Efficacy and safety of vaginal formulations with tyndallized ferments in subjects with nonspecific vulvovaginitis: A randomized study in Italy

AIM

In this study, we tested the efficacy, safety, and tolerability of vaginal ovules and a vaginal douche containing tyndallized ferments in women affected by nonspecific vulvovaginitis, with or without the human papillomavirus (HPV).

METHODS

The study included 91 female patients and had a randomized, controlled sequential design, with parallel groups. Ovules and douche were tested and compared to a control group treated with sterile physiological solution. Total symptom score (TSS), individual signs and symptoms, therapeutic success were evaluated, as well as safety and tolerability.

RESULTS

The tyndallized ferments formulations (ovules and douche) had a safe and tolerable profile, and resulted in a significant decrease in TSS in patients affected by nonspecific vulvovaginitis, both at 5 and 10 days of treatment, when compared to a control group. The treatment was more effective than the control in reducing symptoms such as vulvar erythema, vulvar edema, itching, and burning. Patients affected by vulvovaginitis and HPV-positive received a 30 days treatment either with ovules or ovules + douche, and we observed an improvement at Day 30 compared to Day 0, for both regimens.

CONCLUSIONS

Our study suggests that topical treatment with tyndallized ferments is a safe and effective strategy to reduce symptoms of nonspecific vulvovaginitis.

Vulvar-vaginal-gingival-otic syndrome

In order to retrospectively analyse the multi-site involvement pattern of erosive lichen planus patients, we retrospectively reported the clinical and medical data of three patients with erosive lichen planus which involving their vulva, vagina, gingiva, and ear canal. We confirmed the existence of otic lichen planus, and found that it is more common in patients with vulvovaginal-gingival syndrome of erosive lichen planus. Therefore, we propose 'vulvovaginal-gingival-otic syndrome' to further describe this rare compound pattern of lichen planus.

Comparative study of topical 5-aminolevulinic acid photodynamic therapy and surgery for the treatment of vulvar squamous intraepithelial lesion

BACKGROUND

Vulvar squamous intraepithelial lesion (SIL) is a precursor lesion of vulvar squamous cell carcinoma. The current clinical treatments for vulvar SIL cause damage to the vulvar structure, chronic pain and psychological distress. Topical 5-aminolevulinic acid photodynamic therapy (ALA-PDT) is a novel, non-invasive therapy for intraepithelial lesions. The objective of this study was to compare the clinical efficacy and safety of ALA-PDT with local surgical resection for vulvar SIL.

METHODS

A total of 56 patients with vulvar SIL were enrolled in this retrospective study. Among them, 16 patients received local resection and 40 patients received ALA-PDT. HPV genotyping and ThinPrep cytologic test (TCT) were used to evaluate treatment efficacy. In addition, colposcopy-directed biopsy was performed in all patients at 3-month follow-up and in patients with positive high-risk human papillomavirus (HR-HPV) and/or abnormal TCT results during the follow-up.

RESULTS

At 3-month follow-up and in HSIL group the complete remission (CR) rate of the ALA-PDT group and surgery group was 90.6% (29/32) and 87.5% (14/16) (P = 1.000), respectively. The HPV clearance rate of the ALA-PDT group and surgery group was 45.2% (14/31) and 43.8% (7/16) (P = 0.927), respectively. The average numbers of ALA-PDT treatments were 5.34 for HSIL patients and 4.88 for LSIL patients, respectively. The CR rate of HSIL patients and LSIL patients was 90.6% (29/32) and 75.0% (6/8) (P = 0.550), respectively. The HPV clearance rate of HSIL patients and LSIL patients was 45.2% (14/31) and 37.5% (3/8) (P = 1.000), respectively. The ALA-PDT group showed similar clinical efficacy and milder adverse effects compared with the surgical group.

CONCLUSION

ALA-PDT showed similar clinical efficacy as surgery in the treatment of vulvar SIL, but with milder adverse effects and maintaining the integrity of the vulvar structure.

