A 49-year-old woman comes to the office due to vulvar lesions. The patient first noticed 2 small flat lesions several months ago that have since increased in size and number. Currently, there are 10-15 lesions around her vulva. She has no chronic medical conditions. The patient is sexually active and uses a copper-containing intrauterine device. She has been in her current relationship for 6 months and has had 10 lifetime partners.
Vital signs are normal. BMI is 23 kg/m². Genital lesions are similar to the ones seen in the exhibit. The lesions are nonfriable and there is no associated inguinal lymphadenopathy.
Which of the following is the most likely diagnosis in this patient?

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Quizplus · Accepted Answer

11ec193a_97e6_dea2_853d_ef2dd983002e_MD0002_00 This patient has condyloma acuminata, which occurs due to infection from human papillomavirus (HPV) with low oncogenic risk (eg, types 6 and 11). Condyloma acuminata can have a variable appearance; however, it classically consists of nonfriable, nontender, fungating lesions with no associated lymphadenopathy (as seen in this patient). These lesions can continue to proliferate in size and number, extending throughout the vulva and perianal region. Condyloma acuminata is usually a clinical diagnosis. However, a biopsy is indicated to rule out malignancy if there are atypical features (eg, ulceration, induration) or if lesions do not improve with treatment. Patients with condyloma acuminata also require examination of the urethra, cervix, and anal canal due to the risk of coinfection with high-oncogenic-risk HPV (eg, types 16 and 18). In addition, large internal lesions can result in bowel or bladder obstruction. Treatment is typically with topical therapy (eg, trichloroacetic acid, podophyllotoxin); surgery is reserved for patients who fail conservative management or have extensive disease. (Choice B) Condyloma lata is a manifestation of secondary syphilis characterized by flat pink or gray velvety papules that typically appear on mucosal surfaces (eg, labia minora). (Choice C) Lichen planus is a chronic inflammatory condition that typically presents with vulvovaginal pain and dyspareunia. Lesions appear erythematous and often have ulcerative areas. (Choice D) Melanoma is an uncommon cause of vulvar cancer. Lesions are typically singular, rather than multiple, and may have associated ulceration, pain, and lymph node involvement. Melanoma (Choice E) Seborrheic keratosis can present as wart-like lesions on nonmucosal surfaces (eg, labia majora, vulva); however, they typically have a velvety or oily surface with a "stuck-on" appearance. Seborrheic keratosis Educational objective: Condyloma acuminata are due to low-oncogenic-risk human papillomavirus infection. Lesions appear as multiple nonfriable, fungating lesions over the vulva and perianal region. Diagnosis is made clinically and treatment is typically with topical agents. __________ References: Genital warts. (http://www.ncbi.nlm.nih.gov/pubmed/25155525) Vulvar intraepithelial neoplasia (VIN) and condylomata. (http://www.ncbi.nlm.nih.gov/pubmed/26133495)

A 49-Year-Old Woman Comes to the Office Due to Vulvar