Vulvar Itching Research Articles

Anaphylaxis during pregnancy

Anaphylaxis during pregnancy, labor, and delivery can be catastrophic for the mother and, especially, the infant. Symptoms and signs can include intense vulvar and vaginal itching, low back pain, uterine cramps, fetal distress, and preterm labor. During the first 3 trimesters, etiologies are similar to those in nonpregnant women. During labor and delivery, common etiologies are β-lactam antibiotics, natural rubber latex, and other agents used in medical and perioperative settings. Important caveats in management include injecting epinephrine (adrenaline) promptly, providing high-flow supplemental oxygen, positioning the mother on her left side to improve venous return to the heart, maintaining a minimum maternal systolic blood pressure of 90 mm Hg to ensure adequate placental perfusion, and continuous electronic monitoring. Cardiopulmonary resuscitation and emergency cesarean delivery should be performed when indicated. In all women of child-bearing age, allergy/immunology specialists can help to prevent anaphylaxis in pregnancy through prepregnancy risk assessment and risk reduction strategies, such as confirming the etiology of systemic allergic reactions, providing written instructions for allergen avoidance, and initiating relevant immune modulation. In pregnant women the benefits versus risks of skin tests, challenge tests, desensitization, and initiation of immunotherapy with allergens should be carefully weighed; if possible, these procedures should be deferred until after parturition. Prospective interdisciplinary studies of anaphylaxis during pregnancy are needed.

Telephone Triage

The study aimed to determine which self-reported vulvovaginal symptoms are most consistent with candidiasis confirmed by yeast culture and to establish guidelines to determine who can be appropriately treated by telephone triage versus office examination for women with vulvovaginal symptoms. A retrospective chart review of 105 patients seen in the Saint Louis University Vulvar and Vaginal Disorders Specialty Center during a 14-month period was performed after institutional review board approval. Patient's age, medication use, symptom scores on a Likert rating scale for vaginal/vulvar pain, burning, itching, dyspareunia, wet-mount results, and yeast culture results were recorded. Differences in the occurrence of vaginal/vulvar symptoms of any severity between women with positive and with negative yeast culture results were calculated using χ2 and Fisher exact tests. Differences in symptom scores of any severity were compared between women with positive and with negative yeast culture results using nonparametric Kolmogorov-Smirnov test, owing to a lack of normality of the distributions. Sensitivity of 75% or greater and specificity of 67% or greater were sought for all 9 recorded symptoms. Multiple logistic regression analysis was used to determine which symptoms and their cutoff values were significant independent predictors of a positive yeast culture result. Receiver operating characteristic curve analysis was used to determine the efficacy of individual symptoms and combinations of symptoms for predicting a positive yeast culture result. A value of p < 0.05 was used to denote statistical significance. Four vulvovaginal symptoms met cutoff criteria for analysis to predict a positive yeast culture result: vaginal burning, vulvar burning, vulvar itching, and clitoral pain. Vaginal burning with a score of 6 or greater (p < 0.001) and vulvar itching with a score of 5 or greater (p < 0.05) were significant independent predictors of a positive yeast culture result. Women with both a vaginal burning score of 6 or greater and a vulvar itching score 5 or greater had a positive predictive value of 91.7% (22/24). Vaginal discharge was not shown to be predictive of candidiasis. Diagnosis of candidiasis using self-reported vulvovaginal symptoms by telephone triage is difficult. Self-reported scores for vaginal burning of 6 or greater and for vulvar itching of 5 or greater are significant indicators of a positive yeast culture result. Vaginal discharge was not predictive of a diagnosis of candidiasis. A symptom chart can aid office staff in telephone triage of symptomatic women.

