Leukoplakia of vulva is a chronic dystrophic process of the mucous membrane of the vulva, expressed by proliferation and increased keratinization of the multilayer squamous epithelium and further tissue sclerosis. Leukoplakia of vulva is manifested by the presence of whitish plaques on the mucous membrane, itching, burning, pain in the area of the external genitals. Leukoplakia of vulva is diagnosed by gynecological examination, vulvoscopy, Schiller test, targeted biopsy. Treatment is aimed at reducing the severity of its manifestations and maintaining immune protection; includes hormone therapy, physiotherapy; according to indications – surgical excision of single foci or extirpation of the vulva.
N90.4 Leukoplakia of vulva
Leukoplakia of vulva is the main manifestation of squamous cell hyperplasia – a dystrophic disease of the vulva with a lesion of the multilayered flat non-corneating epithelium. With leukoplakia of vulva, the appearance of normally absent corneal and granular layers in the epithelium, the development of para- and hyperkeratosis, acanthosis (without cellular and nuclear atypia or with atypia) is observed.
Most often, leukoplakia of vulva is observed during menopause. Vulvar leukoplakia may precede or be combined with vulvar kraurosis; recently, their number has been increasing, and among young patients. With vulvar leukoplakia, there is a risk of developing cellular atypia and the potential for its degeneration into vulvar cancer (from 5 to 35% of cases), and when combined with kraurosis, this risk increases.
According to the severity of hyperkeratosis, there are three forms of vulvar leukoplakia: flat (simple), hypertrophic and warty. Flat leukoplakia of vulva is characterized by the appearance of flat smooth whitish spots on the surface of the vulva without visible inflammation, which reappear after removing them with a tampon. Flat leukoplakia can be observed in limited areas, and with a generalized process – on the vast surface of the vulva.
With hypertrophic leukoplakia of vulva, the lesions are represented by dry convex plaques of grayish-white color, which cannot be removed from the vulva mucosa. Leukoplactic plaques can sometimes merge with each other. Warty leukoplakia of vulva is caused by a significant proliferation and keratinization of limited lesions resembling warts; it is often complicated by the formation of cracks, erosions and the development of inflammation. Warty leukoplakia of vulva is considered a precancerous condition.
Current data indicate a variety of etiological and pathogenetic factors that cause dystrophic changes in the genital mucosa in vulvar leukoplakia. Leukoplakia of vulva is considered a kind of protective reaction to the action of various damaging factors, manifested in inadequate proliferation of the epithelium. Leukoplakia of vulva develops against the background of chronic inflammation of the mucous membrane with the development of neuroendocrine, immune and metabolic disorders.
Risk factors for vulvar leukoplakia include age over 40 years; the presence of chronic genital inflammation (including chronic papillomavirus infection and genital herpes serotype 2); cervical dysplasia; short reproductive period; metabolic disorders (diabetes, obesity); neglect of personal hygiene; multiple traumatization and irritation of the vulva mucosa; vitamin A deficiency.
Hormonal failure leading to vulvar leukoplakia is associated with age-related changes in the hypothalamus-pituitary system, hypofunction of the thyroid gland (hypothyroidism), adrenal cortex (adrenal insufficiency), ovarian dysfunction, lack of estrogen in menopause and menopause. It is also believed that the basis of the occurrence of vulvar leukoplakia is a whole complex of psychoemotional disorders.
Leukoplakia of vulva can be asymptomatic, without causing unpleasant sensations in the patient. Manifestations of leukoplakia of vulva are most often observed in the clitoris and labia minora. With leukoplakia of vulva, small, sometimes multiple whitish spots begin to appear on the mucous membrane. As a result of further keratinization, the surface of the foci of leukoplakia acquires a grayish-white and pearlescent hue, epithelial plaques thicken and begin to protrude slightly above the surface of the mucosa. Slowly increasing in size, plaques can merge and spread to a significant surface of the vulva. Foci of leukoplakia of vulva are very persistent, do not disappear during their treatment.
