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

      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.
      • Bunker C.B.
      • Neill S.M.
      The genital, perianal and umbilical regions.
      • Woodruff J.D.
      • Friedrich Jr., E.G.
      The vestibule.
      This normal variant has a smooth surface and similar color to the adjacent mucosa.
      • Woodruff J.D.
      • Friedrich Jr., E.G.
      The vestibule.
      Although common, the condition may be unfamiliar to clinicians and may be misdiagnosed as condyloma acuminata.
      • Moyal-Barracco M.
      • Leibowitch M.
      • Orth G.
      Vestibular papillae of the vulva. Lack of evidence for human papillomavirus etiology.
      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.
      Figure thumbnail gr1
      Fig 1A, Multiple skin-colored, soft, frond-like projections on the left inner aspect of the labia minora. B, Dermatoscopic findings include multiple filiform projections with abundant vascular structures. The bases of the individual projections remain separate.
      Figure thumbnail gr2
      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.)
      Vestibular papillae were first described by Altmeyer.
      • Altmeyer P.
      • Chilf G.N.
      • Holzman H.
      Pseudokondylome der vulva.
      Synonyms have included papillomatosis labialis, hirsuties papillaris vulvae, hirsutoid papilloma of vulva, pseudocondylomas, vestibular microwarts, and vulvar squamous papillomatosis.
      • Woodruff J.D.
      • Friedrich Jr., E.G.
      The vestibule.
      • Altmeyer P.
      • Chilf G.N.
      • Holzman H.
      Pseudokondylome der vulva.
      • Friedrich Jr., E.G.
      The vulvar vestibule.
      Moyal-Barranco et al
      • Moyal-Barracco M.
      • Leibowitch M.
      • Orth G.
      Vestibular papillae of the vulva. Lack of evidence for human papillomavirus etiology.
      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 clinics
      • Costa S.
      • Rotola A.
      • Terzano P.
      • Secchiero P.
      • Di Luca D.
      • Poggi M.G.
      • et al.
      Is vestibular papillomatosis associated with human papillomavirus?.
      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.
      • Ackerman A.B.
      • Kornberg R.
      Pearly penile papules.
      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.
      • Welch 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.
      Although vestibular papillae are usually asymptomatic, they are often accompanied by itching, pain, burning, or dyspareunia.
      • Welch 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.
      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.
      • Prieto M.A.
      • Gutierrez J.V.
      • Sambucety P.S.
      Vestibular papillae of the vulva.
      Moyal-Barranco et al
      • Moyal-Barracco M.
      • Leibowitch M.
      • Orth G.
      Vestibular papillae of the vulva. Lack of evidence for human papillomavirus etiology.
      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 accuminata
      Clinical featuresVestibular papillaeCondyloma accuminata
      DistributionSymmetric or linearIrregular
      PalpationSoftHard
      ColorPink, same as adjacent mucosaPink, white, and red lesions often associated
      BaseBases of individual projections remain separateSuperficial projections coalesce in a common base
      Acetic acid testNo circumscribed whiteningWhitening in most cases
      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,
      • Moyal-Barracco M.
      • Leibowitch M.
      • Orth G.
      Vestibular papillae of the vulva. Lack of evidence for human papillomavirus etiology.
      we believe that characteristic dermatoscopic findings provide additional diagnostic clues to differentiate vestibular papillae from condyloma acuminata.
      Figure thumbnail gr3
      Fig 3Dermatoscopic findings of condyloma acuminata on vestibule of a 6-month-old girl show multiple irregular projections with tapering ends arising from a common base. The projections, whiter and broader than vestibular papillae, have conglomerate vascular structures.
      Because vestibular papillae are unfamiliar to clinicians, they may be misdiagnosed as condyloma acuminata, leading to inappropriate treatment.
      • Prieto M.A.
      • Gutierrez J.V.
      • Sambucety P.S.
      Vestibular papillae of the vulva.
      Dermatoscopy may represent a convenient and helpful modality in the diagnosis of vestibular papillae, especially when they resemble condyloma.

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