). The median time to diagnosis was 6.5 years. Clinical features included recurrent painful papules, pustules or nodules, suppuration (n=22), and pitted scars (n=10) on the labia minora (n=41), the inner labia majora (n=19), the outer labia majora (n=1), and the clitoral hood (n=1). Associated acne vulgaris was seen in 17 out of 26 patients for whom data were available. Hidradenitis suppurativa, androgenic alopecia and hirsutism were observed in 3, 1 and 1 cases respectively. Neutrophilic infiltrates were observed in the 4 available biopsies within or around the Fordyce sebaceous glands in 2 patients. Treatment with tetracyclines and oral zinc was not consistently effective. Isotretinoin led to complete remission in 4 patients unresponsive to tetracyclines.

DISCUSSION

Vulvar sebaceous adenitis/vulvar acne is a clinically identifiable cause of painful recurrent inflammatory lesions affecting the labia minora and the inner labia majora, which are coincidentally sites of Fordyce granules. We therefore suggest a more specific denomination: "vulvar Fordyce adenitis". The relationship with acne vulgaris and hidradenitis suppurativa requires further investigation. We suggest use of an oral anti-acne therapeutic strategy to reduce inflammation and to decrease the secretion of the sebaceous glands.

The Clinical Role of LASER for Vulvar and Vaginal Treatments in Gynecology and Female Urology: An ICS/ISSVD Best Practice Consensus Document

In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. Most of the available studies are limited by their design; for example, they lack a control group, patients are not randomized, follow-up is short term, series are small, LASER is not compared with standard treatments, and most studies are industry sponsored. Because of these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration after LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, although short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. Therefore, at this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: An ICS/ISSVD best practice consensus document

BACKGROUND

The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology is controversial.

AIMS

In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review.

MATERIALS & METHODS

This project was developed between January and September 2018. The development of this document followed the ICS White Paper Standard Operating Procedures.

RESULTS

Most of the available studies are limited by their design; for example they lack a control group, patients are not randomized, follow up is short term, series are small, LASER is not compared with standard treatments, and studies are industry sponsored. Due to these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration following LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women.

DISCUSSION

The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, while short-term complications seem to be uncommon, data concerning long-term outcomes are lacking.

CONCLUSION

At this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

[Miescher's granulomatous vulvitis]

BACKGROUND

Miescher's cheilitis, whether occurring alone or as part of Melkersson-Rosenthal syndrome, is a rare type of granulomatous inflammation of unknown cause with an even rarer genital equivalent. Herein, we describe a case of the latter condition developing over a 12-year period.

PATIENTS AND METHODS

A 27-year-old woman presented episodes of unilateral vulvar oedema, which initially regressed but resulted over time in permanent vulvar and perineal tumefaction. Histology revealed epithelioid histocytic granulomas so mild that they were not noticed at the start of the disease. The oedema remained the sole sign for 12years and two gastrointestinal screening tests for Crohn's disease proved negative, diagnosis of the latter condition was ruled out.

DISCUSSION

Miescher's granulomatous vulvitis requires differential diagnosis, essentially with regard to Crohn's disease. Our case illustrates the difficulty in diagnosing this rare disease as well as the uncertainties surrounding its physiopathology. Diagnosis rests upon repeated sampling and biopsies with repeated levels of sections in order to identify the characteristic perivascular granulomas, which may be very mild.

2016 European guideline for the management of vulval conditions

Vulval conditions may present to a variety of clinicians, such as dermatologists, gynaecologists and general practitioners. Women with these conditions are best managed by a multidisciplinary approach, which includes clear referral pathways between disciplines or access to a specialist multidisciplinary vulval service. Informed consent is a prerequisite for all examinations, investigations and treatments. Consent is particularly important for intimate examinations of the anogenital area, and a chaperone should be offered in all cases. All efforts should be made to maintain a patient's dignity. Depending on symptoms and risk factors, screening for sexually transmitted infections (STI) should be considered. If the patient presents with vulval itch, particularly if also complaining of increased vaginal discharge, vulvaginal candidiasis should be excluded. Sexual dysfunction should be considered in all patients with vulval complaints, either as the cause of the symptoms or secondary to symptoms, and assessed if appropriate. This guideline covers several aspects, such as diagnosis and treatment, of the more common vulval conditions (relatively) often encountered at vulval clinics, i.e. vulval dermatitis (eczema), psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, vulvodynia and vulval intraepithelial neoplasia (VIN).

