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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 49-57

Genital lesions in a female child: Approach to the diagnosis


1 Department of Dermatology, St. Theresa Hospital, Bengaluru, Karnataka, India
2 Department of Dermatology, Venereology and Leprosy, ESIC Medical College and PGIMSR, Bengaluru, Karnataka, India

Date of Web Publication10-Jul-2018

Correspondence Address:
Ragunatha Shivanna
Department of Dermatology, Venereology and Leprosy, ESIC Medical College and PGIMSR, Rajajinagar, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_19_18

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  Abstract 

Genital lesions in a female child cause a lot of apprehension in the parents. Hence, thorough knowledge and proper approach to the diagnosis is very important. The aim of this article is to present an overview of the pattern of diseases affecting genitalia in a female child, significance of these diseases, and an approach to the diagnosis of these diseases. Most of these vulval dermatoses present with one of the four clinical scenarios such as pruritus with/without lesions, pain with/without lesions, discharge with/without lesions, and asymptomatic lesions. The approach to the diagnosis has been discussed accordingly. Diseases such as genital warts and genital herpes which are not common in this age group always raise the suspicion of child sexual abuse. There are certain adult vulval dermatoses such as chronic vulvovaginal candidiasis, which are not seen in prepubertal group.

Keywords: Child sexual abuse, female child, genital lesions, vulvovaginitis


How to cite this article:
Anitha B, Shivanna R. Genital lesions in a female child: Approach to the diagnosis. Clin Dermatol Rev 2018;2:49-57

How to cite this URL:
Anitha B, Shivanna R. Genital lesions in a female child: Approach to the diagnosis. Clin Dermatol Rev [serial online] 2018 [cited 2018 Sep 21];2:49-57. Available from: http://www.cdriadvlkn.org/text.asp?2018/2/2/49/236336


  Introduction Top


Any genital lesion in a female child causes a lot of apprehension in the parents because the genital region is considered to be a very sensitive/private area and lesions in this region invariably arouse the suspicion of child sexual abuse. Hence, a thorough knowledge and proper approach to the diagnosis is very important in the management of genital dermatoses in a female child. This helps to alleviate the anxiousness of parents too. Genital complaints are less frequent in children as compared to adults. However, genital dermatoses in children are almost similar to that of adults, although there are also important differences.

The aim of this article is to present an overview of the pattern of diseases affecting genitalia in a female child, significance of these diseases, and an approach to the diagnosis of these diseases. Almost any disease can affect the vulva, but common dermatoses predominantly involving vulva and/or perianal area will be discussed in this article. Vulva can be involved as a part of generalized disease and certain dermatoses are unique or specific to vulva.

Predisposing factors

Children, especially female children, are predisposed to certain vulval diseases due to the following factors:[1]

  • Anatomy of female genitalia: Due to low estrogen levels in prepubertal girls, the genital tissues become atrophic. The labia majora appears as a thin rim of normal skin encircling the vaginal opening, forming a less protective covering of vaginal opening. The labia minora are thin, almost absent. Vaginal opening lies in proximity to the anus.
  • Diseases can be transmitted to the children from their caretakers
  • Children are vulnerable to sexual abuse
  • Genital hygiene practices such as use of nappies, cleansing methods, and use of skin care products can be the cause for certain dermatoses such as contact dermatitis
  • Delay in seeking consultation of appropriate specialist can lead to severe form of disease.


Genital examination of a female child

Good clinical examination is an important prerequisite to arrive at the correct diagnosis of any disease. Adequate genital examination takes time, patience, and a gentle manner. Proper positioning is also important. A very young child may be examined on the mother's lap. Younger children are best examined in a frog-like position. Older children can be examined in lithotomy position or knee–chest position. A good rapport should be established with the child before starting the examination. Adequate exposure of the genitalia is essential which can be achieved by gently spreading labia majora laterally and dorsally with some pressure against the perineum.[2]

Classification of vulval dermatoses

A wide variety of skin diseases affect genital region in a female child. These diseases can be classified based on etiological factors [Table 1]. However, these vulval dermatoses present with one of the following clinical scenarios:
Table 1: Classification of vulval dermatoses

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  1. Pruritus with/without lesions
  2. Pain with/without lesions
  3. Discharge with/without lesions
  4. Asymptomatic lesions.



  Clinical Scenario 1: Pruritus With/without Skin Lesions Top


Pruritus without skin lesions

Pruritus without skin lesions is a challenging situation for both doctor and the parents. The various causes for this condition are as follows.