COVID-19, Coronavirus Vaccines, and Possible Association with Lipschütz Vulvar Ulcer: A Systematic Review

Lipschütz genital ulcer is a self-limited, non-sexually acquired disorder characterized by the sudden onset of a few ulcers. A primary Epstein-Barr virus infection is currently considered the most recognized cause. Recent reports document cases temporally related with coronavirus disease 2019 (COVID-19) or immunization against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We carried out a review of the literature to investigate the possible association between COVID-19 or the immunization against SARS-CoV-2 and genital ulcer. The pre-registered study (CRD42023376260) was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Excerpta Medica, the National Library of Medicine, and Web of Sciences were searched. Inclusion criteria encompassed instances of acute Lipschütz ulcer episodes that were temporally linked to either COVID-19 or a vaccination against SARS-CoV-2. Eighteen articles were retained. They provided information on 33 patients 15 (14-24) years of age (median and interquartile range), who experienced a total of 39 episodes of Lipschütz ulcer temporally associated with COVID-19 (N = 18) or an immunization against SARS-CoV-2 (N = 21). The possible concomitant existence of an acute Epstein-Barr virus infection was excluded in 30 of the 39 episodes. The clinical presentation and the disease duration were similar in episodes temporally associated with COVID-19 and in those associated with an immunization against SARS-CoV-2. In conclusion, COVID-19 and immunization against SARS-CoV-2 add to Epstein-Barr virus as plausible triggers of Lipschütz genital ulcer.

"Check Your Vulva"-A Patient Education and Virtual Vulva Care Pilot Project

OBJECTIVE

The aim of the study is to identify whether vulvar self-examination learned from a web site could lead to a self-identification of vulvar lesions and the feasibility of virtual vulvar care with patient submitted photos.

MATERIALS AND METHODS

The study used a prospective cohort design in a tertiary academic hospital over a 1-year period. Eligible participants who self-identified a vulvar lesion/skin changes were invited to send vulvar photos through a secure patient portal and schedule a phone consult to discuss diagnosis/management. Clinical data, photo interpretability, and patient satisfaction measures were collected. Self-referral patients versus vulva clinic waitlist patients were analyzed separately.

RESULTS

Few people were interested in submitting vulvar photos online. Twenty-eight participants directly contacted the study, 8 consented, and 6 sent in vulvar photos. Forty four of 476 on the waitlist consented but only 24 of 44 sent in photos (5% of waitlist patients). The median time for a virtual assessment was 7 days for study participants while it was 18 months for the in-person usual care pathway. Most patient submitted photos were assessable. However, 60% participants needed help from another person to take the photos. More than 90% of patients required an in-person visit for their vulvar condition/concerns. While most patients were happy with the virtual process, 58% rated their satisfaction with the ease of taking photos of the genital region as "fair" or "poor."

CONCLUSIONS

Virtual care with photos/phone calls might be feasible, although most patients are unlikely to participate. Because of patient discomfort, unease with taking photos, and patient privacy concerns, vulvar care should continue to be in-person for most new consults.

Plasma Cell Vulvitis: A Case Series and Follow-Up Study

OBJECTIVES

Plasma cell vulvitis (PCV) is a rare inflammatory vulvar condition. The aim of this study was to describe the natural history, treatment, impact on quality of life, and factors associated with poorer outcomes for PCV.

METHODS

A mixed-methods approach was used combining a retrospective case note review with a cross-sectional telephone questionnaire. All women diagnosed with PCV attending the vulvar disorders clinic at the Royal Women's Hospital between January 2011 and December 2020 were included.

RESULTS

During the 10-year study period, 7,500 women were seen at the vulval disorders clinic, of whom 21 were diagnosed with PCV (0.28%). Of these women, 12 who were followed up for more than 12 months agreed to participate in the study. At a median of 5 years follow-up, there was variability in symptom severity, with more than half of the women still symptomatic with pain, precipitated by friction and dyspareunia, resulting in a moderate to large impact on quality of life. There were 5 women who were asymptomatic. Only 1 woman had a preexisting history of lichen planus and lichen sclerosus. Potent topical corticosteroids were identified as the preferred treatment.

CONCLUSIONS

Women with PCV can remain symptomatic for many years with significant impacts on quality of life, which may consequently require long-term support and follow-up.

A strengthening the reporting of observational studies in epidemiology (STROBE): Are HE4 and CA 125 suitable to detect a Paget disease of the vulva?

