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Review Article

Genital Lesions in a Female Child: Approach to the Diagnosis

Abstract Bhakthavatsalam
Genital lesions in a female child cause a lot of apprehension in the parents. Hence, thorough Anitha, Ragunatha
knowledge and proper approach to the diagnosis is very important. The aim of this article is to Shivanna1
present an overview of the pattern of diseases affecting genitalia in a female child, significance of
Department of Dermatology, St.
these diseases, and an approach to the diagnosis of these diseases. Most of these vulval dermatoses
Theresa Hospital, 1Department
present with one of the four clinical scenarios such as pruritus with/without lesions, pain with/without of Dermatology, Venereology
lesions, discharge with/without lesions, and asymptomatic lesions. The approach to the diagnosis has and Leprosy, ESIC Medical
been discussed accordingly. Diseases such as genital warts and genital herpes which are not common College and PGIMSR,
in this age group always raise the suspicion of child sexual abuse. There are certain adult vulval Bengaluru, Karnataka, India
dermatoses such as chronic vulvovaginal candidiasis, which are not seen in prepubertal group.

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

Introduction • Anatomy of female genitalia: Due to

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]
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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
Address for correspondence:
Good clinical examination is an important Dr. Ragunatha Shivanna,
prerequisite to arrive at the correct Department of Dermatology,
diagnosis of any disease. Adequate genital Venereology and Leprosy,
ESIC Medical College and
examination takes time, patience, and a PGIMSR, Rajajinagar,
gentle manner. Proper positioning is also Bengaluru, Karnataka, India.
important. A very young child may be E‑mail: drragus@yahoo.co.in
examined on the mother’s lap. Younger
children are best examined in a frog‑like
position. Older children can be examined in Access this article online
lithotomy position or knee–chest position. Website: www.cdriadvlkn.org
A good rapport should be established with DOI: 10.4103/CDR.CDR_19_18
the child before starting the examination. Quick Response Code:
Adequate exposure of the genitalia is
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.

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Anitha and Shivanna: Genital lesions in a female child

essential which can be achieved by gently spreading labia Table 1: Classification of vulval dermatoses
majora laterally and dorsally with some pressure against Inflammatory disorders
the perineum.[2] Dermatitis: Contact dermatitis, seborrheic dermatitis
Classification of vulval dermatoses Psoriasis
Lichen sclerosus
A wide variety of skin diseases affect genital region in Vitiligo
a female child. These diseases can be classified based Infections and infestations
on etiological factors [Table 1]. However, these vulval Streptococcal vulvovaginitis
dermatoses present with one of the following clinical Staphylococcal folliculitis, impetigo, SSSS
scenarios: MC, genital herpes, genital warts, HFMD
1. Pruritus with/without lesions Scabies and helminthic infestations
2. Pain with/without lesions Tinea, candidiasis
3. Discharge with/without lesions Blisters and ulcers
4. Asymptomatic lesions. Bullous pemphigoid, CBDC
Aphthous ulcers
Clinical Scenario 1: Pruritus with/without Skin Fixed drug eruptions
Lesions EM, SJS, and TEN
Birthmarks and vascular malformations
Pruritus without skin lesions
Pigmentary nevi, epidermal nevi
Pruritus without skin lesions is a challenging situation for Capillary malformations, hemangiomas
both doctor and the parents. The various causes for this Anatomical abnormalities
condition are as follows. Fusion of labia
Pyramidal perineal protrusion
Irritant reaction
Neoplasias
Prolonged contact with irritants such as detergents, Langerhans cell histiocytosis
chemicals, clothes, or discharge can initially present with Melanoma
only symptoms such as pruritus without any dermatitis. Granular cell tumor of vulva
Proper history taking gives clue to the diagnosis. It is very Syringoma
important to identify the irritants and avoid them. Vulval signs of systemic disease
Crohn’s disease
Pinworm infestation Zinc deficiency
Children with pinworm infestation develop itching in Trauma
the perineal region which is worse at bedtime when the Foreign body
worms crawl upon the skin surface to lay eggs. Pruritus Child sexual abuse
may be associated with thin watery vaginal discharge. SSSS: Staphylococcus scalded skin syndrome, HFMD: Hand, foot,
Stool examination with evidence of pinworms confirms the and mouth disease, MC: Molluscum contagiosum, CBDC: Chronic
bullous disease of childhood, SJS: Steven‑Johnson syndrome,
diagnosis.
TEN: Toxic epidermal necrolysis, EM: Erythema multiforme
Foreign body
Children generally insert small objects into the ears and seen in children, especially atopic. Prolonged contact
nose. Likewise, they can insert them into vagina as well. with irritants such as feces or prolonged contact with
Foreign body in the vagina can lead to itching or pain or wet clothes, poor hygiene habits such as wiping the
vaginal discharge. Careful examination of the vagina in perineal area from back to front, and excess use of
appropriate position will reveal the foreign body. Common soaps and detergents cause irritant contact dermatitis.
objects that are inserted are beads, crayons, ball of paper, Allergic contact dermatitis is unusual in children
and seeds. because they are exposed to less potential allergens.
The clinical presentation of contact dermatitis is
Pruritus with skin lesions ill‑demarcated erythema associated with pruritus
Pruritus may be associated with lesions such as erythema, predominantly involving convexities [Figure 1]. In
leukoderma, blisters, and erosions or papules and nodules chronic cases, labia majora becomes scaly and rugose
[Flow Chart 1]. due to lichenification [Figure 2]. The rash often involves
thighs, buttocks, and lower abdominal folds
Pruritus with erythema
• Psoriasis: Vulval psoriasis is more common in children
The following vulval conditions manifest as erythema than in adults. The onset may be at any age from infancy
associated with pruritus: onward. Vulva could be the site of onset in infantile
• Contact dermatitis: It is a very common vulval problem psoriasis occurring as diaper psoriasis [Figure 3].