Vulvar hidradenoma papilliferum (HP) is located on the sites of mammary-like anogenital glands (MLAGs): Analysis of the photographs of 52 tumors

BACKGROUND

Hidradenoma papilliferum (HP) is a benign tumor that primarily affects the anogenital area of adult women. Previously considered apocrine tumors, anogenital HP tumors are now interpreted as adenomas of mammary-like anogenital glands based on their histologic features.

OBJECTIVE

This clinical study was undertaken to determine whether vulvar HP is located on mammary-like anogenital gland sites and to describe its morphologic features.

METHODS

The clinical photographs of 52 histologically confirmed vulvar HP provided by 7 vulva specialists were analyzed.

RESULTS

In all, 90.4% of the HP were located on the interlabial sulcus, adjacent zone, or the perineum. These tumors were polymorphous in terms of number (1 or multiple), size (<1-4.5 cm), color (pink, red, blue), surface (ulcerated or not), and architecture (unilobular or multilobular).

LIMITATIONS

Eight histologic reports could not be reviewed by the authors but the contributors confirmed that the photographs sent were only those of histologically confirmed HPs.

CONCLUSIONS

Vulvar HP is mainly located on mammary-like anogenital gland sites, thereby providing further evidence to their histogenesis. Although a nonulcerated or ulcerated tumor of the interlabial sulcus should evoke a HP diagnosis, the latter must be confirmed histologically.

Vulvar dermatosis

Vulvar dermatoses are inflammatory conditions responsible for chronic or recurrent itching and soreness. The lesions are either circumscribed to the vulva or associated with extragenital localizations which may help to assess the diagnosis. They should be differentiated from infectious or neoplastic diseases which may have clinical similarities. As opposed to the majority of all dermatoses that have a benign and regular course, lichen sclerosus or lichen planus could exceptionally foster the occurrence of an epithelial cancer precursor which may evolve to squamous cell carcinoma. Topical corticosteroids are the mainstay treatment of vulvar dermatosis. We do not know if the treatment of vulvar lichen sclerosus and vulvar lichen planus prevents squamous cell carcinoma.

Anti-HPV16 E2 protein T-cell responses and viral control in women with usual vulvar intraepithelial neoplasia and their healthy partners

T-cell responses (proliferation, intracellular cytokine synthesis and IFNγ ELISPOT) against human papillomavirus 16 (HPV16) E2 peptides were tested during 18 months in a longitudinal study in eight women presenting with HPV16-related usual vulvar intraepithelial neoplasia (VIN) and their healthy male partners. In six women, anti-E2 proliferative responses and cytokine production (single IFNγ and/or dual IFNγ/IL2 and/or single IL2) by CD4+ T lymphocytes became detectable after treating and healing of the usual VIN. In the women presenting with persistent lesions despite therapy, no proliferation was observed. Anti-E2 proliferative responses were also observed with dual IFNγ/IL2 production by CD4+ T-cells in six male partners who did not exhibit any genital HPV-related diseases. Ex vivo IFNγ ELISPOT showed numerous effector T-cells producing IFNγ after stimulation by a dominant E2 peptide in all men and women. Since the E2 protein is absent from the viral particles but is required for viral DNA replication, these results suggest a recent infection with replicative HPV16 in male partners. The presence of polyfunctional anti-E2 T-cell responses in the blood of asymptomatic men unambiguously establishes HPV infection even without detectable lesions. These results, despite the small size of the studied group, provide an argument in favor of prophylactic HPV vaccination of young men in order to prevent HPV16 infection and viral transmission from men to women.

Incomplete efficacy of 5-aminolevulinic acid (5 ALA) photodynamic therapy in the treatment of widespread extramammary Paget's disease

Photodynamic therapy (PDT) using 5-aminolevulinic acid (5-ALA) is an effective treatment for several conditions such as Bowen's disease, subsets of basal cell carcinomas and actinic keratosis. Surgical resection is the first-choice therapy for extramammary Paget's disease (EMPD), but extensive resection is highly invasive and recurrences are frequent. We report two cases of genital EMPD treated by PDT with partial efficacy. The first patient, a 78-year-old male, suffered from pubic and scrotal Paget's disease for 6 years despite numerous treatments. The second patient, a 78-year-old female, had vulvar involvement for 2 years that was resistant to multiple treatments. The disease was recurrent and chronic with important pruritus and significant impact on the quality of life. Methyl 5-aminolevulinate was applied for 3 h, and irradiation was applied with red light (630 nm) using a total light dose of 37 J/cm(2) for a period of 10 min. The patients were treated every 2 to 4 weeks for a total of at least three treatments. Both patients experienced a partial transient reduction in their symptoms. One patient had a partial transient remission (< 50% reduction of the involved surface), whereas in the other patient, PDT failed to reduce the surface area of the lesions.