ABSTRACT

Paget disease is a complex disorder that can be identified in the breast (mammary Paget disease) or in other locations (extramammary Paget's disease) such as ano-genital skin (Paget disease of the vulva -PVD). This condition is associated with low mortality, but a late diagnosis and recurrence can negatively impact the prognosis. Therefore, the main objective of this study is to evaluate if the human epididymis protein 4 (HE4) and cancer antigen125 (CA125) can promote recognition of PVD in early stages and during the relapses.we have conducted a prospective, observational and laboratory-based study, that included 50 patients, whose 25 healthy women represented the control group and 25 PVD patients, which have been operated in our Oncology Institute, from May 2017 to September 2019. Both in the control group and in PVD patients, the CA-125 and HE4 were evaluated before surgery and after 6 months. Finally, a comparison of markers serum level, both between before/after surgery and with control group, and a ROC (Receiver Operating Characteristic) curve were performed.Dosing the markers in PVD patients, 3/25 (12%) showed a higher value of CA125 and 11/25 (44%) an increased HE4. In addition, after surgical treatment there were no statistically significant difference between levels of CA-125 (P = .3) and HE4 (P = .19). On the other hand, comparing HE4 in PVD patients with the control group, a statistically significant difference was found (P-value = .0036). Contrary, comparing CA-125 in PVD patients with the control group (P-value= .1969), no statistically significant difference was evidenced. Moreover, ROC (Receiver Operating Characteristic) curve showed low sensitivity and specificity for CA125 with area under curve (AUC) = 0.5608. Instead, the ROC curve of HE4 revealed a sensitivity and specificity of 76% and 88% respectively (AUC = 0.7408) using a cut-off at 90 pmol/L.Despite the limited cases, our data showed that CA125 is not a sensitive marker for PVD. On the other hand, in 44% of PVD we've seen an increase in HE4. So, this could be a starting point for further research that could confirm the possibility to use this marker in order to support PVD early identification.

Vulvar Ulcers in Children: Dramatic But Self-Limited

OBJECTIVE

We aimed to describe our experience in diagnosing and managing Lipschutz ulcers in children.

METHODS

This was a retrospective data review in a tertiary referral clinic for pediatric and adolescent gynecology. We identified patients referred with a vulval ulcer and recorded relating symptoms, presentation, and resolution.

RESULTS

We identified 7 nonsexually active girls with vulvar ulcers presenting within the course of an upper respiratory infection, including fever and cough. Average age was 12.25 years (range, 11-14.5 years). All patients presented with at least one large painful ulcer within the inner surface of the labium minor, of up to 2 cm in diameter.Initial presentation was of a bullous lesion that was then ulcerated, covered by a black gangrenous scab. Over the course of the week, the scab fell leaving a white-based ulcer that gradually healed. All children complained of dysuria stemming from contact irritation with urine. The ulcer gradually disappeared, leaving no mark within 10 days of initial presentation.Two of 7 patients presented with 3 similar recurrences after flu-like symptoms.None of the patients qualified for diagnosis of Behcet disease.

CONCLUSIONS

Lipschutz ulcers are painful genital lesions causing anxiety to the girl and her family. Pediatricians and gynecologists should be aware of the condition, diagnose it where appropriate, avoid unnecessary medication, and reassure the patient that it is self-limited.

FIRST EXPERIENCE OF THE METHOD APPLICATION IN UKRAINE

The aim of the study is to evaluate the tolerability and effectiveness of photodynamic therapy (PDT) of patients with premalignant diseases of the vulva. The study was performed on 10 patients on the basis of the National Cancer Institute of Ukraine (Kyiv). The age of patients ranged from 31 to 67 years old (mean age: 53.3±3.6 years old). The diagnosis was made on the basis of medical history, complaints and clinical examination of patients, vulvoscopy and the results of morphological examination of pathologically altered vulvar tissues. A drug of the chlorine series "Photolon" (RUE "Belmedpreparaty", Republic of Belarus) in doses from 1 to 2.5 mg/kg was used as a photosensitizer (FS). Photoirradiation of pathologically altered foci was performed 3-4 hours after the end of the infusion of FS using a laser coagulator universal "Lika-surgeon" ("Photonics Plus", Ukraine, λ = 660 nm) with a radiation power of 0.4 W in exposure doses of 100 up to 150 J/cm2. PDT tolerability was assessed basing on the frequency and severity of adverse reactions (CTCAE, version 3.0). The effectiveness of PDT was assessed basing on the presence / absence of complaints, data from visual observation of changes in the area of treated lesions and morphological examination data at 3 and 6 months after treatment (WHO criteria). No serious adverse reactions associated with the introduction of FS and PDT session were observed: no allergic reactions (Quincke's edema, urticaria, drop in blood pressure, bronchospasm), no symptoms of skin phototoxicity. In the specified control patients' observation terms, the remission of disease clinical symptoms (an itch in the area of vulva) in the treated pathological centers as well as high frequency of clinical and morphological regressions were noted. The obtained results indicate the relevance and prospects of further research in the field of laser technology and PDT as options for organ-preserving treatment of premalignant diseases of vulva.