Irritant reaction

Prolonged contact with irritants such as detergents, chemicals, clothes, or discharge can initially present with only symptoms such as pruritus without any dermatitis. Proper history taking gives clue to the diagnosis. It is very important to identify the irritants and avoid them.

Pinworm infestation

Children with pinworm infestation develop itching in the perineal region which is worse at bedtime when the worms crawl upon the skin surface to lay eggs. Pruritus may be associated with thin watery vaginal discharge. Stool examination with evidence of pinworms confirms the diagnosis.

Foreign body

Children generally insert small objects into the ears and nose. Likewise, they can insert them into vagina as well. Foreign body in the vagina can lead to itching or pain or vaginal discharge. Careful examination of the vagina in appropriate position will reveal the foreign body. Common objects that are inserted are beads, crayons, ball of paper, and seeds.

Pruritus with skin lesions

Pruritus may be associated with lesions such as erythema, leukoderma, blisters, and erosions or papules and nodules [Flow Chart 1].



Pruritus with erythema

The following vulval conditions manifest as erythema associated with pruritus:

  • Contact dermatitis: It is a very common vulval problem seen in children, especially atopic. Prolonged contact with irritants such as feces or prolonged contact with wet clothes, poor hygiene habits such as wiping the perineal area from back to front, and excess use of soaps and detergents cause irritant contact dermatitis. Allergic contact dermatitis is unusual in children because they are exposed to less potential allergens. The clinical presentation of contact dermatitis is ill-demarcated erythema associated with pruritus predominantly involving convexities [Figure 1]. In chronic cases, labia majora becomes scaly and rugose due to lichenification [Figure 2]. The rash often involves thighs, buttocks, and lower abdominal folds
  • Psoriasis: Vulval psoriasis is more common in children than in adults. The onset may be at any age from infancy onward. Vulva could be the site of onset in infantile psoriasis occurring as diaper psoriasis [Figure 3]. It presents as itchy well-demarcated symmetrical plaques with glazed shiny surface involving the vulva, perineum, and often natal cleft but sparing vagina. It can also present as well-demarcated symmetrical scaly plaques, but the plaques are smaller and scales are finer and thinner [Figure 4]. Family history will be usually present and the disease runs a mild course compared to adults
  • Zinc deficiency: Zinc deficiency can occur either at birth or later in infancy during weaning or due to low zinc content in mother's breastmilk as acrodermatitis enteropathica. Lesions appear as symmetrical, erythematous, and eczematous plaques with erosions and very well-demarcated margins. Perioral lesions may also be present
  • Fungal infections: Tinea, though uncommon in vulval region, can occur as well-defined, asymmetrical, annular, erythematous plaques with central clearing [Figure 5]a and [Figure 5]b. Candidiasis can occur in infants where it usually complicates diaper dermatitis with characteristic satellite pustules. Chronic candidiasis does not occur in prepubertal children because of low estrogen levels in these children. Candidiasis is an estrogen-dependent condition. Estrogen acts on both fungus and the reproductive tract epithelium of the host to enhance fungal adhesion, hyphal growth, and colonization. Estrogen also has immunosuppressive effect. Hence, vaginal candidiasis easily occurs in the presence of estrogen.[1]
Figure 1: Contact dermatitis: Erythema and scaling involving convexities

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Figure 2: Rugose and thickened labia majora due to chronic contact dermatitis

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Figure 3: Glazed erythematous scaly patch involving vulva and crural region along with postinflammatory hypopigmentation seen in diaper psoriasis

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Figure 4: Well-demarcated scaly plaques involving vulva and adjacent region seen in psoriasis

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Figure 5: (a) Erythematous annular papules with central clearing on mons pubis, (b) similar lesion on buttock in the same patient

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Pruritus with pigmentary lesions

Lichen sclerosus in children is uncommon; however, it is an important differential diagnosis in any prepubertal girl presenting with chronic vulval symptoms. The most common presenting symptoms are itching and soreness. Other symptoms are bleeding, dysuria, and constipation. The typical clinical appearance is well-demarcated white, wrinkled plaque with scattered telangiectasia [Figure 6]. When it extends to involve anus, classical figure-of-eight appearance is seen. In neglected long-standing case, there can be total loss of labia minora and resorption of the clitoris. Lichen sclerosus usually resolves at puberty but may recur in adulthood with the risk of squamous cell carcinoma. Diagnosis can be confirmed by biopsy. In children, noninvasive procedure such as dermatoscopy is preferred. Dermatoscopic features of lichen sclerosus are structure-less areas, telangiectasia, and comedo-like openings.
Figure 6: Atrophic depigmented patch involving vulva and perineal region seen in lichen sclerosus

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Pruritus with blisters and erosions

Bullous pemphigoid and chronic bullous disease of childhood can occur on vulva rarely, but vulva could be the site of onset. Bullous pemphigoid presents with tense bullae, and chronic bullous disease of childhood has an eczematous appearance and string of pearl distribution of blisters.

