Immunosuppressed patients typically display multifocal and multicentric disease, and are resistant to standard treatment paradigms. The small vesicles characteristic of herpes simplex can coalesce and form large ulcers, fungal conditions can be persistent despite adequate topical treatment, and vulvar dysplasia can be widespread and persist or be more prone to recurrence after treatment. Adequate diagnosis in this population depends on one's familiarity with the wide array of vulvar infections, dystrophies, and dysplasias. Again, liberal biopsy as well as culture is the key to confirming a diagnosis. When treating the immunosuppressed for vulvar conditions, a more aggressive approach should be considered, including early intravenous therapy in severe or refractory cases, and antibiotic or viral suppression and/or prophylaxis. In the case of dysplasias, coexisting disease in other sites is the norm rather than the exception. Treatment needs to be tailored and timed with antiretroviral therapy. For example, some dysplasias can show improvement with elevated CD4 counts.
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