[Focused ultrasound therapy for reducing recurrence of vulvar lichen simplex chronicus in rats: efficacy and mechanism]

OBJECTIVE

To explore the changes of collagen fibrosis in the vulva skin of SD rats with lichen simplex chronicus (LSC) after focused ultrasound therapy and explore the mechanism by which focused ultrasound reduces the recurrence of vulvar LSC.

METHODS

Fifty female SD rat models of vulvar LSC were established and randomly divided into the treatment group and the control group (n=25) for treatment with focused ultrasound and sham treatment, respectively. Before and after the treatment, vulvar skin tissues were sampled to observe the pathological changes with HE staining and assess the density of collagen fibers using Masson staining. The ultrastructure of the collagen fibers in the superficial dermis was observed using transmission electron microscopy. The expressions of notch1 and c-fos in the vulvar tissue were detected by immunohistochemistry and Western blotting.

RESULTS

After 4 weeks of focused ultrasound therapy, 16% (4/25) of the rats in the treatment group showed lesion progression to LSIL, 4% (1/25) still had LSC, and 80% (20/25) showed normal vulvar skin. In the control group, progression to LSIL occurred in 19 (76%) rats, 3 (12%) rats still showed LSC, and only 3 (12%) had normal vulvar skin. The difference in the cure rate differed significantly between the two groups (P < 0.05). The density of collagen fibers in the superficial dermis and the expressions of notch1 and c-fos in the vulvar skin were significantly lower in the treatment group than in the control group (P < 0.05).

CONCLUSIONS

Focused ultrasound therapy can inhibit superficial collagen fibrosis of the dermis by lowering the expressions of notch1 and c-fos in the vulvar skin to reduce the recurrence of vulvar LSC in rats.

Vertebral Osteomyelitis in Pregnancy from a Methicillin-resistant Staphylococcus Aureus Vulvar Abscess. A Case Report

BACKGROUND

Osteomyelitis is a rare problem in pregnancy but can present challenges for diagnosis and treatment. This case report describes a patient with a history of vulvar abscess who developed methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and osteomyelitis during pregnancy.

CASE

A 20-year-old woman, gravida 1, at 33 weeks' gestation, developed sepsis from MRSA bacteremia after a vulvar abscess drainage. She developed acute respiratory distress syndrome (ARDS) and was found to have osteomyelitis on her thoracic spine level 7. The diagnosis of osteomyelitis was based on clinical findings and magnetic resonance imaging. An emergent cesarean section was undertaken due to worsening ARDS. The osteomyelitis was treated with intravenous daptomycin with symptomatic improvement. However, back pain returned and the patient was readmitted and required a spinal brace and 6 weeks of intravenous vancomycin.

CONCLUSION

Osteomyelitis in pregnancy is a rare complication and a challenging diagnosis that requires a high index of suspicion. The treatment of osteomyelitis in pregnancy versus nonpregnancy is the same. This case is unique because this pregnant patient developed osteomyelitis secondary to a vulvar abscess.

Vulvar skin disorders throughout lifetime: about some representative dermatoses

The objective of this paper is to present general considerations which should be kept in mind by clinicians in charge of women with vulvar diseases. Four representative vulvar dermatoses are described. Lichen simplex chronicus is a pathological condition related to chemical and mechanical irritant agents. Detrimental effects of these irritants, in the presence of other dermatoses, have to be considered when therapeutic responses are unsatisfactory. Lichen sclerosus is the most common vulvar dermatosis in elderly. However, it should be kept in mind that it may be diagnosed at any age. Lichen planus, in spite of sharing a similar range of etiological factors with lichen sclerosus, is a very distinct entity. Finally, Paget's disease, although rare, is also described especially because of the challenge it represents both clinically and therapeutically.