Pruritus with papules and nodules

Scabetic nodules are often seen on the vulva and groin, but usually it is part of a generalized eruption. Positive family history makes the diagnosis easy. Papular urticaria could be another possibility for papules on the vulva.


  Clinical Scenario 2: Pain With/without Skin Lesions Top


Pain with skin lesions

Pain in genital area may be associated with skin lesions such as blisters and erosions, ulcers, pustules, and pigmentary changes such as erythema and leukoderma [Flow Chart 2].



Blisters and erosions

Bacterial infections, herpes genitalis, Steven–Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) are some of the conditions which present with blisters and erosions in the vulval and perineal regions. Bacterial infections include bullous impetigo and Staphylococcal scalded skin syndrome. Herpes genitalis is very uncommon in children. It presents with painful grouped vesicles and lymphadenopathy. A primary attack of herpes genitalis in a prepubertal child should raise the suspicion of sexual abuse. More serious conditions such as SJS and TEN involve vulva along with other body sites and mucous membranes.

Ulcers

Aphthous ulcers, herpes genitalis, and Jacquet's dermatitis present with painful ulcers in vulval region.

  • Aphthous ulcers: Aphthous ulceration is less common in children. In older prepubertal girls, Lipschutz's ulcer, a form of major aphthous ulceration, can occur. These large, very painful ulcers are of sudden onset and may be preceded by fever. They heal with scarring. Aphthous ulcers are generally small, shallow, and round. Behcet's disease can also be a cause of vulval ulceration, though very rare. It presents with larger, deeper, and irregular ulcers, which are very painful
  • Herpes genitalis: Herpes genitalis in severe form can also present with grouped ulcers which are usually recurrent
  • Jacquet's dermatitis: Jacquet's erosive dermatitis is an uncommon, severe diaper dermatitis that can occur as a result of the combined influence of warmth, urine, moisture, friction, feces, and secondary infection.[3] A history of chronic dermatitis will usually be present. It is characterized by well-demarcated, punched-out ulcers or erosions with elevated borders [Figure 7]. It is typically associated with frequent liquid stools, poor hygiene, infrequent diaper changes, or occlusive plastic diapers. It is more common in children with chronic diarrhea or incontinence such as those with spina bifida or Hirschsprung's disease.
Figure 7: Well-demarcated punched-out ulcers and erosions in perianal region seen in Jacquet's dermatitis

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Pustules

Staphylococcal folliculitis and secondary pyoderma should be considered in case of painful pustules [Figure 8]. Staphylococcal folliculitis is common on the buttocks in children. Occasionally, it may spread to involve the vulva or may occur there primarily. Secondary bacterial infection can superimpose on the preexisting dermatoses and present with painful pustules.
Figure 8: Follicular pustule and erosion with crusting seen in folliculitis and impetigo, respectively

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Erythema and edema

Streptococcal vulvovaginitis is an important cause of painful erythematous and edematous vulva [Figure 9]. This condition is seen only in prepubertal children. The etiological agent is Group A β-hemolytic Streptococcus. It presents acutely with sudden onset of an erythematous, swollen, painful vulva, with a thin mucoid discharge, but may also occur as subacute vulvitis.[4] A perianal eruption with dermatitis may precede vulvitis. It may precede or supervene upon vulval psoriasis.
Figure 9: Erythema and edema of vulva with erythematous nodule on adjacent thigh, suggestive of streptococcal vulvovaginitis

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Fixed drug eruption (FDE) and angioedema are other causes for erythema and edema associated with pain in the vulval region. FDE presents with a sudden onset of well-demarcated erosive vulvitis which may spread to the groin and buttocks.[5]

Leukoderma

Lichen sclerosus should be considered when a well-demarcated white wrinkled plaque associated with soreness is seen in the vulval region.

Pain without skin lesions

Foreign body insertion should be suspected when there is vulval pain without any external skin lesions. A careful examination of the vulva clinches the diagnosis.


  Clinical Scenario 3: Discharge With/without Skin Lesions [Flow Chart 3] Top



Discharge with skin lesions

Streptococcal vulvovaginitis manifests with a sudden onset of painful erythematous swollen vulva with thin mucoid discharge. Herpes simplex infection can cause a thin, watery vaginal discharge with painful vulvar eruptions.