Recognition and Management of Vulvar Dermatologic Conditions: Lichen Sclerosus, Lichen Planus, and Lichen Simplex Chronicus

Lichen sclerosus, lichen planus, and lichen simplex chronicus are dermatologic conditions that can affect the vulva. Symptoms include vulvar itching, irritation, burning, and pain, which may be chronic or recurrent and can lead to significant physical discomfort and emotional distress that can affect mood and sexual relationships. With symptoms similar to common vaginal infections, women often seek care from gynecological providers and may be treated for vaginal infections without relief. Recognition and treatment of these vulvar conditions is important for symptom relief, sexual function, prevention of progressive vulvar scarring, and to provide surveillance for associated vulvar cancer. This article reviews these conditions including signs and symptoms, the process of evaluation, treatment, and follow-up, with attention to education and guidelines for vulvar care and hygiene.

Pinworms in menstrual blood

We report an unusual case of enterobius vermicularis adult live worms recovered from the menstrual blood. A 35-year-old multiparous woman presented with intense vulval itching and a four-month history of passage of worms in the menstrual blood. There was no history of passage of worms in the intermenstrual period or any perianal itching. Her 16-year-old daughter had had similar complaints for two months. The family had changed their residence four months ago. Speculum examination revealed a healthy cervix and vagina with a slight non-offensive vaginal discharge.

Role of Vulvar Care Guidelines in the Initial Management of Vulvar Complaints

This study aimed to determine the effectiveness of vulvar care guidelines as the initial treatment of vulvar complaints. A chart review was conducted at the Saint Louis University Vulvar and Vaginal Disease Center. Women with vulvar symptoms in the absence of specific identifiable causes were evaluated and given guidelines for vulvar care. An 11-point Likert scale was used to rate symptoms at the initial and follow-up visits. Compliance level was determined. A decrease in mean scores was shown for dyspareunia (7.5 ± 2.0 to 4.6 ± 3.1, p < .001), burning after intercourse (6.8 ± 2.7 to 3.4 ± 2.4, p = .10), vulvar burning (5.7 ± 2.6 to 2.1 ± 1.9, p < .001), vulvar itching (4.9 ± 2.8 to 2.5 ± 2.6, p < .001), and vulvar pain (5.8 ± 2.8 to 2.2 ± 3.0, p < .01). The mean dyspareunia difference scores were significant between the low- and high-compliance groups. Vulvar care guidelines are successful for the management of vulvar complaints.

Acquired lymphangioma circumscriptum of the vulva

A lymphangioma is a rare proliferation of the lymphatic system. The condition is unpleasant but benign. There are 3 types of lymphangioma: circumscriptum, cavernous, and cystic. Lymphangioma circumscriptum is considered primary if it is present at birth or it develops in early childhood, or secondary or acquired if it is caused by impaired lymph flow. Involvement of the vulva is rare [1,2]. The differential diagnosis of lymphangioma circumscriptum of the vulva includes genital warts, molluscum contagiosum, tuberculosis verrucosa cutis, lymphogranuloma venereum, and filariasis [3]. Lymphangioma circumscriptum can be caused by infections (filariasis, sexually transmitted infections, tuberculosis, erysipelas, lymphogranuloma venereum); Crohn's disease; surgical or radiotherapy procedures (radical hysterectomy, pelvic lymphadenectomy, radiation for cervical cancer); trauma; keloids; scleroderma; dermopathy from penicillamine or corticosteroids; and lymphatic obstruction associated with neoplasia [1,4]. A 44-year-old woman presented with vesicles in the vulvar region, watery discharge, and itching. The patient reported occasional foul-smelling white vaginal discharge and no history of sexual contact. Clinical examination revealed well-defined, multiple, grouped, dome-shaped papulovesicular lesions over the labia majora and mons pubis. The lesions were not tender and showed diffuse induration. Inguinal lymph nodes were absent. The perianal region was without lesions (Fig. 1). Speculum examination revealed copious foul-smelling white discharge around the cervix. Other general examination was unremarkable. Histologic examination of the lesions revealed acanthosis and prominent elongation of epidermal rete ridges. The spaces between the rete pegs were distended by dilated spaces lined by endothelium and contained pale secretory material. Adjacent dermis showed infiltration by lymphocytes. The diagnosis of lymphangioma circumscriptum was proposed. Pap smear ruled out intraepithelial malignancy.