Acute vulvar pain in a lady with post circumcision inclusion cyst of the vulva containing stones: a case report

BACKGROUND

Despite global eradication efforts, female genital cutting is still deep routed practice in some parts of Asia and East Africa. The crude and unscientific natures of the practice lead to many complications. Epidermoid inclusion cysts of the vulva are one of the late complications of female genital cutting and typically present as painless cystic swellings. But clinical presentation as 'stone' containing, hard vulvar mass is reported only once in the literature and presentation with acute vulvar pain has never been documented.

CASE PRESENTATION

A 21 yrs old, Ethiopian, unmarried, lady presented with sever acute vulvar pain, discharge, and a stony hard vulvar swelling 13 years after type-III female genital cutting (infibulation). Surgical excision of the cyst, which contained two 'stones' inside it, and defibulation were done. Histopathology confirmed calcified, keratinizing epidermoid inclusion cyst of the vulva.

CONCLUSIONS

Clinicians, in areas where female genital cutting is prevalent, should be aware of such unusual late vulvar complication of the practice which might be misdiagnosed for other solid vulvar swellings and be familiar with the appropriate management.

Effects of sexual arousal on genital and non-genital sensation: a comparison of women with vulvar vestibulitis syndrome and healthy controls

The relationship between sexual arousal and sensory perception has been a topic largely neglected within the realm of human sexuality research. The present study assessed the influence of sexual arousal on genital and non-genital sensation in women. It also examined the theory that painful intercourse is associated with insufficient sexual arousal. A total of 20 healthy women and 20 women with Vulvar Vestibulitis Syndrome (VVS) underwent genital and non-genital sensory testing at baseline and in response to erotic and neutral stimulus films. Touch and pain thresholds were assessed at the vulvar vestibule, inside the labia minora, and on the volar surface of the forearm. Sexual arousal was assessed via the measurement of surface skin temperature changes of the labia minora using a labial thermistor clip. Participants also completed questionnaires pertaining to mood, pain, and sexual functioning. In response to the erotic stimulus, both groups evidenced a significant increase in physiological sexual arousal and vulvar sensitivity. Women with VVS reported a significantly lower desire to engage in intercourse after having viewed the erotic film and reported lower levels of desire and arousal on questionnaire measures. Women with VVS also exhibited significantly more genital and non-genital pain sensitivity than healthy women across all conditions, in addition to more catastrophizing, hypervigilance, and fear of pain. Contrary to some theories, these data suggest that women with VVS are not lacking in physiological sexual arousal, and that physiological sexual arousal may actually increase vulvar sensation. Lack of subjective sexual arousal, however, may yet be implicated in vulvar pain during intercourse.

Pediatric Gynecology: Assessment Strategies and Common Problems

Pediatric gynecology is an emerging subspecialty involving the collaborative efforts of health professionals from gynecology, pediatrics, and urology. The gynecologic problems encountered in the pediatric population are unique to this age group and involve physician skills differing from those utilized with an adult population. The purpose of this manuscript is to describe the normal anatomy and physiology of the reproductive tract and genitalia and common problems seen in the prepubertal female. Common anatomic variations are considered. Suggestions on assessment techniques for evaluation of the young child are discussed. Presentation of common gynecologic problems in the prepubertal child will include common symptoms, evaluation and testing, and management to enable the practicing gynecology health professional to provide compassionate and quality care to the young female.

Vulvar conditions and their treatment. Evaluation of a patient information booklet

OBJECTIVE

To identify the effectiveness of a patient information booklet on vulvar conditions and to evaluate future patient needs.

STUDY DESIGN

A patient education booklet and satisfaction survey were distributed to 75 new patients with various vulvar conditions who were seen at the University of Michigan Center for Vulvar Diseases in 1996. This population's desire for health and disease information was analyzed. The 48-page booklet contains information on specific vulvar conditions most often seen, their common manifestations and treatment options. A survey with an attached, stamped envelope addressed for return to the Center for Vulvar Diseases was given to the patient along with the booklet during her initial visit to the clinic. Factors evaluated included the usefulness of the material, ease of reading, need for additional information and enhancement of communication with health care providers.

