What is the differential diagnosis for a female with painful tiny white bumps, not vesicles or pustules, in the genital area, who shaves her genitalia?

Differential Diagnosis for Painful Tiny White Bumps on Female Genitalia in a Patient Who Shaves

The most likely diagnosis is folliculitis, which presents as small, mildly tender papules in the pubic hair region and is particularly common in patients who shave their genitalia. 1

Primary Diagnosis: Folliculitis

Folliculitis should be your first consideration given the clinical presentation of tiny white bumps (not vesicles or pustules) with pain in a patient who shaves. 1

• Folliculitis presents as papules and pustules primarily in the pubic hair region that can be mildly tender 1
• These lesions are usually smaller than other inflammatory conditions like hidradenitis suppurativa 1
• The condition is particularly common with the increased popularity of shaving pubic hair 1
• Patients should be counseled that shaving should be performed carefully with adequate lubrication to minimize trauma 1

Secondary Differential Considerations

Hidradenitis Suppurativa

• Causes larger, tender, draining lesions that represent recurrent infection of apocrine glands 1
• These are distinctly larger than folliculitis lesions and typically drain 1

Normal Anatomical Variants (Fordyce Spots/Vestibular Papillae)

• Genital papillae (Papillae coronae vulvae) present as normal cutaneous papillae with functional significance 2
• These are physiological findings that may be falsely interpreted as pathological 2
• However, these are typically not painful, making them less likely in this case 2

Human Papillomavirus (HPV) Infection

• Genital warts can present as flat or exophytic lesions 1
• HPV types 6 and 11 are the most common causes of visible genital warts 1
• Genital warts can be painful, friable, and/or pruritic depending on size and anatomic location 1
• However, the description of "not vesicles, not pustules" and the shaving history makes folliculitis more likely 1

Infectious Causes (Less Likely Given Description)

• Herpes simplex virus typically presents with vesicles and ulcers, which contradicts the stated presentation 1
• Molluscum contagiosum presents as umbilicated papules, not typically described as "tiny white bumps" 3, 4
• Condylomata lata (secondary syphilis) are flesh-colored papules on mucous membranes but are not associated with shaving 1

Diagnostic Approach

Perform a focused external genital examination looking specifically for:

• Distribution of lesions in relation to hair-bearing areas (folliculitis clusters in pubic hair region) 1
• Size of lesions (folliculitis lesions are smaller than hidradenitis suppurativa) 1
• Presence of drainage or abscess formation (suggests hidradenitis suppurativa rather than simple folliculitis) 1
• Location on the labia minora or vestibule versus hair-bearing areas (helps distinguish from other conditions) 1

Management Recommendations

For folliculitis related to shaving:

• Counsel the patient on proper shaving technique with adequate lubrication to minimize trauma 1
• Consider recommending temporary cessation of shaving to allow resolution 1
• Topical or oral antibiotics may be indicated if there is evidence of secondary bacterial infection 1

Critical Pitfalls to Avoid

• Do not assume all small genital bumps are sexually transmitted infections, especially in the context of recent shaving 1
• Do not biopsy normal anatomical variants like vestibular papillae, which can be mistaken for pathology 2
• Do not overlook the temporal relationship between shaving and symptom onset, which strongly suggests folliculitis 1
• If lesions do not respond to conservative management or worsen, consider biopsy to rule out other diagnoses including premalignant lesions, though this is unlikely given the clinical context 1