�Vulvar syringoma: A rare case report�

SUMMARY Syringomas are intraepidermal eccrin sweat gland adenomas which can usually be seen in adolescent ages. Typical involvement includes the malar areas and the lower eyelids, however vulvar involvement is rare. These lesions are characterized with papules which are small, yellowish, firm seperated from each other and can be 1-5 mm in diameter, and are often associated with increased vulvar discomfort and itching. The lesions are generally multiple, bilateral and symmetrical. A 35-year-old woman presenting with a 3-year history of vulvar papules, sometimes itching and increasing in time is presented to our clinic. The patient has been diagnosed as syringoma with clinical and histopathological results. Due to the fact that the patient is symptomatic, we preferred laser vaporization as a treatment option and presented our case with the preoperative and postoperative pictures.

Pruritus Vulvae

Pruritus vulvae refers to persistent vulval itching and affects up to 1 in 10 women at some point in their life. Frequently, there is a delay in seeking medical advice, and women often self-medicate with over-the-counter preparations before seeing their GP. These preparations may exacerbate the problem further. As pruritus vulvae has a wide range of causes, a careful history and examination are essential. Management involves both general measures to reduce itching as well as those targeted at the specific cause. This article summarizes the common causes of pruritus vulvae and an approach to assessment and management.

Perception of Vaginal Discharge and Care Seeking Behaviour among Obstetric and Gynaecological Clinic Attendees in Abakaliki, Southeastern Nigeria.

Background: Vaginal discharge is a major complaint among women attending gynaecological clinics. While some seek treatment services for the symptom, others just tolerate it despite the associated long term disabilities. Aims and Objective: This study assessed the perception of vaginal discharge and care seeking behavior among women in Ebonyi State. Materials and Methods: Yhis is a descriptive cross sectional study of women visiting obstetric and gynaecological clinic of Ebonyi State University Teaching Hospital, Abakaliki, between 1st April and 31st August 2010.The data was analyzed using EPI-info 3.3.2 and results presented in tabular forms as frequencies and percentages. Result: The age of the 163 participants ranged between 18 and 52 years with a mean of 29.6 + 6.8 years. Majority of participants 68(41.7%) had tertiary education while eight (4.9%) had no formal education. Seventy nine (48.5%) had experienced abnormal vaginal discharge. Over 64% of them attributed vaginal discharge to dirty toilet seats and 13 (16.5 %) to sexual intercourse. Associated symptom in most cases was vulval itching (74.7%) while coital bleeding was the least (3.8%). Majority felt sad 35(44.3%) about having the symptom, eight (10.1%) thought it normal. Only Fifty- four (68.4%) of the participants who experienced vaginal discharge consulted a doctor, Six (7.6%) ignored the symptoms. Most of the patients, 36 (45. 6%), believed infertility is a possible consequence. EMJ 2010; 9(2): 101-105 Conclusion: The relative high educational attainment of the participants and their paradoxical poor knowledge about the causes of vaginal discharge underscore the need to incorporate reproductive health education into secondary schools curriculum in Nigeria.Keywords: Vaginal discharge, antenatal, perception, health

P3-S7.06 Vaginal discharge in women living with HIV attending an AIDS clinic in Manaus, Brazil

