A wide spectrum of benign, premalignant, and malignant lesions may involve the vulva. The challenge to the clinician is to differentiate between normal variants, benign findings, and potentially serious disease, and this is not always easy.
The most useful means of generating a differential diagnosis of vulvar lesions is by morphologic findings (table 1) rather than by symptomatology, which is often nonspecific. Table 2 lists the most common diagnoses of vulvar lesions based on morphology (table 2A-B) [1,2], and Table 3 lists uncommon diagnoses by etiology (table 3). As with any presentation, the possibility of a multifactorial etiology should be considered.
An overview of benign vulvar lesions will be provided here. Vulvar intraepithelial neoplasia, vulvar cancer, vulvar dermatitis, and vulvodynia are discussed in detail separately (see individual topic reviews). The general approach to evaluation of vulvar lesions, including the history, physical examination, and diagnostic studies, is also reviewed separately. In all cases, one or more vulvar biopsies should be performed if the lesion is clinically suspicious for malignancy (asymmetry, border irregularity, color variation, rapid change, bleeding, non-healing). If a diagnosis cannot be made confidently by visual inspection and noninvasive methods, or if the lesion does not resolve after standard therapy, then a biopsy should also be strongly considered. (See "Diagnostic evaluation of vulvar lesions".)
Vulvar intraepithelial neoplasia — Vulvar intraepithelial neoplasia is a precancerous skin lesion of the vulva that may eventually progress to invasive carcinoma if left untreated. Most vulvar intraepithelial neoplasia lesions are multifocal and located in the nonhair-bearing parts of the vulva. The lesions are often raised and/or verrucous and white (picture 1A-B), but the color may be red (picture 2), pink, gray, or brown (picture 3). Macular lesions mostly occur on adjacent mucosal surfaces. (See "Vulvar intraepithelial neoplasia".)
Cancer — Most patients with vulvar cancer present with a unifocal vulvar plaque, ulcer, or mass (fleshy, nodular, or warty) on the labia. Lichen sclerosus and erosive lichen planus may predispose to vulvar cancers (picture 4). Ulcerations that do not heal, especially in postmenopausal women and women with a history of lichen sclerosis, should be biopsied . (See "Vulvar cancer: Clinical manifestations, diagnosis, and pathology".)