Vulval Squamous Intraepithelial Lesions
Previously called vulval intraepithelial neoplasia or VIN
What are vulval squamous intraepithelial lesions?
Low grade squamous intraepithelial lesions (LSIL), high grade squamous intraepithelial lesions (HSIL) and differentiated vulval intraepithelial neoplasia (dVIN) are the names given to the presence of abnormal squamous skin cells on the vulval skin. These areas can occur as one patch or they may affect several areas of the skin at the same time. They are a group of pre-cancerous conditions of the vulva. These lesions are not cancer. LSIL are also known as warts. They do not become cancer and do not need treatment unless they are causing symptoms. HSIL and dVIN may develop into cancer if not treated.
Who gets LSIL, HSIL, dVIN of the vulva?
These lesions can occur in women of all ages. LSIL and HSIL are commonly seen in young women and the dVIN type is typically seen in older women.
What causes LSIL, HSIL and dVIN of the vulva?
The strains of human papilloma virus (HPV) which cause most genital warts are usually related to LSIL of the vulva. The strains of HPV that can cause genital cancers can cause HSIL of the vulva. The low grade and high grade squamous intraepithelial lesions are more common in smokers. They are also more common in women who are immunosuppressed, either from disorders affecting their immune system or from medication used to treat other types of disease. dVIN is often seen in women with other chronic vulval skin conditions such as lichen sclerosus and lichen planus.
What are the symptoms of HSIL and dVIN?
Some women with HSIL experience itching or burning, but many women have no symptoms at all. dVIN usually occurs in women with a long history of itching, soreness and dryness.
What do the HSIL and dVIN lesions look like?
The abnormal area of skin may be noted at a routine examination or may be found by the patient who can feel it or see the abnormal area. They do not have a specific pattern. Sometimes HSIL presents as one patch or there may be several patches. Lesions can be white, grey, brown or red. They can be rough or smooth, flat or raised. They can occur anywhere on the vulva or around the anal area and may be misdiagnosed as genital warts. The changes of dVIN are less specific than HSIL. dVIN is suspected when treatment resistant, poorly demarcated pink or white areas are seen on examination of the vulva. The dVIN lesions are sometimes difficult to distinguish from the associated dermatoses (lichen sclerosus or lichen planus).
How is this condition diagnosed?
Dr Kliman will ask relevant questions relating to your symptoms and will examine the area with a microscope (vulvoscopy). A simple procedure called a skin biopsy will confirm the diagnosis. A small piece of skin from the affected area will be removed under local anaesthetic and then sent off for analysis. The abnormal area may be painted with 5% acetic acid (vinegar) to identify lesions (especially those due to HPV).
What happens to LSIL of the vulva?
Many areas of LSIL will resolve without treatment. There are a variety of treatments for genital warts that can be used including medications on the skin or surgical removal.
What happens to HSIL of the vulva?
The majority of HSIL cases require treatment because some areas may develop into an invasive vulval cancer. If the area is small then it can be removed surgically. If there are multiple lesions or larger affected areas then surgical excision, or treatment with local anticancer creams such as imiquimod or fluorouracil can be used. Dr Kliman will discuss the best treatment for your case with you. It is important to note that these lesions do not affect your fertility.
What happens to dVIN of the vulva?
As dVIN has a high chance of becoming cancerous it is often treated promptly. Excisional treatment is recommended to exclude the presence of cancer. dVIN is especially associated with the skin disorder lichen sclerosus.
What follow-up is required?
Regular follow-up is essential to detect any recurrence. Unfortunately recurrences are common. It is also important that you have regular cervical screening as it is common to have cervical lesions in addition to vulval lesions. In fact 60% of women with HPV related pre-cancer of the vulva or vagina will have pre-cancerous lesions on their cervix.
What can be done to prevent these lesions from occurring?
If you smoke it is advised that you stop smoking as this can decrease the chance of having a recurrence of vulval HSIL. The HPV vaccine has been shown to decrease the chance of developing vulvar LSIL/genital warts and vulval HSIL. The vaccine will not get rid of a HPV strain that you already have but most people do not have all of the strains the vaccine covers and therefore the vaccine is still recommended. Effective treatment of inflammatory skin conditions such as lichen sclerosus and lichen planus may help reduce the risk of developing dVIN.
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