RESULTS

Fifty-six percent of the surveys were returned. The majority of the patients found the material to be very useful and easy to read and understand. The booklet allowed better communication between patients and their health care providers. All the patients surveyed would recommend the booklet to a friend. Several of the patients utilize and desire computerized patient education.

CONCLUSION

There is great consumer interest in patient education. A comprehensive booklet such as ours provides consistent information. Evaluation of patient education can provide important quality-improvement information to optimize health care services. Future patient needs are important factors to consider. The information in the booklet is available to the public on the internet at http:/(/)www.med.umich.edu/obgyn/vulva/ vulvedu.html.

Childhood sexual and physical abuse. Incidence in patients with vulvodynia

OBJECTIVE

To compare the incidence of sexual and/or physical abuse in women with vulvodynia (chronic, burning vulvar pain in the absence of clear medical findings) as compared to women with chronic vulvar symptoms due to specific, objective vulvar disease and with women from a general dermatology practice.

STUDY DESIGN

An invitation to participate in this questionnaire study was sent to 300 women over 18 years of age from a vulvo-vaginal clinic and 280 women from a general dermatology practice. These questionnaires asked for basic demographic information as well as information on childhood sexual experiences and physical abuse.

RESULTS

Questionnaires from 89 patients with vulvodynia, 65 patients with chronic vulvar symptoms due to specific, objective vulvar disease and 166 patients from a general dermatology practice were examined. There were no differences as to the incidence of childhood sexual or physical abuse between patients with vulvodynia and either those with general dermatology complaints or those with chronic vulvar symptoms due to objective disease.

CONCLUSION

There is no evidence from these data that women with vulvodynia experience a higher incidence of sexual or physical abuse during childhood as compared to women in a general dermatology office or women with chronic vulvar symptoms from specific, observable pathology.

Office gynecology for the primary care physician, part II: pelvic pain, vulvar disease, disorders of menstruation, premenstrual syndrome, and breast disease

Approaches to patients with pelvic pain, vulvar disease, disorders of menstruation, premenstrual syndrome, and breast diseases are addressed. In the great majority of cases, it is appropriate for the primary care physician to initiate evaluation and management of these problems. It is hoped that the brief introductions contained here suggest a diagnostic approach to each disorder and guide referral to consultants as needed.

Growth characteristics of nonmalignant cells in the ATP cell viability assay

Over the last 5 years, the ATP cell viability assay (ATP-CVA) has been used to study the in vitro response of cell lines and fresh gynecologic human tumors to a variety of antineoplastic agents including chemotherapeutic agents, hormones and biological response modifiers. This assay measures light production as intracellular ATP interacts with the luciferin-luciferase complex. Quantitation of the light produced has been shown to directly correspond with the number of viable cells. A past criticism is that in the ATP-CVA, when applied to fresh tumor tissue, normal cells (fibroblasts, macrophages and lymphocytes) also produce ATP, and if present in sufficient numbers, could lead to errors in chemosensitivity testing results. This study was designed to evaluate the growth characteristics of various benign cells found in fresh tumors. The cells were studied under multiple plating conditions to show the relative increase or decrease of fractional ATP measured at different time points. We found that agar/McCoy underlayer and agarose-coated wells do not permit the growth of nonmalignant cells. In the culture conditions of the ATP-CVA, non-malignant cells do not contribute relevant ATP levels when treated samples are compared to controls on day 6. Therefore, results of the ATP-CVA in fresh tumors should not be affected.

Primary breast cancer of the vulva

Supernumerary breasts on the vulva are a rare occurrence. There have been 26 cases previously reported and only 4 case reports of primary mammary carcinoma of the vulva. This is the fifth case report of mammary carcinoma of the vulva and the second report using tamoxifen for adjuvant treatment.

Vulvar dystrophies and intraepithelial neoplasias

The warmth and moisture present in all intertriginous locations distorts the lesional morphology of many vulvar diseases. Specifically, wetness leads to the development of a nondistinctive, white hyperhydration of any scale that is present, and this, in turn, masks the characteristic features of the underlying pathology. These same factors increase the severity of pruritus and thus lead to scratching and eczematization of what, in other locations, would be more readily recognizable disease. Those diagnostic hallmarks that do remain are emphasized in this article, and those aspects of therapy that are unique to a vulvar location are discussed.