Filiform projections of the vestibular mucosa: What’s your diagnosis?

Abstract

29-year-old recently married woman was reffered by her gynecologist to our dermatology department for suspected vulvar condyloma acuminatum. She had no history of any extramarital sexual contacts and her partner was free of any clinical features of genital HPV infections. She was anxious about the origin of her lesions and the risk of her husband’s contamination. She reported burning sensation, irritation and vulvar pain. On clinical examination soft digitate mucous colored papules with a smooth surface were noted at the vulvar vestibule. These papillomatous projections were pearly, uniformly arranged and had separate bases (Fig. 1). Dermatoscopy demonstrated regular and linear pinkish projections arranged in a symmetric distribution. Irregular linear vascular channels were observed (Fig. 2). Figure 1: Clinical aspect: multiple skin-colored filiform and soft projections. Figure 2: Dermatoscopy showing regular and linear pinkish projections arranged in a symmetric distribution. WHAT’S YOUR DIAGNOSIS? ANSWER: Vestibular Papillomatosis Vestibular papillomatosis (VP) is a normal variant of the female genital mucosa [1,2]. It is first described in 1981 by Altemeyer and named pseudocondylomata of the vulva [3]. VP is frequently misdiagnosed as condyloma acuminatum and presents a source of anxiety in patients, aggressive investigations and inappropriate treatment [2]. This entity is most often asymptomatic, but it can be accompanied, as our case, by a feeling of burning, pain or dyspareunia. To avoid the misdiagnosis of VP as genital warts, Moyal-Barranco et al. had proposed five clinical parameters [4]. Unlike condyloma acuminatum, VP is formed by regular, soft and pink-colored papillae arising from a separate base. It is also characterized by the lack of circumscribed whitening on 5% acetic acid application. Dermoscopy can help to differentiate these two conditions by allowing a better identification of these clinical parameters. Linear vessels may sometimes be observed in the transparent core of the finger-like projections [5]. On the other hand, dermoscopy of condyloma acuminatum shows irregular whitish projections with tapering end that arise from a common base and comprise conglomerate vessel. Based on these clinical criteria and the dermoscopic aspect, biopsies will be unnecessary to confirm the diagnosis of VP.