Vulvar vestibular papillomatosis: All genital lesions are not sexually transmitted diseases

Vulvar vestibular papillomatosis (VVP) is considered as normal anatomical variant of the vulva. A 19-year-old female presented with asymptomatic pinkish filliform papules symmetrically distributed on vulva. She denied having any sexual exposure. Clinical differential diagnosis included genital wart and vestibular papillomatosis, however biopsy was consistent with Vestibular papillomatosis. PAS stain was negative. Application of 5% acetic acid did not show any change in color. We report this case to create awareness about normal variant of vulva and unnecessary exaggerated treatment and proper counseling of patient to decrease psychological trauma and associated venereophobia.


INTRODUCTION
Vulvar vestibular papillomatosis (VVP) is known to be a normal anatomical variant of the vulva [1]. It was first described by Altmeyer in 1981 as pseudocondylomata of the vulva. In the past there are studies which quoted rare association of VVP with human papilloma virus but recently studies have found no relation of HPV with VVP [2,3]. Prevalence rates range from 1% to 33% [4].
Vulvar Vestibular papillomatosis (VVP) are considered the female equivalent of pearly penile papules [5]. VVP have been called with different names in the literature, such as hirsutoid papiloma of vulva, vulvar squamous papillomatosis, micropapillomatosis labialis and squamous vestibular micropapilloma [6]. HPV had been thought to be the etiological agent of VVP in the past but diagnostic techniques with PCR and in situ hybridization revealed no association with HPV [3,7,8].
Clinically, lesions of vestibular papillomatosis are symmetrical and have linear array in distribution, soft pink as adjacent mucosa, bases of which remain separated with no circumscribed whitening on applying 5% acetic acid. While Genital warts are irregular, hard, flesh colored to pink and greyish with projections can coalesce in common base [6,7,9]. VVP is considered by few authors as an asymptomatic clinical entity. In few patients, however premonitory vulvar vestibular pruritus, pain or burning and dyspareunia were observed [5]. According to Growdon et al. patients with VVP can be divided into two groups as asymptomatic patients and those with symptoms like vulvar pruritus, burning and dyspareunia. [10] On the basis of diagnostic tool like histological and in situ hybridization data, they proposed that symptomatic VP was HPV-induced and asymptomatic VP a variant of normal mucosa [5].

CASE REPORT
A 19-year-old female presented with filiform genital lesions which she noticed over the last 2 years. Patient denied having any sexual exposure in the past. On clinical local examination there were multiple filiform papules of sizes 1 to 2mm on the labia minora; more over vestibule but symmetrically distributed. The papules were pinkish in colour resembling colour of the labia minora as shown in Figure 1. Acetic acid 5% was spread on the lesions but there was no change of any color. Laboratory investigation to rule out other sexually transmitted diseases, like HIV serology, VDRL, TPHA, Hepatitis B, C were all found to be negative. Biopsy was performed. The histopathology revealed acanthotic epidermis with multiple vacuolated cells with round to oval nuclei with irregular nuclear contours in areas, visible nucleoli and abundant cytoplasm in epidermis as shown in Figure 2. To differentiate it being glycogen or koilocytes, PAS stain was done which was found to be negative. Biopsy report was suggestive of Vestibular papillomatosis with recommendation to do further PCR for Human papilloma virus (HPV).
Patient denied for PCR for HPV or IHA for HPV due to financial constraints. Patient was counselled for the disease and no further treatment was done. She was advised for regular follow-up.

CONCLUSION
Awareness about VVP as a normal anatomical variant among dermatologists and gynecologists is warranted to avoid any unnecessary exaggerated treatment in the form of topical or surgical modality should be avoided. Proper counseling of patient should be done to decrease psychological trauma and venereophobia associated with this condition.
Copyright by Deeptara Pathak Thapa. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source of Support: Nil, Confl ict of Interest: None declared.