BackgroundA vaginal discharge and/or vulvar itching and irritation usually characterise Vaginitis, and a vaginal odour might be present. The three diseases most frequently associated with vaginal discharge are BV (replacement of the normal vaginal flora by an overgrowth of anaerobic microorganisms, (Gardnerella vaginalis), trichomoniasis, and candidiasis.ObjectivesTo estimate the prevalence of vaginal discharge in HIV women attending the Institute of Tropical Medicine in Manaus, Amazonas, Brazil.MethodsA cross-sectional study performed among women attending the AIDS clinic from March to December 2010. They were invited to take pat in the study and answered an interview including demographic, behavioural and clinical data. They underwent in a gynaecological examination and it was collect vaginal samples for diagnosingTrichomonas vaginalis, Gardnerella vaginalisandCandida spp.ResultsA total of 338 women were included in the study. Median age was 32 (IQR (IQR): 27; 38) years and median of schooling nine (IQR: 4; 11) years. Prevalence rate of vaginal discharge was 45.8% (95% CI 40.5% to 51.1%). Prevalence ofTrichomonas vaginaliswas 1.2% (95% CI 0.5% to 2.4%),Gardnerella vaginalis35.8% (95% CI 30.7% to 40.9%) and Candidiasis 21.3% (95% CI 16.9% to 25.7%). Median of first sexual intercourse was 16 (IQR: 14; 17) years and 53.6% were married or reported a stable partner. Risk factors reported were: injecting drug use (1.2%), no-injecting drugs (15.2%), previous STI (32.4%), commercial sex workers (16.4%), more than one partner in the last year (12.4%) and in life (94.7%). Regarding clinical symptoms, 50,9% reported chronic pelvic pain, 53.3% vaginal discharge, 47.6% vaginal itching, 22.8% dysuria and 9.5% genital bleeding. CD4 counts were more than 500 cells/mm3in 29.4% and viral load were &lt;1.00 copies/ml in 53.8%. A total of 53.9% of women reporting vaginal discharge had a positive test for at least one disease. In the final model of logistic regression the only variable remained was having viral load &lt;1000 copies/ml decreased the risk of vaginal discharge.ConclusionsRegardless the low cost and large availability of GRAM stain and cytological tests in health services for women with AIDS, there are difficulties which remain to identify interventions that refer to social, cultural and environmental influences on vaginal infections in this group.

Vulval Diseases - Lichen sclerosus

Clinical presentation Vulval itching (pruritus vulvae) can be an embarrassing and distressing symptom. It can be associated with systemic disease (e.g. jaundice), infections, general dermatological conditions and conditions specific to the vulva

Diagnostic performance of urgent referrals for suspected gynaecological malignancies

The objective of this study was to investigate the outcome of the urgent referrals with suspected gynaecological malignancy. Retrospective analysis of the data of the urgent referrals for suspected gynaecological cancers over a 12-month period at a gynaecological oncology cancer centre in the UK. A total of 233 patients (70.61%) were referred with suspected endometrial pathology, 59 patients (17.88%) with suspected ovarian, 25 patients (7.58%) with suspected cervical and 13 patients (3.94%) with suspected vulval malignancy. The positive predictive value of referrals for diagnosing endometrial, ovarian, cervical and vulval malignancy was 11.6, 23.7, 12.0 and 15.4%, respectively. Amongst the indications for referral for suspected endometrial cancer, presence of postmenopausal vaginal bleeding had the higher odds for cancer (odds = 0.13; 95% CI 0.08-0.21). The odds for cancer for women referred with a pelvic mass was 0.17 (95% CI, 0.07-0.42) and for women referred with abdominal bloating was 0.66 (95% CI, 0.18-2.36). All the cases of malignancy were diagnosed in women referred with suspicious appearance of the cervix on clinical examination. The odds for cancer was 0.50 if the indication for referral was vulval itching. The majority of cases of gynaecological cancers during the study period were diagnosed following routine referrals. The overall predictive value of two-week wait referrals for suspected gynaecological malignancies is low. Refinement of the current referral guidelines is required with particular emphasis in the premenopausal women where the diagnostic performance of the urgent referrals is significantly poorer.