With sclerosis and infection of the vulva tissues, there is a constant severe itching and burning sensation, which increases at night, after urination, during movement and sexual intercourse; paresthesia (numbness, tingling) appears. The warty form of vulvar leukoplakia with dense keratinized growths is complicated by the appearance of painful and poorly healing chronic cracks, erosions and ulcers, which are joined by a microbial infection. The development of inflammation in vulvar leukoplakia is accompanied by edema and hyperemia. Soreness during sexual intercourse interferes with the intimate life of the patient, leads to the development of neuropsychiatric symptoms.
Diagnosis of vulvar leukoplakia is based on the patient’s complaints, the results of gynecological examination, instrumental and laboratory studies. Since similar manifestations can also be observed in diabetes mellitus, various dermatoses (lichen planus, eczema, psoriasis, neurodermatitis), lupus erythematosus, syphilis, etc., it is necessary to carry out differential diagnosis with these diseases.
Patients with leukoplakia complain of itching, burning sensation in the vulva. During a gynecological examination, you can find characteristic whitish foci on the mucous membrane. Colposcopy (vulvoscopy) is necessarily performed, which, with leukoplakia of vulva, reveals a whitish-gray or yellowish color of the mucosa, a translucent keratinized bumpy surface, the absence or lack of expression of the vascular pattern. Colposcopy also helps to identify the presence of dysplastic and atrophic processes of the genitals accompanying leukoplakia of vulva, to exclude malignant neoplasms.
When conducting a Schiller test with Lugol’s solution, foci of vulvar leukoplakia do not stain and become clearly visible to the naked eye. Microscopic examination of the smear for microflora and oncocytological changes of the vulvar mucosa is also performed.
A targeted biopsy is performed from areas suspected of having vulvar leukoplakia, followed by a histological examination of the material showing the nature of changes in the cells and tissues of the mucosa. Carrying out a complete diagnostic examination in gynecology allows you to detect vulvar leukoplakia with an accuracy of up to 100%. The detection of vulvar leukoplakia without signs of atypia allows us to consider it a background process, with the presence of atypia – a precancerous condition.
Treatment of vulvar leukoplakia is complex and long-term, taking into account the age and concomitant diseases of the patient; it includes drug therapy, diet, physiotherapy, psychotherapist’s help, if necessary, surgical intervention. Physical therapy is recommended; walks in the fresh air, a dairy – vegetable diet; carrying out hygienic procedures using boiled water and herbal infusions, refusal of soap, potassium permanganate, douching; elimination of irritating factors (woolen and synthetic underwear, tampons and synthetic pads). With leukoplakia of vulva, hot baths and prolonged insolation are contraindicated.
Local anti-inflammatory and antipruritic treatment is prescribed using ointments, creams, vaginal balls with hormones, antiseptics. In hormonal therapy, prednisone, estrogens in combination with androgens, estrogen – progestogenic drugs, unconjugated estrogens and estriol derivatives are used (cyclically or in contraception mode with 2-3 monthly courses). It is possible to take vitamins and trace elements, antihistamines, with persistent itching – novocaine blockades.
Modern physiotherapy procedures (ultraphonophoresis of medicines, oxygenotherapy with modulation of brain rhythms) with vulvar leukoplakia have an anti-inflammatory, desensitizing effect, normalize metabolic processes, hormonal and psycho-emotional background, strengthen the immune system. Correction of the psychoemotional state with the use of sedatives and techniques is an important element of the treatment of vulvar leukoplakia.
In the absence of the effect of conservative treatment of vulvar leukoplakia, modern gynecology uses surgical excision of single foci of leukoceratosis with a scalpel, a radionog, as well as their removal with a laser and cryodestruction. In severe cases of vulvar leukoplakia, a radical operation is performed – extirpation of the vulva, which, if there are signs of malignancy, is combined with courses of radiotherapy.
Patients with vulvar leukoplakia are taken under the dynamic dispensary supervision of a gynecologist or oncologist (in the presence of malignancy of the lesion) with mandatory colposcopic and cytological control and repeated courses of treatment.
Prognosis and prevention
The flat form of vulvar leukoplakia is considered reversible, warty (in the stage of erosion) is considered as a precancerous condition. Prevention of vulvar leukoplakia consists in the prevention and timely correction of hormonal disruptions in a woman’s body, the treatment of concomitant inflammatory and metabolic disorders.