What is the most common type of vulvar lesion?

Most Common Vulvar Lesion

The most common vulvar lesion is condyloma acuminatum (genital warts), which are benign HPV-induced proliferative lesions caused predominantly by HPV types 6 and 11.

Epidemiology and Clinical Significance

Condyloma acuminatum represents the most frequently encountered vulvar lesion in clinical practice. 1

• Approximately 90% of all anogenital warts are associated with HPV types 6 and 11 1
• An estimated 1% of sexually active adolescents and adults in the United States have clinically apparent genital warts at any given time 1
• Over 500,000 new cases of anogenital warts are diagnosed annually in the United States 1
• Approximately 10% of men and women will develop anogenital warts at some point in their lives 1

Clinical Presentation and Characteristics

Condylomata acuminata appear as exophytic, sessile, or pedunculated growths with papillary projections. 1

• These lesions can appear pink or white depending on the degree of keratinization 1
• They are typically asymptomatic but can occasionally be painful, friable, or pruritic 1
• The average time to development after infection with HPV types 6 or 11 is approximately 2-3 months 1
• Not all persons infected with HPV types 6 or 11 will develop visible genital warts 1

Important Clinical Pitfalls

While condylomata are benign, they can harbor high-risk HPV types and may contain dysplasia, particularly in immunosuppressed patients. 1, 2

• Although most condylomata are caused by low-risk HPV types 6 and 11, high-risk HPV types (16,18,31,33,35) can be detected in these lesions 1, 2
• Research demonstrates that 64.6% of condylomata acuminata specimens contain high-risk HPV types, with HPV 16 being the most common high-risk type detected (32.3% of specimens) 2
• Immunosuppressed patients have significantly more HPV types in their condylomata (100% contained high-risk types) compared to otherwise healthy individuals (43.9%) 2
• Biopsy is indicated when the diagnosis is uncertain, lesions don't respond to standard therapy, disease worsens during therapy, the patient is immunocompromised, or warts are pigmented, indurated, fixed, or ulcerated 1

Natural History and Management Considerations

Many condylomata regress spontaneously (20-30%), but recurrence is common (approximately 30%) whether clearance occurs spontaneously or following treatment. 1

• The primary goal of treatment is removal of symptomatic warts 1
• If left untreated, visible genital warts may resolve on their own, remain unchanged, or increase in size or number 1
• Surgical excision is the recommended treatment, with recurrence believed to be caused by incomplete removal of infected epithelium at the lesion base 1

Distinction from Other Vulvar Lesions

It is critical to distinguish condylomata acuminata from other vulvar lesions, particularly premalignant conditions. 3, 4, 5

• Vulvar intraepithelial neoplasia (VIN) represents premalignant lesions that can progress to squamous cell carcinoma 3, 4, 5
• Lichen sclerosus, while less common than condylomata, is an important chronic inflammatory condition associated with approximately 60% of vulvar squamous cell carcinomas in older women 1
• Differentiated VIN (dVIN) associated with lichen sclerosus has higher malignant potential than usual VIN (uVIN) associated with HPV 3, 4, 5