[Vulvodynia and chronic pelvic and perineal pain]

OBJECTIVE

To define vulvodynia and to describe the main approaches to treatment.

MATERIAL AND METHODS

Review of the literature concerning vulvodynia.

RESULTS

Vulvodynia is defined as chronic vulvar discomfort, usually with a burning nature, with no relevant clinical lesions and no clinically identifiable neurological lesion. Localized provoked vulvodynia essentially affects young women and is responsible for major sexual and psychological repercussions. Treatment consists of local anaesthetics, drugs used to treat neuropathic pain, physiotherapy and psychotherapy. Vestibulectomy is only very rarely indicated.

CONCLUSION

Many unknowns persist especially concerning the aetiology of vulvodynia. Evaluation of symptoms and treatment have not been clearly defined. However, symptomatic management provide satisfactory long-term results.

2006 ISSVD classification of vulvar dermatoses: pathologic subsets and their clinical correlates

The International Society for the Study of Vulvovaginal Disease (ISSVD) has, as one of its major societal goals, the development and promulgation of nomenclature and classification of vulvar disease. A committee of the ISSVD has developed new nomenclature and classification for the specific area of vulvar dermatoses. This classification was approved by the ISSVD members at the most recent international congress, held in New Zealand in February 2006.

The Vulvodynia Guideline

OBJECTIVE

To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia.

MATERIALS AND METHODS

Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition.

RESULTS

Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient.

CONCLUSIONS

Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.

Treatment of Undifferentiated Vulvar Intraepithelial Neoplasia With 5% Imiquimod Cream

OBJECTIVE

To assess the efficacy of 5% imiquimod cream on undifferentiated vulvar intraepithelial neoplasia (VIN), a disease caused by high-risk human papillomavirus.

DESIGN

Prospective, uncontrolled study.

SETTING

University hospital vulvar clinic. Patients Twelve consecutive patients treated with 5% imiquimod cream for undifferentiated VIN between March 1, 1999, and May 31, 2001.

INTERVENTION

Self-application of 5% imiquimod cream, initially 3 times a week, then adjusted according to tolerance, for up to 7 months according to clinical response.

MAIN OUTCOME MEASURES

Therapeutic response, clinically assessed by successive photographs and histologically confirmed for complete responders, was scored as complete, partial (> or =50% decrease in lesion size), or failure. Tolerance was evaluated at each visit.

RESULTS

A total of 3, 4, and 5 patients achieved complete response, partial response (> or =75% reduction in lesion size for all such cases), and failure, respectively. Mean duration of treatment was 3.6 months (37.3 applications), 5.0 months (50.7 applications), and 3.4 months (25.2 applications) for complete responders, partial responders, and failures, respectively. Follow-up after treatment was 5 to 18, 14 to 32, and 2 to 28 months, respectively, with 1 partial responder lost to long-term follow-up. No patient developed invasive carcinoma. All but 2 patients experienced vulvar discomfort, resulting in treatment withdrawal for 3. Two patients had flulike symptoms.

CONCLUSIONS

Imiquimod cream could be a therapeutic option for undifferentiated VIN. Although poorly tolerated, this self-applied treatment could spare patients, either totally or partially, the classic painful and sometimes mutilating treatments of VIN. Controlled, randomized studies are needed to evaluate its efficacy and tolerance.

Diagnosis and therapy of anogenital lichen planus

Genital lichen planus is a fairly common disease of genital skin that exhibits a widely variable morphology. Lichen planus occurring on the mucosal surfaces is chronic, and most often erosive and painful, frequently producing debilitating scarring. Mild, non-erosive disease is controllable with topical corticosteroids. Although erosive disease is much more difficult to manage, the use of topical corticosteroids, sometimes in combination with other topical or systemic medications, maximizes comfort and preserves function, especially with careful attention to local care and secondary infection.

[A model-based comparison of cost effectiveness of imiquimod versus podophyllotoxin for the treatment of external anogenital warts in France]

OBJECTIVES

For the National health scheme, to compare the costs and the efficacy of treatment of external anogenital warts with imiquimod and podophyllotoxin and laser therapy in the case of failure or relapse.

PATIENTS AND METHODS

A model simulating the two successive treatments was built. In the first phase, the two topical treatments applied by the patients: podophyllotoxin for 4 weeks and imiquimod for 16 weeks were compared. In the case of failure or relapse, laser therapy that is widely used in France in this indication and, was applied. The efficacy of the topical treatments was assessed after reanalysis of the results of two controlled clinical trials versus placebo. These two trials were retained because they were comparable in method and had been recently published at the same time. A review of the literature assessed the results of laser therapy. A survey was conducted to collect the medical resources consumed by the different treatments.

