By Frederick R. Jelovsek, M.D.,
Vulvar diseases are usually considered problems of older women.
They can, however, occur in girls prior to their first menses (prepubertal)
and when they do, they encompass a wide range of conditions and
are often different problems than seen in older women.
In a recent literature review, Fivozinsky KB, Laufer MR:
Vulvar disorders in prepubertal girls: A literature review.J
Reprod Med. 1998;43:763-773, the different conditions seen
were summarized. The occurrence ranged from newborns to toddlers
to girls before they started their first menstrual periods.
In addition to diaper rash, infants have an increased risk of
skin infection because the sweat gland function is not fully
developed and skin is continually exposed to urine and feces.
Milaria rubra is a skin rash with blisters and pustules due to
sweat gland obstruction and overheating. Impetigo is another skin
rash with vesicles that crust over and is caused by staphylococcal
and streptococcal organisms.
Labial adhesions in which the lips create a flat, scarred
appearance can occur in young girls less than 6 years of age.
It's cause is unknown but it responds to topical estrogen creams.
Since the anus is closer to the vulva in young girls and they
lack the protection of the vulvar fat pads and hair that older
women have, they are more prone to a vulvar infection by
gastrointestinal bacteria such as shigella or Yersina
enterocolitica. Pinworms can infect the vagina and cause a
secondary vulvitis just as a foreign body in the vagina (toilet
tissue, hair pins, pieces of stick etc.,) by a 2-4 year old can
cause vaginitis and vulvitis.
A true bacterial vulvitis is most commonly caused by staph or
strep or haemophilus influenzae. Yeast (candida) is rare in the
prepubertal girl except as seen with diaper rash, antibiotics or
diabetes. Other fungal infections can occur and many have no
cause found. Occasionally, overly aggressive cleaning regimens can
break down the skin of the vulva and actually cause vulvitis.
Allergic and contact dermatitis occurs in prepubertal girls just
as it does in any women. About 48 hours after exposure to a
sensitizer, a rash, occasionally blisters and often itching and
burning takes place. Common allergic sensitizers include topical
steroid preparations, local anesthetics, benzyl alcohol,
propylene glycol, feminine hygiene sprays and deodorized
sanitary products, nickel, rubber, latex, neomycin sulfate,
Balsam of Peru, and nickel sulfate. Irritant dermatitis, on the
other hand, gives an immediate stinging and burning and redness.
Common irritants include soaps, alcohol, propylene glycol,
fragrances, adhesives and even bromide in swimming pools.
Viral infections can affect the vulva such as herpes, molluscum
contagiosum, chickenpox, and human papilloma virus (HPV). With
HPV and herpes infections in young girls, doctors always worry
about the possibility of sexual abuse, but they can sometimes
happen by hand contact.
Non bacterial inflammation can take place with conditions such as
lichen sclerosis (an itchy white/red lesion around the opening),
lichen planus (small violet color polygon spots), and lichen
simplex chronicus (a rash from incessant rubbing and scratching).
Skin manifestations of drug reactions, psoriasis, pemphigoid, and
skin rashes of generalized medical diseases can also occur just
as it can in later years.
Tumors of the vulva are fortunately rare in childhood; moles
(nevi) and hemangiomas (vascular birth marks) are more frequent,
while smooth muscle tumors or melanomas are
not.
In summary, there are many of the same processes that occur on
the vulva in children as do in older women. So if there is any
indication of a problem, the same biopsy steps should be carried
out if they would be indicated in older women. There are unique
problems, especially infectious vulvar problems that may take
different diagnostic detective work and therapies to tackle these
unusual problems in female children.
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