Discharge without skin lesions

Discharge from the vagina with normal-appearing vulva could be due to foreign body insertion or infections and infestations or due to physiological causes.

Foreign body

Long-standing presence of foreign body in the vulva can lead to bleeding due to trauma or brownish foul-smelling discharge due to secondary infection.

Infections and infestations

  • Bacterial: Respiratory pathogens such as Haemophilus influenza, Group A and B β hemolytic Streptococci, and Streptococcus pneumonia can cause yellowish-to-greenish purulent vaginal discharge. Fecal contamination of the vagina due to wiping the perineum from anus to vagina can lead to vaginal infection. Shigella flexneri causes a mucopurulent, sometimes bloody vaginal discharge.  Escherichia More Details coli infection causes a thin, watery, foul-smelling discharge
  • Protozoal: Enterobius vermicularis (pinworm) causes severe pruritus with thin colorless discharge
  • Fungal: Candidal infections are rare in nonestrogenized prepubertal girls, but it may rarely occur following treatment with a course of antibiotics or in immunocompromised situation. It is characterized by well-demarcated erythematous rash with thick curdy white vaginal discharge, which is often described as resembling cottage cheese.


Physiological

Physiological vaginal discharge may be present during postnatal and prepubertal periods.

  • Postnatal: During the early neonatal period, maternal estrogens cause estrogenization of the genital tract. As a result of which mucoid vaginal discharge, often bloody, is not an uncommon finding during the first 14 days of life.
  • Pubertal: A rise in the estrogen levels at the onset of puberty results in production of a physiologic leucorrhea which is characteristically milky white or clear mucoid discharge.



  Clinical Scenario 4: Asymptomatic Skin Lesions Top


Various genital lesions occur as asymptomatic pigmentary patch or discrete papules or verrucous growths. Few of these conditions are discussed below [Flow Chart 4].



Vitiligo

Genital vitiligo is characterized by asymptomatic chalky white macules and patches with fairly distinct scalloped margins without any epidermal changes unlike lichen sclerosus where epidermal atrophy is seen. Diagnosis can be confirmed by noninvasive diagnostic technique, dermatoscopy rather than biopsy, which is more convenient in children. A characteristic dermatoscopic feature of vitiligo lesion is absent or reduced pigmentary network.

Postinflammatory hyperpigmentation

A preexisting skin lesion can resolve leaving behind brown hyperpigmented asymptomatic patch which can be confirmed by taking proper history [Figure 10].
Figure 10: Brown-colored patches at the site of preexisting dermatoses

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Nevi

Pigmented nevi may occur on the vulva either as congenital lesions or as late-onset nevi. Congenital nevi are usually larger and more complex than those of late onset. Pigmented nevi of the vulva usually raise anxiety regarding the possibility of melanoma.

Epidermal nevi are uncommonly found on the vulva. They may be localized or part of larger systematized nevus. With age, they may become increasingly hyperkeratotic. They may be easily confused with genital warts.

Hemangiomas

Capillary hemangiomas of the vulva appear similar to the lesions elsewhere on the skin. They can be superficial, deep, or mixed. Size can range from small and insignificant to large, causing major deformation of the vulva. Ulceration is very common on this site. Large vulval hemangiomas may involve bladder, rectum, and vagina, and may be associated with lower spinal cord abnormalities [Figure 11].
Figure 11: Well-demarcated red plaque with nodular surface on labia majora seen in hemangioma

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Molluscum contagiosum

Lesions of molluscum contagiosum are quite common on vulva in girls, but usually it is part of a more extensive eruption. They occur as discrete pearly white papules with central umbilication [Figure 12]a and [Figure 12]b.
Figure 12: (a) Pearly papules on vulva seen in molluscum contagiosum, (b) similar lesions on the perianal region

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Genital warts

Genital warts are also uncommon in prepubertal children. These occur as skin-colored filiform or verrucous plaques involving the vulva and perianal area [Figure 13]. They are usually asymptomatic. Genital warts raise the suspicion of sexual abuse. However, they may also be transmitted in a nonsexual way by autoinoculation from warts on the child's hands or hetero inoculation from other family members and fomite transformation.
Figure 13: Skin-colored verrucous papules in the perianal region seen in the warts

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Syringomas

Vulval syringomas are very rare in children but have been described.[6] These occur as yellow- or skin-colored smooth-surfaced papules. They are usually asymptomatic, but genital syringomas may occasionally cause pruritus.

