Leukoplakia vulva: what is it, how to treat the disease?

Leukoplakia vulva is currently the number one problem, as this is a frequent condition in women, and can be a precancerous condition. This problem should be diagnosed at the initial stages, in which case the forecast is more favorable. Therefore, every woman should know the symptoms and manifestations.

[1], [2], [3], [4]

Epidemiology

Statistics of the spread of leukoplakia among women indicate that the percentage of affected cases is estimated at 1-3%. Leukoplakia is more common with age, usually does not occur until age 30. Lethality from the pathology itself is not determined, but the degree of malignancy depends on the form and can reach 56%.

[5], [6], [7], [8]

Causes of the leukoplakia and vulva

There are many known conditions that have a white lesion of the vulvar mucosa, but most of these spots do not have a known cause. They are called leukoplakia, when other probable possibilities are excluded. There are also several recognized subtypes of leukoplakia, described in accordance with the clinical appearance of lesions.

Almost all such spots are usually the result of keratosis. The normal mucosa of the vulva is red-pink due to the main vascular network in the lamina layer, manifested through a thin layer of epithelium. Almost all white spots are benign, that is non-malignant, but leukoplakia has a high potential for transformation into a malignant form, which must be taken into account.

Over the past few years, interest in the disease of the vulva has increased significantly. Vulva is part of the female genital tract. Embryologically, this is the result of the connection of the cloacal endoderm, urogenital ectoderm, and parameconephric mesodermal layers. Various epithelia, from the keratinized flat epithelium to the flat mucous membrane, cover the vulva. The epithelium of the vestibule is neither pigmented nor keratinized, but contains eccrine glands. This is important for understanding the development of the pathogenesis of leukoplakia.

Benign vulval disorders are a serious problem for women of all ages. These disorders include vulvar atrophy, benign tumors, hamartomas and cysts, infectious disorders and neoplastic epithelial disorders. Infectious disorders include diseases caused by known transmissible agents, such as viruses, bacteria, fungi and protozoa. First, they can be seen by doctors of different specialties, including dermatologists and gynecologists, and often require a multidisciplinary approach. All these pathologies can be concomitant, and can become a trigger mechanism for the development of leukoplakia.

Violations of the development of the vulva are usually rare. Atrophy of the vulva can be associated with advanced age or other disorders, but these anomalies often represent an almost physiological finding in the elderly. Leukoplakia can often develop against a background of atrophy.

The causes of leukoplakia are not exactly clear. But the following factors are possible:

1. Systemic factors such as: diabetes, endocrine disorders, malnutrition, vitamin deficiency, dysfunction of the pituitary-ovarian system. A major role in the development of leukoplakia is played by viral infection, Candida albicans, HPV infection is observed in 22% of patients. The mutation of the p53 gene is one of the causes leading to abnormal cell proliferation.
2. Local factors, such as: excessive heat stimulation, rubbing, age-related atrophy, mucosal damage or ulcers. 

[9], [10], [11]

Risk factors

Risk factors for the development of pathology include women over 30 years of age. Leukoplakia is considered a precancerous condition, as pathological foci can be malignant.

[12], [13], [14]

Pathogenesis

The pathogenesis of leukoplakia is the excessive growth of pathological cells. This proliferative lesion of the mucosa or epidermal epithelium. The normal epithelium of the vulvar mucosa does not contain the stratum corneum and the granular layer. In leukoplakia, the epithelium of the mucosa becomes significantly keratinized. In leukoplakia, the epithelium of the mucosa becomes keratinized within the thickness of the granular layer in the place where normal keratin should not be present. First, due to the action of the pathological factor on the vulvar mucosa, epithelial hyperplasia of the mucosa occurs to repair the damaged layer (which is why leukoplakia often occurs against the background of erosions or cracks). After this occurs, the acanthosis thickening of the epithelium and the infiltration of dermal lymphocytes and plasma cells. This leads to a thickening of the granular layer and substantial hyperkeratosis with the subsequent appearance of irregularly shaped cells and mitotic figures, which may become a motivation for a further neoplastic process. 