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Anitha and Shivanna: Genital lesions in a female child

Pruritus with lesions

Blisters Erythema Leukoderma Papulonodules

Tense Eczematous/ Symmetry LSEA Family H/o

String of pearl

Symmetrical Asymmetrical No Yes

BP CBDC Well defined Well defined Ill-defined IBR Scabies

Satellite Eczema Glazed Scaly Annular

Pustules plaques

Candidiasis Zinc Diaper Psoriasis Tinea CID

Deficiency Psoriasis
Flow Chart 1: Approach to genital lesions with pruritus. BP: Bullous pemphigoid, CBDC: Chronic bullous disease of childhood, CID: Contact irritant
dermatitis, IBR: Insect bite reaction, LSEA: Lichen sclerosus et atrophicus

It presents as itchy well‑demarcated symmetrical

Figure 1: Contact dermatitis: Erythema and scaling involving convexities
Figure 2: Rugose and thickened labia majora due to chronic contact
dermatitis
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 5a and 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]
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

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Anitha and Shivanna: Genital lesions in a female child

common presenting symptoms are itching and soreness. Pruritus with papules and nodules
Other symptoms are bleeding, dysuria, and constipation.
Scabetic nodules are often seen on the vulva and groin, but
The typical clinical appearance is well‑demarcated white,
usually it is part of a generalized eruption. Positive family
wrinkled plaque with scattered telangiectasia [Figure 6].
history makes the diagnosis easy. Papular urticaria could be
When it extends to involve anus, classical figure‑of‑eight
another possibility for papules on the vulva.
appearance is seen. In neglected long‑standing case, there
can be total loss of labia minora and resorption of the Clinical Scenario 2: Pain with/without Skin
clitoris. Lichen sclerosus usually resolves at puberty but may
Lesions
recur in adulthood with the risk of squamous cell carcinoma.
Diagnosis can be confirmed by biopsy. In children, Pain with skin lesions
noninvasive procedure such as dermatoscopy is preferred.
Pain in genital area may be associated with skin lesions
Dermatoscopic features of lichen sclerosus are structure‑less
such as blisters and erosions, ulcers, pustules, and
areas, telangiectasia, and comedo‑like openings.
pigmentary changes such as erythema and leukoderma
Pruritus with blisters and erosions [Flow Chart 2].
Bullous pemphigoid and chronic bullous disease of Blisters and erosions
childhood can occur on vulva rarely, but vulva could be
Bacterial infections, herpes genitalis, Steven–Johnson
the site of onset. Bullous pemphigoid presents with tense
bullae, and chronic bullous disease of childhood has an syndrome (SJS), and toxic epidermal necrolysis (TEN)
eczematous appearance and string of pearl distribution of are some of the conditions which present with blisters
blisters. and erosions in the vulval and perineal regions. Bacterial

Figure 3: Glazed erythematous scaly patch involving vulva and crural region Figure 4: Well-demarcated scaly plaques involving vulva and adjacent
along with postinflammatory hypopigmentation seen in diaper psoriasis region seen in psoriasis

b
Figure 5: (a) Erythematous annular papules with central clearing on mons Figure 6: Atrophic depigmented patch involving vulva and perineal region
pubis, (b) similar lesion on buttock in the same patient seen in lichen sclerosus

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Anitha and Shivanna: Genital lesions in a female child

Pain with lesions

Blisters & erosions Ulcers Leukoderma Edema Pustules

Mucosal involvement Aphthous like/Recurrent Recurrent Follicular

No Yes Yes No LSEA No Yes No Yes

Recurrent SJS/TEN Grouped Unilateral Erythema Erythema Secondary infection

/Grouped /Pemphigus

No Yes No Yes Diffuse Well-defined Absent/evanescent

Yes No
Shape HSV Jacquet’s Streptococcal FDE Angioedema
HSV SSSS/ Vulvovaginitis
Impetigo Irregular Round Herpes Zoster