A case of usual (basaloid)-type vulvar intraepithelial neoplasia that failed to respond to imiquimod cream: clinical implications

The authors report a case of usual-type (basaloid-type) vulvar intraepithelial neoplasia (VIN) 3 that failed to respond to imiquimod cream. A 51-year-old Japanese woman visited her local gynecologist complaining of vulvar itching. Atypical cells were noted in cytology smears, but nine vulvar biopsy specimens showed benign proliferation of epithelial tissue. The patient was placed under careful observation for 8months, when the vulvar smears once again showed atypical cells and biopsy specimens revealed VIN3. The patient was then referred to our hospital where she was given a diagnosis of VIN 3, basaloid type of usual type. The biopsy specimens were positive for p16 and the lesions were confirmed to be human papilloma virus (HPV)-related. We recommended simple vulvectomy but the patient requested conservative treatment with imiquimod cream. With her written informed consent, we prescribed imiquimod cream to be self-administered 3 times a week. Colposcopy and pap smear test were performed every 2weeks. Four weeks after the start of treatment, a fingertip-sized papule was detected at the patient's vaginal introitus. By 6weeks, the lesion had enlarged, and biopsy specimens revealed invasive squamous cell carcinoma. At 7weeks, we performed simple vulvectomy. The surgical specimen showed stage pT1b keratinizing-type squamous cell carcinoma. HPV-16 DNA was detected in the specimen.

Atrophic vaginitis

With the loss of estrogen that occurs with menopause, physiologic and structural changes occur within the vulvovaginal mucosa that lead to a condition commonly called atrophic vaginitis. Although mild genital changes occur in most women, 10-47% of postmenopausal women will develop one or more debilitating symptoms that include vulvovaginal dryness, dyspareunia, vulvar itching or pain, recurrent urinary tract infections, as well as abnormal vaginal discharge. Topical estrogen replacement therapies reverse these mucosal changes and are effective treatments for the symptoms of atrophic vaginitis. Vaginal moisturizers and lubricants also provide symptomatic relief for vaginal dryness and dyspareunia, respectively.

Adjuncts to case assessment of vaginal discharge syndrome in pregnant women

Objective To investigate the aetiology of abnormal vaginal discharge, using a non-culture based method, among pregnant women presenting at the University of Calabar Teaching Hospital, Calabar, Nigeria. Methods Two hundred consecutive antenatal patients, aged 18 to 38 years, with complaints of abnormal vaginal discharge between 1st April and 31st July 2004 were investigated clinically for the characteristics of the vaginal discharge. High vaginal swabs taken from the vaginal fornices were examined using a non-culture based method to determine the possible aetiology of the discharge. The possibility of integrating non-culture based laboratory methods in the syndromic case management of abnormal vaginal discharge in an antenatal clinic setting is discussed. Results The commonest form of abnormal discharge was curdy white in 66% of cases. Ten (5%) women had malodourous vaginal discharged, 92% had vulval itching; and superficial dyspareunia was seen in 29% of cases. Microscopic studies of vaginal discharge revealed the following findings: lactobacilli (96%), polymorphs (96%), 'clue' cells (4%); positive Whiff test (5%), and pH > 4.5 (7%). The clinical and laboratory assessment of each patient lasted between 35 and 45 minutes. The procedures used were acceptable to 78% of women. Conclusion The use of non-culture based laboratory methods in the initial assessment of abnormal vaginal discharge can be a useful adjunct in the syndromic case management of abnormal vaginal discharge in pregnant women.

Simple and inexpensive point‐of‐care tests improve diagnosis of vaginal infections in resource constrained settings