Many people are interested in whether the vulvar leukoplakia is contagious? Since this is a non-infectious disease, it is not betrayed to men and is not contagious. The only thing, if a woman has concomitant bacterial, fungal or viral sexual infections, only they can be transmitted.

[15], [16], [17]

Symptoms of the leukoplakia and vulva

Leukoplakia of the vulva is relatively unusual and can be manifested by nonspecific clinical signs.

The first signs of the disease are the appearance on the mucous formations in the form of white-pink or gray-white spots, which have clear contours. The dimensions are often different and the distribution is different. Usually the appearance of these pathological formations does not give the woman any sensations. Therefore, the first signs of the progression of the disease can be seen only when examined by a doctor for a completely different reason.

Symptoms, however, may be in some women, and this can be considered a happy case, since there is a high chance of early detection.

Early symptoms can be manifested by genital itching, the appearance of secretions of unusual character or in greater quantity. Sometimes there may be a burning sensation or a feeling of heaviness, vulvodynia.

Late symptoms are a local burning sensation with a significant spread of the leukoplakia, tingling and itching, a local skin mucosa with varying degrees of pigment loss, often with swelling, cracked and scattered superficial ulcers. Visually, the woman can not see the manifestations of the disease, she can only be suspected because of the appearance of any symptoms.

When viewed visually, one can see a symptom of white thickened infiltrative epithelium with transparent borders, and small fragments of erosions and ulcers are possible. Skin lesions occur in the mucous membrane of the vagina, the mucous membrane of the urethra, the clitoris, inside and outside the labia in the form of one or more irregular white and milky-white spots or plaques slightly elevated above the entire mucous surface. Some of them may not bulge, but the surface of the keratosis is rough and, touching this spot, for example, when scraping the surface of the mucous membrane, the base easily bleeds. A site of leukoplakia, usually due to scratching or rubbing, can bleed, there may be erosion or lichenification.

Leukoplakia of the vulvar neck is more difficult to diagnose, because a visually small spot may not be noticeable. But this arrangement has a higher risk of malignancy. Symptomatically, cervical leukoplakia can often bleed, can cause more symptoms of discomfort than elsewhere.

Kraurosis, like vulvar leukoplakia, is considered one of the potentially carcinogenic conditions. Kraurosis develops in older women and is accompanied not only by thickening and hyperkeratosis of the epithelium, but also areas of sclerosis that do not lend themselves to conservative treatment. In essence, these are two different diseases that have histological differences, but leukoplakia can potentially also be sclerosed.

Leukoplakia vulva in a child is rare, mainly in young girls prepubertal age. Basically this kind includes the skin of the vulva (the area surrounding the vaginal opening), but sometimes it can also include the anus. In children, leukoplakia is dangerous and characterized by the presence of symptoms for months or years before the condition is diagnosed.

The most common symptoms that occur in girls with leukoplakia are itching and soreness. These symptoms can range from mild to severe. Girls can react or express their discomfort in different ways. For example, some girls may simply complain that their "intimate area" hurts or itchs, while others can react by holding the genital area or rubbing and scratching it. The degree of discomfort may not be proportional to the amount of disease present. The most important thing is that the girl does not hesitate to say about the symptoms.

Leukoplakia in children can also cause painful urination, and even constipation. Painful urination occurs when urine passes through the skin of the vulva, which can be irritated and inflamed. Constipation arises from holding the stool out because of painful cracks in the skin near the anus.

Stages

The stages of leukoplakia are clinically difficult to track, and one can only assume that the types of leukoplakia are consecutive stages of one process. Distinguish between flat and hyperkeratical leukoplakia. Flat vulva leukoplakia is characterized by the formation of areas of whitish color that do not protrude above the skin. They can be barely noticeable and are often asymptomatic. The warty leukoplakia of the vulva is the formation of dense patches that rise above the surrounding mucosa, can be of different sizes. Because of this, such areas can be traumatized and are often accompanied by the appearance of bleeding or other symptoms.