Aphthous Folliculitis/Furuncle
Behcet’s
Flow Chart 2: Approach to genital lesions with pain. FDE: Fixed drug eruption, HSV: Herpes simplex virus infection, LSEA: Lichen sclerosus et atrophicus,
SJS: Steven–Johnson syndrome, SSSS: Staphylococcus scalded skin syndrome, TEN: Toxic epidermal necrolysis

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. Figure 7: Well-demarcated punched-out ulcers and erosions in perianal
• Aphthous ulcers: Aphthous ulceration is less common region seen in Jacquet’s dermatitis
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 Figure 8: Follicular pustule and erosion with crusting seen in folliculitis
and impetigo, respectively
ulcers or erosions with elevated borders [Figure 7]. It
is typically associated with frequent liquid stools, poor
hygiene, infrequent diaper changes, or occlusive plastic Pustules
diapers. It is more common in children with chronic Staphylococcal folliculitis and secondary pyoderma should
diarrhea or incontinence such as those with spina bifida be considered in case of painful pustules [Figure 8].
or Hirschsprung’s disease. Staphylococcal folliculitis is common on the buttocks in

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Anitha and Shivanna: Genital lesions in a female child

children. Occasionally, it may spread to involve the vulva Leukoderma

or may occur there primarily. Secondary bacterial infection
can superimpose on the preexisting dermatoses and present
with painful pustules.
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.
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]
Figure 9: Erythema and edema of vulva with erythematous nodule on
adjacent thigh, suggestive of streptococcal vulvovaginitis
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]
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 coli infection
causes a thin, watery, foul‑smelling discharge

Vaginal Discharge

With lesion Without lesion

Erythematous, Bloody/ Mucopurulent/ Thin Mucoidoften Clear mucoid/

edematous Foul smelling bloody watery bloody milky white

Thin mucoid Foreign body Shigella Foul smelling Post-natal Pubertal

Streptococcal No Yes
Vulvovaginitis

Pin worm E.coli

Flow Chart 3: Approach to vaginal discharge with or without genital lesions

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Anitha and Shivanna: Genital lesions in a female child

• Protozoal: Enterobius vermicularis (pinworm) causes Postinflammatory hyperpigmentation

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
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.
A preexisting skin lesion can resolve leaving behind
brown hyperpigmented asymptomatic patch which can be
confirmed by taking proper history [Figure 10].
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].
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 12a and b].
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

Asymptomatic lesions

Discrete papules Pigmentary changes Blisters Verrucous/irregular surface

Skin color pearly white Leucoderma Brown HFMD Red Skin color

Syringoma MC Epidermal changes Since birth Pre-existing Since birth Acquired

Atrophy, hemorrhagic spots No Pigmentary Nevi PIH Hemangioma Warts

LSEA Margins Linear Non-linear

Serrated Scalloped Irregular Linear epidermal Epidermal Nevus

Nevus

Nevus anemicus/ Vitiligo Contact leucoderma

Depigmentosus
Flow Chart 4: Approach to asymptomatic genital lesions, HFMD: Hand, foot, and mouth disease, LSEA: Lichen sclerosus et atrophicus, MC: Molluscum
contagiosum, PIH: Postinflammatory hyperpigmentation

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Anitha and Shivanna: Genital lesions in a female child
Figure 10: Brown-colored patches at the site of preexisting dermatoses
b
Figure 12: (a) Pearly papules on vulva seen in molluscum contagiosum,
(b) similar lesions on the perianal region
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.
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
56
Figure 11: Well-demarcated red plaque with nodular surface on labia majora
seen in hemangioma
Figure 13: Skin-colored verrucous papules in the perianal region seen in
the warts
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]
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Anitha and Shivanna: Genital lesions in a female child
• 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
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.
Clinical Dermatology Review | Volume 2 | Issue 2 | July-December 2018
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
1. Makwela  MR. Paediatric vaginal discharge. S  Afr Fam Pract
2007;49:30‑1.
2. Herman‑Giddens ME, Frothingham TE. Prepubertal female
genitalia: Examination for evidence of sexual abuse. Pediatrics
1987;80:203‑8.
3. Humphrey S, Bergman JN, Au S. Practical management
strategies for diaper dermatitis. Skin Therapy Lett 2006;11:1‑6.
4. Dar  V, Raker  K, Adhmi  Z, Mckenzie  S. Streptococcal
vulvovaginitis in girls. Pediatr Dermatol 1993;10:366‑7.
5. Sehgal  VH, Gangwani  OP. Genital fixed drug eruptions.
Genitourin Med 1986;62:56‑8.
6. Di Lervia V, Bisighini G. Localised vulvar syringomas. Pediatr
Dermatol 1996;13:80‑1.
7. Tipton A. Child sexual abuse. Physical examination techniques
and interpretation of findings. Adolesc Pediatr Gynecol
1989;2:10‑25.
8. Pride HB. Child abuse and mimickers of child abuse. Adv
Dermatol 1999;14:417‑55.
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.
10. Powell J. Paediatric vulval disorders. J Obstet Gynaecol
2006;26:596‑602.
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