To date, there are many controversial issues in the interpretation of background and precancerous diseases. In 1987, the International Medical Association for the Study of Vulvar Diseases decided to summarize the old names for histogenetically related processes mentioned above under the general term “Non-tumor dystrophic lesions”.
Non-tumor degenerative lesions of the skin and mucous membrane
• Sclerosing lichen (vulvar kraurosis and atrophic vulvitis).
• Squamous cell hyperplasia (leukoplakia).
• Mixed forms (atrophic and hyperplastic changes).
• Other dermatoses.
Sclerosing lichen (lichen) is observed mainly in elderly women. Microscopic signs include smoothing and complete disappearance of the epidermal processes and subepithelial eosinophilic homogenization of the dermis with a pronounced reduction or absence of elastic fibers. Due to the concomitant disappearance of the pigment, a picture of the “white vulvar lesion” (leukoplakia) is created. According to modern data, sclerosing lichen does not have a direct genetic connection with tumor processes. The latter are usually directly caused by additionally occurring isolated foci of squamous hyperplasia. Squamous cell hyperplasia (leukoplakia) is regarded as an inadequate proliferative response of the vulva epithelium to the effects of a large number of irritating factors. It can develop at any age, but is most often noted in the pre- and postmenopausal periods. Microscopic signs include primarily acanthosis and hyperkeratosis. Papillomatous structures are absent, which distinguishes squamous hyperplasia from genital warts. Mixed type dystrophic changes are noted in approximately 15% of cases. This type of change is characterized by areas of skin that have signs of sclerosing lichen, while others show a typical picture of squamous hyperplasia. A true precancerous disease is dysplasia. Vulvar intraepithelial neoplasia (V1N): I degree – mild dysplasia (VIN 1) (mild atypia); II degree – moderate dysplasia (VIN 2) (moderate atypia); Grade III – severe dysplasia (VIN 3) (severe atypia) or carcinoma in situ. Under the guise of clinically determined non-tumor dystrophic lesions (kraurosis and leukoplakia), precancerous diseases (VIN 2 and VIN 3) and initial forms of vulvar cancer may be hidden. Long-term conservative treatment of patients with non-tumor dystrophic diseases of the vulva without histological examination is a very common mistake and leads to delayed diagnosis. Severe dysplasia often develops against the background of non-tumor dystrophic lesions of the vulva, in particular sclerosing lichen, squamous hyperplasia and other dermatoses. The latter have an unfavorable pathogenetic value, due to the vastness of the lesion and the multifocal tumor transformation of the integumentary epithelium of the vulva. Dysplasias that develop on the background of unchanged labia skin in young women rarely turn into invasive vulvar cancer due to their possible spontaneous regression.
Sclerosing and atrophic lichen vulva
The etiology is not fully understood, the viral or bacterial genesis is not conclusively proven. Hormonal effects are of some importance, since the disease often manifests itself for the first time before the onset of the first menstruation or after menopause. In children, the disease is rare. The first symptoms occur in the late phase of the hormone dormancy period.
First, the polygonal shape of the whitish-yellow papules is revealed, merging into plaques with a pearly sheen and in a later stage experiencing sclerotic and atrophic changes. The main symptom is severe itching, scratching can be seen around skin lesions. In almost 50% of girls, the process is localized in the anogenital region, in the rest – in other areas.
Only clinical or morphological cytological data to establish a diagnosis is not enough. Histological diagnosis is always needed. Histological examination against the background of a thinned epidermis and pigment changes reveals pronounced hyperkeratosis. Elastic fibers are sharply hyalinized. Collagen fibers with round cell infiltrates adjacent to them are also visible. The prognosis for children is better than for adults. During puberty, spontaneous remission may occur.
Pathogenetic therapy is not possible. Therefore, to improve the condition, it is often enough to observe the hygiene of the genitals for constant medical supervision. In case of unbearable itching, effective local treatment with ointments containing corticosteroids. Local treatment with estrogen in girls before puberty is not carried out.
Lipoma, or vulvar fibrolipoma
Lipoma, or fibrolipoma, is a benign tumor of adipose and connective tissue. Lipoma is located not only in the thickness of the large shameless lips, but also on the pubis. Recognizing it is not difficult. Tumor nodes are located on a wide base or on a stalk, can reach significant sizes and are available for direct examination. In case of circulatory disturbance, edema, hemorrhage, necrosis develop in them, a secondary infection joins, which can lead to the forwarding of the tumor. Surgical treatment. The forecast is favorable.
In the case of this disease, atrophy as such is absent, although the first clinical impression often leads to this conclusion. Symmetric depigmentation of a large number of skin areas is detected more often, and anogenital area is often affected. Vitiligo is observed, although rarely, in girls before puberty. The disease proceeds with mild symptoms, without itching, but can progress.
The treatment in girls is useless, and it can be omitted. If vitiligo is limited only to the area of the external genitalia, then it should be explained to the mother that later the process can spread to other parts of the body; mother should be reassured that in this case there is no danger to health.