[18]

Complications and consequences

The consequences that can be all women are very different. The most common is a complication, such as sclerosing. The sclerosis virus is a common complication of the vulvar leukoplakia and perianal part. There is atrophy of the mucosa in the place of leukoplakia, and the mucosa gradually becomes thinner, which is mainly associated with long-term leukoplakia of the vulva caused by the body's own immune dysfunction.

Some cases of leukoplakia of the vulva can be complicated by diabetes and the impact of these factors is mutual. Leukoplakia vulva gradually increases the condition, which can lead to endocrine disorders, induced diabetes and an increase in the degree of vulva damage.

Irregular menstruation can be a consequence of leukoplakia, as with endocrine disorders, clinically diagnosed, and with the need for treatment.

[19]

Diagnostics of the leukoplakia and vulva

The main diagnosis is based on histopathological examination and clinical manifestations. If there are epithelial or epidermal changes in the mucosa, it is easier to diagnose the problem. Nevertheless, the diagnosis of leukoplakia is often diagnosed at later stages.

Diagnosis of leukoplakia is also based on the results of a gynecological examination, the presence of complaints in patients. Analyzes that are used in this pathology are a clinical blood test, an immunogram, a cytological examination of smears from the affected area.

Instrumental diagnosis of leukoplakia includes colposcopy (taking smears from pathological foci for further examination with a microscope), biopsy, ultrasound, Schiller test.

When the doctor found a white spot on the mucosa, he can only assume that this is the area of leukoplakia. Biopsy and histological examination are necessary for confirmation. Microscopic examination of keratinocytes taken from the vulvar area, purified from the mucosa is used as a diagnosticum. Usually tissue biopsy is performed to exclude other causes of white spots, as well as to allow for a detailed histological examination and to assess the presence of any epithelial dysplasia. This is a measure of malignant potential and usually determines the interval of management and return. Areas of leukoplakia lesions, which are predominantly biopsy, are areas that show condensation (hardening) and erythroplasia (reddening), as well as erosive or ulcerated areas. These areas are more likely to exhibit dysplasia than homogeneous white areas.

After a microscope, a histological examination is mandatory to exclude atypical cells (cancer). Leukoplakia has a wide range of possible histological manifestations. The degree of hyperkeratosis, the thickness of the epithelium (acanthosis / atrophy), dysplasia and inflammatory cell infiltration, underlying the lamina propria, can vary. In the mucous membranes, hyperkeratosis can be defined as an increase in the thickness of the keratin layer of the epithelium or the presence of such a layer in a place where it is usually not expected. In leukoplakia, hyperkeratosis varies in thickness and can be either ortho- or para-keratosis (depending on whether the cell nuclei are lost or stored) or a mixture of both in different areas of the lesion. The epithelium may manifest hypertrophy (for example, acanthosis) or atrophy. Red regions in leukoplakia are atrophic or immature epithelium, which has lost its ability to keratinize. The transition between the lesion and the normal surrounding mucosa can be well demarcated or poorly defined. Hyperkeratosis and altered epithelial thickness may be the only histological signs of leukoplakia, but some manifest dysplasia. The word "dysplasia" usually means "abnormal growth", and specifically in the context of vulvar lesions refers to microscopic changes ("cellular atypia") in the mucosa that indicate the risk of malignant transformation. In the presence of dysplasia, inflammatory cell infiltration is usually observed in lamina samples. Severe dysplasia is synonymous with carcinoma in situ, which indicates the presence of neoplastic cells that have not yet penetrated the main membrane and have not invaded other tissues. That is why it is so important to carry out not only a histological examination of leukoplakia, but also to determine the diagnosis in time, because sometimes it can be an initial stage of cancer.

[20]

Differential diagnosis

Differential diagnosis of leukoplakia can be considered in accordance with the appearance of similar spots on the vulvar mucosa, which, according to the picture, may resemble leukoplakia.

Leukoplakia can not be erased from the mucosa, which distinguishes it from white spots, such as pseudosemited candidiasis, where the white layer can be removed to reveal an erythematous, sometimes bleeding surface. White color, associated with leukemia, disappears when the mucosa extends. Other causes of white spots usually require a pathological examination of a biopsy specimen to distinguish it from leukoplakia.

