Portal de Periódicos da CAPES

The use of dermatoscopy to differentiate vestibular papillae, a normal variant of the female external genitalia, from condyloma acuminata

2009; Elsevier BV; Volume: 60; Issue: 2 Linguagem: Inglês

10.1016/j.jaad.2008.08.031

1097-6787

Suhan Kim, Sang‐Hee Seo, Hyun‐Chang Ko, Kyung‐Sool Kwon, Moon-Bum Kim,

Urologic and reproductive health conditions

To the Editor: Vestibular papillae of the vulva are very small asymptomatic filiform or soft, frond-like projections on the vestibular epithelium or the inner aspect of the labia minora.1Bunker C.B. Neill S.M. The genital, perianal and umbilical regions.in: Burns D.A. Breathnach S.M. Cox N.H. Griffiths C.E.M. Rook's textbook of dermatology, 7th ed, vol. 4. Blackwell Publishing, Oxford2004: 53-68Google Scholar, 2Woodruff J.D. Friedrich Jr., E.G. The vestibule.Clin Obstet Gynecol. 1985; 28: 134-141Crossref PubMed Scopus (55) Google Scholar This normal variant has a smooth surface and similar color to the adjacent mucosa.2Woodruff J.D. Friedrich Jr., E.G. The vestibule.Clin Obstet Gynecol. 1985; 28: 134-141Crossref PubMed Scopus (55) Google Scholar Although common, the condition may be unfamiliar to clinicians and may be misdiagnosed as condyloma acuminata.3Moyal-Barracco M. Leibowitch M. Orth G. Vestibular papillae of the vulva. Lack of evidence for human papillomavirus etiology.Arch Dermatol. 1990; 126: 1594-1598Crossref PubMed Scopus (68) Google Scholar A 39-year-old female presented with multiple papillary projections on the vulva. Three months earlier, she had complained of vulvodynia after childbirth and first recognized multiple grouped papillary projections on the inner left side of the labia minora. These had smooth surfaces and were the same color as the adjacent mucosa (Fig 1, A). At an obstetrics/gynecologic clinic, she was diagnosed as having condyloma acuminata, and at dermatologic clinic she was believed to have Bartholin adenitis. She was prescribed a first-generation cephalosporin (an oral dose of cephradine 1 g a day for 7 days) for the presumed Bartholin adenitis. The vulvodynia improved, but the objective findings remained unchanged without associated itching or tenderness. Dermatoscopy with the DermLite II Pro (3Gen, San Juan, Capistrano, CA) demonstrated a regular, often symmetrical and linear, array of papillae over the vestibule. Individual vestibular papillae were juxtaposed, and their respective bases remained separate. Abundant, irregular vascular channels were observed in the transparent core of the papillae (Fig 1, B). Routine laboratory investigations and potassium hydroxide examinations were normal or negative. An excisional biopsy was performed; this showed anastomosing vascular projections covered by a normal epithelium with no histologic features of viral infection (Fig 2). Polymerase chain reaction studies for human papillomavirus (HPV) were also negative.Fig 2A, Prominent fibrovascular cores with chronic inflammation and dilated capillaries in the papillary projections. B, High power magnification. Koilocytes are not observed. (Hematoxylin–eosin stain; original magnification: A, ×20; B, ×100.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Vestibular papillae were first described by Altmeyer.4Altmeyer P. Chilf G.N. Holzman H. Pseudokondylome der vulva.Geburtshilfe Frauenheilkd. 1981; 41 ([in German]): 783-786Crossref PubMed Scopus (18) Google Scholar Synonyms have included papillomatosis labialis, hirsuties papillaris vulvae, hirsutoid papilloma of vulva, pseudocondylomas, vestibular microwarts, and vulvar squamous papillomatosis.2Woodruff J.D. Friedrich Jr., E.G. The vestibule.Clin Obstet Gynecol. 1985; 28: 134-141Crossref PubMed Scopus (55) Google Scholar, 4Altmeyer P. Chilf G.N. Holzman H. Pseudokondylome der vulva.Geburtshilfe Frauenheilkd. 1981; 41 ([in German]): 783-786Crossref PubMed Scopus (18) Google Scholar, 5Friedrich Jr., E.G. The vulvar vestibule.J Reprod Med. 1983; 28: 773-777PubMed Google Scholar Moyal-Barranco et al3Moyal-Barracco M. Leibowitch M. Orth G. Vestibular papillae of the vulva. Lack of evidence for human papillomavirus etiology.Arch Dermatol. 1990; 126: 1594-1598Crossref PubMed Scopus (68) Google Scholar reported that vestibular papillae were not related to HPV infection. Using molecular hybridization, they detected HPV DNA sequences in only two (6.9%) of the 29 specimens of vestibular papillae, compared to 96% of specimens from vulvar warts. Vestibular papillae are now believed to represent an anatomic or functional variant of the normal genital epithelium. They are thought to be present in 1% of woman who visit obstetrics/gynecology clinics6Costa S. Rotola A. Terzano P. Secchiero P. Di Luca D. Poggi M.G. et al.Is vestibular papillomatosis associated with human papillomavirus?.J Med Virol. 