Epithelial Lesions

Seborrheic Keratosis

Seborrheic keratoses can occur anywhere on the body, but are occasionally seen on the vulva, usually in middle-aged to older women (Fig. 13A and B). The lesion

Table 10 Papillary Hidradenoma

Diagnosis

Symptoms

Clinical appearance

Differential diagnosis

Therapy

Papillary

None, or

Nodule 1 cm or

Clinically squamous

Simple

hidradenoma

mass

less, often red

cell carcinoma,

excision

and ulcerated

microscopically

adenocarcinoma

Medical Vulva
Figure 11 Trichoepithelioma. (A) Epithelial subunits surrounded by a dense fibroconnective tissue stroma. (B) Detail of basaloid cells of an epithelial subunit.
Vulva Insert
Figure 12 (See color insert) Syringoma: the characteristic comma-shaped epithelial nests in a collagenous background are seen.

Table 11 Trichoepithelioma

Diagnosis

Symptoms

Clinical appearance

Differential diagnosis

Therapy

Trichoepithelioma None

Small, flesh-colored plaque or nodule

Basal or squamous cell carcinoma

Excision

Table 12 Syringoma

Clinical

Diagnosis Symptoms

appearance

Differential diagnosis

Therapy

Syringoma None or

Multiple small

Candidiasis, lichen simplex

None usually

pruritus

flesh to yellow

chronicus, condyloma

required,

colored

acuminatum, hemangioma,

but are

papules or

lymphangioma circumscriptum,

sometimes

nodules

Fox-Fordyce disease (26)

excised

Vulvar Lesion

Figure 13 Seborrheic keratosis. (A) Seborrheic keratoses are in the differential diagnosis of pigmented lesions. (B) Benign squamous epithelium containing several horn cysts containing keratin.

presents as an elevated flesh-colored to brown papule or plaque, usually up to several millimeters in diameter, with a ''stuck-on'' appearance. The lesion may be slightly greasy to the touch. Histologically, there is hyperkeratosis, acanthosis, papillomatosis, and intraepidermal horn cysts (Table 13) (22).

Warty Dyskeratoma

Warty dyskeratomas (WDs) may occur anywhere on the skin, and occasionally occur on the vulva (Fig. 14A and B). The lesions are single, which distinguishes them from Darier's disease, a histologically identical condition inherited in an autosomal dominant fashion and manifested as multiple lesions (27). Grossly, the lesions present as single flesh-colored to brown papules. The most common and distinctive histologic manifestation of WD is a cup-shaped lesion filled with a parakeratotic plug, although the lesions may also be cystic or nodular (28). The proliferating cells of the lesion show dyskeratosis and suprabasal acantholysis and may resemble koi-locytes. Studies have not shown an association with HPV, however (Table 14) (27).

Keratoacanthoma

Keratoacanthomas are benign neoplasms that may raise the concern of malignancy because of their rapid growth. They then tend to regress in three to six months (Fig. 15A and B) (29).

Table 13 Seborrheic Keratosis

Diagnosis

Symptoms

Clinical appearance

Differential diagnosis

Therapy

Seborrheic

None, or may

Papule or plaque, Nevus, condy-

None required,

keratosis

be a cosmetic

brown to flesh

loma,

but local

issue

colored,

squamous cell

destruction/

slightly

carcinoma,

excision

''greasy'' to

melanoma

sometimes

touch

Excision Vulva
Figure 14 Warty dyskeratoma. (A) Low power shows the typical suprabasal acantholysis. (B) Suprabasal acantholysis with acanthosis, hyperkeratosis, and dyskeratosis.
Figure 15 Keratoacanthoma. (A) Low-power view of a papule with a central hyperkeratotic plug. (B) The typical eosinophilic cells of the lesion. The rapid growth as well as the atypia that may be seen histologically may lead to a suspicion of a squamous cell carcinoma.

Table 14 Warty Dyskeratoma

Diagnosis

Symptoms Clinical appearance Differential diagnosis Therapy

Warty dyskeratoma

None Single flesh to brown papule with hyperkeratotic plug in center

Seborrheic keratosis, vulvar Excision intraepithelial neoplasia, SCC, condyloma, Darier's disease, keratoacanthoma

Abbreviation: SCC, squamous cell carcinoma.

Table 15 Keratoacanthoma

Diagnosis

Symptoms Clinical appearance

Differential diagnosis

Therapy

Keratoacan- Rapidly Raised pink or flesh- Squamous cell Excision or thoma growing colored nodule on vulva, carcinoma, observation as nodule up to several cm, with warty dys- lesion regresses keratinaceous plug keratoma

Keratoacanthomas are raised pink or flesh-colored lesions with a characteristic central invagination filled with keratin (22). If untreated, they will eventually involute and leave a scar. Histologically, the characteristic cup-shaped architecture with the keratin-filled crater is best appreciated on lower power. The cytoplasm of the squamous cells may be very eosinophilic and "glassy" (22), with minimal atypia or mitotic activity (29). The lesion may be difficult to differentiate from squamous cell carcinoma on a small biopsy, and a larger excisional biopsy may be required to make the distinction (29). The cup shape of the lesion may mimic a WD; however keratoacanthomas are likely to lack the acantholysis of WD, as well as have more atypia and mitotic activity than WD (Table 15) (28).

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