Atrophic areas of the vulva may outwardly resemble leukoplakia. Conventional mucous leukoplakia is hypertrophic dystrophy of the vulva, usually not accompanied by vulvar atrophy, histopathology of thickening of the epidermis layer, cell heterogeneity and atrophy of solidification. In contrast, atrophic dystrophy of the vulva looks like a lesion of the skin in the form of atrophic blue and white flat spots that have complete degeneration of the cutaneous collagen fibers, the bottom of the inflammatory cell infiltration that can be identified.

Also, leukoplakia must be differentiated with vulvar dermatitis. Vulvar dermatitis are white spots distributed on both sides of the labia, itching, often accompanied by damage to other parts of the skin, skin pigmentation damage, histopathological changes in chronic dermatitis, thickening of the skin layers.

Treatment of the leukoplakia and vulva

In a systematic review, it was found that no treatment methods commonly used for leukoplakia were effective in preventing malignant transformations. Some methods of treatment can lead to healing of leukoplakia, but do not prevent relapse of lesions or malignant changes. Regardless of the treatment used, the diagnosis of leukoplakia almost always leads to the recommendation that possible causative factors should be eliminated, and also assumes long-term clinical examination of the lesion to detect any malignant changes early. However, drugs are used in each case individually.

Many different topical and systemic drugs have been studied, including anti-inflammatory drugs, antifungal agents, carotenoids (precursors for vitamin A, for example beta-carotene), retinoids (preparations similar to vitamins A), and cytotoxic drugs. Vitamins C and E have also been studied for the treatment of leukoplakia. Some of these studies are conducted on the basis of the hypothesis that antioxidant nutrients, vitamins and cell growth suppressor proteins (for example, p53) are antagonists to oncogenesis. High doses of retinoids can cause toxic effects.

Local treatment is one of the priority, and includes also some recommendations for care.

1. Keep the vulva clean and dry, avoid excessive cleansing with soap and so on. Itching can be significantly reduced when using local corticosteroids, such as hydrocortisone ointment, hydrocortisone oil cream. For topical use, a suppository with hydrocortisone is recommended. Method of intravaginal application, dosage - one suppository at night in the vagina, no more than seven days. Side effects can be in the idea of developing candidiasis, since the suppository slightly inhibits local immunity.
2. Terzhinan with leukoplakia vulva is used when a woman has a concomitant bacterial or fungal infection, or candidiasis, which could cause this problem. This is a complex drug, which includes antibacterial agent (ternidazole and neomycin), antifungal (nystatin) and hormonal (prednisolone). Method of intravaginal application in the form of suppositories, dosage - one candle once a night for six consecutive days. Side effects are not frequent, there may be a burning sensation after the administration of the drug, itching. 
3. Ointments and creams from leukoplakia of the vulva are used as a local therapy. Cream of Iranian saffron - this is one of the effective, according to users' reviews, funds. The composition of the drug includes several types of Chinese herbs without the addition of hormonal drugs and synthetic drugs. The drug consists of a set of gel and cream. Method of application - first you need to gel wash, then dry with a towel and apply the cream. Side effects are not determined.
4. Ointment 999 is a complex preparation that contains camphor, menthol, biologically active herbs, as well as antimicrobial hormone hexamethasone. The drug has an anti-inflammatory and antibacterial effect. The way of application of the preparation - in the form of a cream it is necessary to apply to the site of leukoplakia. Dosage - a small amount once a day. There may be complications with the use of the drug due to the inconvenience of self-use. Precautions - if there are areas with erosion or damage, then use the ointment is not recommended.

Fenistil with leukoplakia of the vulva is not particularly effective for treatment, but as an antihistamine, it can relieve or reduce itching.

Vitamins are used in complex therapy, since leukoplakia is considered one of the pathologies of hypovitaminosis. You can give preference to any multivitamin complexes - Kvadevit, Supervit, Vitrum. 