1991; 35: 7-13Crossref PubMed Scopus (16) Google Scholar and are probably the female equivalent of pearly penile papules, the smooth, flesh-colored, and regularly distributed elevations of the corona of the glans penis.7Ackerman A.B. Kornberg R. Pearly penile papules.Arch Dermatol. 1973; 108: 673-675Crossref PubMed Scopus (51) Google Scholar If a large number of papillae cover the entire surface of labia minora in a symmetric fashion, the condition is referred to as vestibular papillomatosis.8Welch J.M. Nayagam M. Parry G. Das R. Campbell M. Whatley J. et al.What is vestibular papillomatosis? A study of its prevalence, aetiology and natural history.Br J Obstet Gynaecol. 1993; 100: 939-942Crossref PubMed Scopus (44) Google Scholar Although vestibular papillae are usually asymptomatic, they are often accompanied by itching, pain, burning, or dyspareunia.8Welch J.M. Nayagam M. Parry G. Das R. Campbell M. Whatley J. et al.What is vestibular papillomatosis? A study of its prevalence, aetiology and natural history.Br J Obstet Gynaecol. 1993; 100: 939-942Crossref PubMed Scopus (44) Google Scholar In our case, the patient visited the obstetrics/gynecologic clinic for vulvodynia in postpartum period. The lesions remained constant in size and shape after the pain disappeared. These normal anatomic structures could be misdiagnosed as condyloma acuminata, leading to inappropriate treatment.9Prieto M.A. Gutierrez J.V. Sambucety P.S. Vestibular papillae of the vulva.Int J Dermatol. 2004; 43: 143-144Crossref PubMed Scopus (17) Google Scholar Moyal-Barranco et al3Moyal-Barracco M. Leibowitch M. Orth G. Vestibular papillae of the vulva. Lack of evidence for human papillomavirus etiology.Arch Dermatol. 1990; 126: 1594-1598Crossref PubMed Scopus (68) Google Scholar suggested five clinical parameters that can be used to differentiate vestibular papillae from vulvar condylomata acuminate (Table I). In our case, we observed rod or teardrop shaped papillae. Individual papillae were juxtaposed, and their respective bases remained separate. We could confirm these finding using dermatoscopy. These clinical criteria differentiated vestibular papillae from condyloma acuminata without the need for HPV typing.Table IClinical differential diagnosis with vestibular papillae and condyloma accuminataClinical featuresVestibular papillaeCondyloma accuminataDistributionSymmetric or linearIrregularPalpationSoftHardColorPink, same as adjacent mucosaPink, white, and red lesions often associatedBaseBases of individual projections remain separateSuperficial projections coalesce in a common baseAcetic acid testNo circumscribed whiteningWhitening in most cases Open table in a new tab We are unaware of any previous report detailing the characteristic dermatoscopic findings of vestibular papillae versus condyloma acuminata. Dermatoscopy of vestibular papillae reveals abundant and irregular vascular channels in the transparent core of uniform-sized cylindrical papillae, which have separate bases. This differs from the dermatoscopic appearance of condyloma acuminata. In our experience, dermatoscopy of condyloma acuminata shows multiple, irregular projections with tapering ends arising from a common base. The projections have conglomerate vascular structures and are more white and broader than vestibular papillae; this might correlate with the hyperkeratotic and acanthotic features of condyloma acuminata (Fig 3). Therefore, along with the five clinical parameters suggested by Moyal-Barranco et al,3Moyal-Barracco M. Leibowitch M. Orth G. Vestibular papillae of the vulva. Lack of evidence for human papillomavirus etiology.Arch Dermatol. 1990; 126: 1594-1598Crossref PubMed Scopus (68) Google Scholar we believe that characteristic dermatoscopic findings provide additional diagnostic clues to differentiate vestibular papillae from condyloma acuminata. Because vestibular papillae are unfamiliar to clinicians, they may be misdiagnosed as condyloma acuminata, leading to inappropriate treatment.9Prieto M.A. Gutierrez J.V. Sambucety P.S. Vestibular papillae of the vulva.Int J Dermatol. 2004; 43: 143-144Crossref PubMed Scopus (17) Google Scholar Dermatoscopy may represent a convenient and helpful modality in the diagnosis of vestibular papillae, especially when they resemble condyloma.