Bacterial vaginosis (BV) and Trichomonas vaginalis infection (TV) have been associated with adverse birth outcomes and increased risk for HIV. We compare the performance of simple inexpensive point-of-care (POC) tests to laboratory diagnosis and syndromic management of BV and TV in poor settings. Between November 2005 and March 2006, 898 sexually active women attending two reproductive health clinics in Mysore, India were recruited into a cohort study investigating the relationship between vaginal flora and HSV-2 infection. Participants were interviewed and screened for reproductive tract infections. Laboratory tests included serology for HSV-2; cultures for TV, Candida sp., and Neisseria gonorrhoeae; Gram stains; and two POC tests: vaginal pH; and Whiff test. Of the 898 participants, 411 [45.7%, 95% confidence interval (95% CI): 42.4-49.0%] had any laboratory diagnosed vaginal infection. BV was detected in 165 women (19.1%, 95%CI: 16.5-21.9%) using Nugent score. TV was detected in 76 women (8.5%, 95%CI: 6.7-10.4%) using culture. Among the entire study population, POC correctly detected 82% of laboratory diagnosed BV cases, and 83% of laboratory diagnosed TV infections. Among women with complaints of vulval itching, burning, abnormal vaginal discharge, and/or sores (445/898), POC correctly detected 83% (60 of 72 cases) of laboratory diagnosed BV cases vs. 40% (29 of 72 cases) correctly managed using the syndromic approach (P < 0.001). Similarly, POC would have detected 82% (37 of 45 cases) of TV cases vs. 51% (23 of 45 cases) correctly managed using the syndromic approach (P = 0.001). In the absence of laboratory diagnostics, POC is not only inexpensive and practical, but also significantly more sensitive than the syndromic management approach, resulting in less overtreatment. .

Quinacrine sterilization for human immunodeficiency virus–positive women

To evaluate the safety of nonsurgical quinacrine sterilization for HIV-positive (HIV+) women. An open trial of quinacrine sterilization was carried out in women infected with HIV and women who were HIV negative (HIV-). Comparison of the results with the two groups provided an assessment of the safety and effectiveness of quinacrine sterilization for HIV+ women. University Medical School outpatient services. A total of 258 women who desired sterilization were offered quinacrine sterilization as a means of limiting family size. Sixty-four were HIV+, and 194 were HIV-. Women who were HIV+ had CD4 counts >200 and were otherwise healthy. A modified Copper T intrauterine device inserter was used to place 252 mg of quinacrine, divided into seven pellets (36 mg each) into the uterine cavity. Three insertions of this formulation were performed, 1 month apart. Viral load and CD8 and CD4 lymphocytes were measured both before and after quinacrine sterilization and at follow-up visits. Pregnancies and adverse events were recorded carefully. A decrement life table was made to statistically analyze results. RESULT(S) AND MAIN OUTCOME MEASURE(S): No serious adverse event occurred in any patient in this study. Adverse effects related to quinacrine sterilization were abdominal cramping, vulvar itching, nausea, and vaginal bleeding. Vaginal bleeding was the only short-term side effect noted to occur more frequently in HIV-infected women after quinacrine sterilization. Among HIV+ women, 35.9% had complaints of increased bleeding, whereas only 8.2% of those who were HIV- had such complaints, which probably were insertion related. Viral load and the CD4+ and CD8+ lymphocyte measures displayed no statistically significant difference after quinacrine sterilization. Quinacrine sterilization is a safe method for the sterilization of HIV-infected women and has no short-term effect on the pathology of the disease.

Skin graft failure mimicking abscess masking local recurrence of vulvar cancer: a case report

Vulvar cancer is a rare gynecological malignancy and its local recurrence is even more uncommon. To date, no cases of recurrent vulvar cancer in split thickness graft area have been reported. We describe the first case of such recurrence. A 65-year-old G4P3013 presented with vulvar mass and itching. She had a 2 x 2-cm sized mass on clitoris and an ulcerated bulgy mass of 2 x 2.5 cm size was localized on left labia majora, of which a biopsy revealed invasive squamous cell carcinoma. She underwent a radical vulvectomy and bilateral inguinofemoral lymph node dissection via separate incisions. Her postoperative course was complicated by wound separation which was cored with a split thickness skin graft. Patient was advised to integrate her treatment with radiotherapy, but she refused it. Two months later, she consulted for a painful swelling in the operation field. The swelling resembled an abscess formation so it was drained and an outpatient antibiotic treatment was prescribed. At her second visit, it was noted that the above-mentioned lesion was persisting and so fine needle aspiration biopsy (FNAB) was performed and a local recurrence was retrieved beneath the graft failure. Then she underwent a wide local excision and adjuvant radiotherapy was initiated after patient's approval. Careful surveillance is warranted as squamous cell carcinoma recurrence can even occur beneath the split thickness skin graft, especially in conjunction with graft failure. And for high risk patients adjuvant radiotherapy is critically important for avoiding recurrences.