Physiotherapy treatment is not widely used, as external additional stimulation or stimulation can cause complications.

Alternative treatment

Alternative therapies have no proven efficacy, nor has it been proven that such methods may not trigger the onset of malignancy. Therefore, it is better to use such methods only after consulting with the doctor.

1. To prepare the medicine you need to take 30 g Sophora, Nepeti 12 g, 6 g red peony, safflower 6 grams, 20 g astragalus. All you need to soak hot water and make a bath. Take such baths can be 2 times a day, each dose of steamed grass can be used 2-4 times.
2. You can make an ointment at home. To do this, 20% ointment of fish oil 20 g, 10 g of dexamethasone, 5-fluorouracil, and with hydrocortisone ointment can be added. After mixing, apply on a cotton swab and make such a suppository once a night for seven days.
3. For the next infusion, you need a deer of grass 30 grams, 30 grams of alcohol spleen, cicada 15 grams. Mix everything and make a bath, filtering the contents. Take such a hot bath twice a day to treat leukoplakia of the vulva.

Hirudotherapy with leukoplakia of the vulva is widely discussed as one of the methods of non-traditional treatment of the disease. The effect of this procedure is not clear, but some women notice a decrease in symptoms after several procedures. For such treatment, you need a special center in which to deal with pathology and use proven techniques with ecological types of leeches.

Homeopathy can be used, but also it is not necessary to attach great importance to this kind of therapy, since complications can be missed. It is not recommended to use homeopathic methods on its own.

Surgical treatment of leukoplakia is the first choice of treatment for many clinicians. However, the effectiveness of this method of treatment can not be assessed because of insufficient available evidence. This can be done by traditional surgical removal using a scalpel or by laser or cryotherapy. Often, if the biopsy demonstrates moderate or severe dysplasia, then the decision to use the surgical technique is more readily accepted. Sometimes white spots are too large to completely disappear, and instead they are carefully monitored. Even if the lesion is completely removed, regular examinations are mandatory, since leukoplakia can recur, especially if predisposing factors such as infection do not stop.

Treatment of leukoplakia of the vulva with a laser is considered the least invasive method. It is used if the focus is small. When women do not want to take risks and think that it is possible to turn leukoplakia into a malignant character, then laser treatment can be an option.

Extirpation of the vulva with the disease of leukoplakia is not carried out. Such a radical treatment can be chosen when there are serious complications with the development of cancer.

Nutrition and diet with leukoplakia of the vulva is of great importance. The diet of a woman should be as full of vitamins, minerals, fiber. Normal work of the immune system is not possible without sufficient protein, and therefore the food should be full without harmful fats. Women with this diet have less risk of developing leukoplakia, and if they already have it, the risk of complications is also less.

[21], [22]

Prevention

Prevention of this pathology comes from the correct mode of a woman, a regime not only nutrition, but also sex life and hormonal background. It is always necessary to undergo preventive examinations on time to exclude risk factors for leukoplakia.

Vaccination from the vulvar leukoplakia as a disease is not developed. But there is an inoculation against the papilloma virus, which can cause cancer in women, especially if there is leukoplakia. To make such an inoculation the woman should before the beginning of sexual activity.

Clinical observation of leukoplakia of the vulva is carried out necessarily until the moment when it is not cured or will undergo surgical intervention. Even after surgical treatment, a woman is actively observed for a year about this pathology.

[23], [24], [25]

Forecast

The prognosis of leukoplakia depends on many factors - age, hormonal background, infections, type of pathology. For example, mixed red and white lesions (erythroleukoplakia / spotted leukoplakia) have a higher risk of malignant changes than homogeneous leukoplakia. Elderly women with leukoplakia are also at higher risk. In general, there are spontaneous regressions of spots, there is their disappearance against a background of complex therapy. The most favorable prognosis for recovery is the use of invasive diagnostic methods.

Leukoplakia vulva should not be a common problem for a woman, because this is one of the conditions that must be controlled. And although leukoplakia often proceeds asymptomatically, it is important to undergo preventive examinations at the gynecologist regularly to detect this pathology.

[26], [27]