RESULTS

Imiquimod provided a clearance rate of 49.5 p. 100, i.e., the disappearance of the lesions at 16 weeks, greater than that of podophyllotoxin (28.3 p. 100) at 4 weeks. The relapse rate was lowest with imiquimod (13.3 p. 100) than with podophyllotoxin (30.9 p. 100). The remission rate without relapse 3 months after the end of treatment was, including the laser, of 62 p. 100 following imiquimod and of 47 p. 100 following podophyllotoxin. The costs per patient cured was of 668 Euros for imiquimod and of 689 Euros for podophyllotoxin.

CONCLUSION

Imiquimod, because of its greater initial efficacy, is at least as cost-effective as podophyllotoxin the treatment of external genital warts.

Current treatments and perceptions of genital herpes: a European-wide view

A European panel of physicians reviewed the current treatments and perceptions of recurrent genital herpes (GH) across the continent. The panel consisted of specialists in dermatology and venereology from France, Finland, Germany, Italy, Norway, Spain, Sweden and the UK. A wide variety of factors that influence GH management were considered, including different health delivery systems, funding and cultural differences. The poor awareness of GH among both the general public and physicians was highlighted. The effectiveness of GH management was then examined from a patient's viewpoint, including the confirmation of the diagnosis, information and counselling about GH, as well as prescriptions for treatment. It was agreed that both physicians and patients often feel uncomfortable about discussing the disease, and that a European-wide effort is needed to re-educate patients and physicians about GH. The panel identified clear and unmet needs to manage a patient with clinical recurrences and to attempt to reduce the risk of GH transmission. Finally, resiquimod, an immune response modifier, was considered as a potential treatment option for GH.

Perineoplasty for the treatment of introital stenosis related to vulvar lichen sclerosus

OBJECTIVE

The objective of this study is to assess the usefulness of perineoplasty for introital stenosis related to vulvar lichen sclerosus.

STUDY DESIGN

The records of 64 patients who underwent perineoplasty for this indication were reviewed retrospectively. The median age of patients was 49 years, and the median duration of lichen sclerosus was 60 months. Ninety percent of patients complained of dyspareunia. Patient satisfaction with the outcome was assessed by means of a questionnaire. Persistence of dyspareunia and impaired quality of sexual intercourse were considered as treatment failure. Risk factors of failure that were evaluated included duration of lichen sclerosus, age, previous topical steroid therapy, previous perineotomy, time since surgery, and histologic stage. Statistical analysis was performed by use of Fisher exact test.

RESULTS

Of the 64 patients, 12 were lost to follow-up and 2 patients did not respond to the questionnaire. Perineoplasty improved dyspareunia in 45 of the 50 patients (90%) and quality of sexual intercourse in 43 of 50 patients (86%). None of the risk factors evaluated were associated with failure of perineoplasty.

CONCLUSION

Perineoplasty provides good functional results for women with introital stenosis related to vulvar lichen sclerosus.

[Treatment of vulvar vestibulitis by posterior vestibulectomy. Twelve case reports]

Many patients with dyspareunia suffer from vulvar vestibulitis syndrome. When all conservative treatments have failed, surgery is attempted. We appreciated results and complications of this treatment. During 1993 and 1994, at the gynecological department of the intercommunal hospital of Creteil (France), twelve women suffering from this condition for longer than six months had undergone a posterior crescent-shaped vestibular excision followed by vaginal advancement. Three weeks after surgery, three partial dehiscences have been observed, which secondary healed. The average duration of follow-up was 8 months. The interview of the patients in January 1995 revealed: six patients obtained painless sexual intercourse, four patients improved significantly, one had no improvement and one complained of severe vulvar burning instead of dyspareunia. Our results are weighing against the initial enthusiasm to surgical treatment. Collaboration between gynecologists and psychologists to specify the indications and previous treatment of an associated vaginismus should be helpful for the treatment of these patients.

Vulvar vestibulitis. Lack of evidence for a human papillomavirus etiology

Prompted by contradictory papers on the subject, we performed a prospective study to assess the possible human papillomavirus (HPV) etiology of vulvar vestibulitis. Eleven patients with periglandular vestibulitis, as well as a control group of 11 patients with condylomata acuminata, were selected. Biopsy specimens were taken for histologic and virologic evaluation. One specimen of vestibulitis showed koilocytosis. Using the polymerase chain reaction, none of the vestibulitis specimens, including the one with koilocytosis, were found to harbor HPV DNA, whereas all the condylomata acuminata contained HPV 6/11 DNA. Our results do not support an HPV etiology of vestibulitis.