Pattern of non-venereal dermatoses of female external genitalia in South India

Non-venereal dermatoses tend to be confused with venereal diseases, which may be responsible for mental distress and guilt feelings in patients. We conducted the study to find the pattern of non-venereal dermatoses of female external genitalia and to correlate non-venereal dermatoses with various clinical parameters. The study included 120 female patients with non-venereal dermatoses of female external genitalia presenting over a period of 22 months from September 2005 to June 2007. The demographic characteristics and clinical findings were recorded. Cases having venereal diseases were excluded from the study. A total of nineteen non-venereal dermatoses were noted in the study. The most common non-venereal dermatoses were lichen sclerosus (26 cases or 21.7%), vitiligo (19 cases or 15.8%), lichen simplex chronicus (16 cases or 13.3%), and vulval candidiasis (11 or 9.2%). Other dermatoses included lymphedema, invasive squamous cell carcinoma, tinea cruris, psoriasis, furuncle, folliculitis, lichen planus, epidermal inclusion cyst, herpes zoster, irritant contact dermatitis, acrochordon, Bartholin cyst, fibroepithelial stromal polyp, molluscum contagiosum (autoinoculated), and streptococcal vulvitis. This study highlights the importance of diagnosing non-venereal dermatoses and refutes the general misconception that all vulval itching is the result of fungal infection. The two most common causes of vulval itching observed in the study were lichen sclerosus and lichen simplex chronicus.

A Comparative Analysis of Lichen Sclerosus of the Vulva and Lichen Sclerosus That Evolves to Vulvar Squamous Cell Carcinoma

Lichen sclerosus (LS) is a chronic inflammatory disease of unknown cause which is found most often in the vulvar region. Vulvar LS has been associated with squamous-cell carcinoma (SCC) of the vulva; estimates of the prospective risk of malignant transformation range from 3% to 5%. In this study, the proliferative index was determined using the cell proliferation marker Ki67 and expression of the tumor suppressors p16 and p53 was quantified in 8 women with histologically confirmed vulvar LS who, after 10 months to 9 years of follow-up, developed vulvar SCC. A comparison group consisted of 8 women with vulvar LS who did not develop cancer during follow-up for 9 years or longer. Immunoperoxidase staining utilized the monoclonal antibody MIBI. All patients described vulvar itching and/or burning. Mean ages were approximately 60 years for both groups of patients. Nuclear atypia was observed in epidermal keratinocytes in 2 of the 8 women with unchanged vulvar LS and in 5 of those who developed SCC, not a statistically significant difference. All cancers were of the keratinizing type with LS present in the nearby skin. Significantly higher MIBI labeling indices were found in cases evolving to vulvar SCC than in those that remained unchanged. The mean p53 labeling index was also significantly greater in evolving than in nonevolving cases of vulvar LS, but there was no such difference in pl6-positive staining between the 2 groups. Suprabasilar extension of p53 was observed in half of the evolving cases and in a single nonevolving case. All cases of evolving LS and none of those that did not become cancerous exhibited at least 2 of 3 characteristics: a MIBI labeling index (LI) exceeding 50%; a p53 LI exceeding 70%; suprabasilar extension of p53. Immunohistochemical staining for MIBI and p53 may help to identify those women with vulvar LS who are relatively likely to develop SCC. Periodic status checks or adjunctive biopsies would be appropriate for these patients.