Child sexual abuse

When a child develops vulval lesions, most of the parents will be anxious considering the possibility of sexual abuse. It is a tough situation for the doctor too because the diagnosis of child sexual abuse is a much-disputed issue. Young children who have been sexually abused will usually not have signs of physical injury because abusive behavior does not involve attempts at penetration, and minor genital injury such as bruising resolves rapidly.[7],[8] The role of the dermatologist is usually not to diagnose sexual abuse. A thorough knowledge about the pathological conditions affecting the genitalia helps the dermatologist to reassure the parents that the child's vulval dermatoses is a skin condition and not an indicator that the child has been abused.

Of course, presence of a skin condition does not rule out the possibility of sexual abuse. It should be suspected based on other grounds related to household composition, parental concerns, presence of sexually acquired infections, and behavioral abnormalities in the child.[9] It is very difficult to diagnose sexual abuse in a child even in expert hands. Only disclosure from the child or a relative can prove the sexual abuse. If suspected, referral to an appropriate authority such as child protection unit should be the first step for a dermatologist or any other treating doctor.

Adult vulval dermatoses not seen in children

Although there are many similarities between pediatric and adult groups of patients with vulval disease, there are also important differences. It is therefore important to remember that there are certain adult vulval dermatoses which are not seen in children.[10]

  • Vulvo-vaginal candidiasis: Once a child is no longer wearing diapers, candida is usually not found until after puberty as it is estrogen dependent
  • Infection with sexually transmitted organisms such as Gardnerella vaginalis is usually not found in children until they become sexually active
  • Vulval intraepithelial neoplasia III and squamous cell carcinoma are not seen in children, although they can occur rarely in young adults who have had poorly controlled or untreated lichen sclerosus
  • Hidradenitis suppurativa may not occur before puberty
  • Erosive lichen planus is rare in children
  • Vulvodynia is also rare in children.



  Conclusion Top


Genital lesions in children although rare should be given utmost importance when present. Majority of children with genital lesions can be diagnosed on clinical appearance and history alone without the need for investigation. Complete examination of all parts of the genitalia in an appropriate position is very important. Proper elicitation of history of genital hygiene and skin care practices is essential to identify the irritants or allergens.

A thorough knowledge about pathological conditions affecting the genitalia helps in arriving at an accurate diagnosis and to address the concern of sexual abuse. Sexual abuse is an important issue in vulval disease in children for two reasons: every attempt should be made to deal with it if there is reason to suspect it and conversely, incorrect diagnosis of sexual abuse when there is nothing more than a skin condition present should be avoided.

Most of the genital diseases will be dermatological condition rather than gynecological. Establishment of dedicated vulval clinic in association with obstetrics and gynecology and pediatric departments is an important measure to efficiently manage a female child with genital lesions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Makwela MR. Paediatric vaginal discharge. S Afr Fam Pract 2007;49:30-1.  Back to cited text no. 1
    
2.
Herman-Giddens ME, Frothingham TE. Prepubertal female genitalia: Examination for evidence of sexual abuse. Pediatrics 1987;80:203-8.  Back to cited text no. 2
    
3.
Humphrey S, Bergman JN, Au S. Practical management strategies for diaper dermatitis. Skin Therapy Lett 2006;11:1-6.  Back to cited text no. 3
    
4.
Dar V, Raker K, Adhmi Z, Mckenzie S. Streptococcal vulvovaginitis in girls. Pediatr Dermatol 1993;10:366-7.  Back to cited text no. 4
    
5.
Sehgal VH, Gangwani OP. Genital fixed drug eruptions. Genitourin Med 1986;62:56-8.  Back to cited text no. 5
    
6.
Di Lervia V, Bisighini G. Localised vulvar syringomas. Pediatr Dermatol 1996;13:80-1.  Back to cited text no. 6
    
7.
Tipton A. Child sexual abuse. Physical examination techniques and interpretation of findings. Adolesc Pediatr Gynecol 1989;2:10-25.  Back to cited text no. 7
    
8.
Pride HB. Child abuse and mimickers of child abuse. Adv Dermatol 1999;14:417-55.  Back to cited text no. 8
    
9.
Weinberg R, Sybert VP, Feldman KW, Neville J. Outcome of CPS referral for sexual abuse in children with condylomata acuminata. Adolesc Pediatr Gynecol 1994;7:19-24.  Back to cited text no. 9
    
10.
Powell J. Paediatric vulval disorders. J Obstet Gynaecol 2006;26:596-602.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
 
 
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