Journal of Lower Genital Tract Disease • Volume 19, Number 2, April 2015
score in vaginal flora evaluation.5,6 In our study, the PCR technique was more sensible than the Nugent score, which is in good agreement with Cartwright et al. and Fredricks et al. To sum up, we compared another PCR-based approach with another microscopy approach (compared to those used by Cartwright et al. and Fredricks et al.), which does not allow direct comparison of the results obtained. Tatiana Rumyantseva, MD Central Research Institute for Epidemiology Moscow, Russian Federation
REFERENCES 1. Rumyantseva TA, Bellen G, Romanuk TN, Shipulina OI, Guschin AE, Shipulin GA, et al. Utility of microscopic techniques and quantitative real-time polymerase chain reaction for the diagnosis of vaginal microflora alterations. J Low Genit Tract Dis 2014 [E-pub ahead of print]. 2. Cartwright CP, Lembke BD, Ramachandran K, Body BA, Nye MB, Rivers CA, et al. Development and validation of a semiquantitative, multitarget PCR assay for diagnosis of bacterial vaginosis. J Clin Microbiol 2012;50:2321–9. 3. Fredricks DN, Fiedler TL, Thomas KK, Oakley BB, Marrazzo JM. Targeted PCR for detection of vaginal bacteria associated with bacterial vaginosis. J Clin Microbiol 2007;45:3270–6. E-pub 2007 Aug 8. 4. Fredricks DN, Fiedler TL, Marrazzo JM. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med 2005;353: 1899–911. 5. Donders GG, Vereecken A, Dekeersmaecker A, Van Bulck B, Spitz B. Wet mount microscopy reflects functional vaginal lactobacillary flora better than Gram stain. J Clin Pathol 2000;53: 308–13. 6. Donders GG, Vereecken A, Salembier G, Van Bulck B, Spitz B. Assessment of vaginal lactobacillary flora in wet mount and fresh or delayed gram's stain. Infect Dis Obstet Gynecol 1996;4:2–6.
Labioplasty Specimens: When Should Pathological Findings Be Considered as Abnormal? To the Editor arrett and Carlson1 recently reported the histological findings occurring in 34 labia minora labioplasties of 31 women with labia minora hypertrophy. Their review of the medical records indicated that all patients apparently had excessive, but normal-appearing, labia minora tissue. Approximately half of the patients presented
B
with aesthetic concerns and approximately 30% had discomfort; itching was not mentioned. They found that all the labia histologically demonstrated lymphedema, 94% demonstrated lichenification, and 60% showed sebaceous gland hyperplasia. Their study comes during an explosion of aesthetic reduction labioplasties. The Barrett and Carlson manuscript “medicalizes” what we believe to be normal variation in labial size and appearance and, as a result, is likely to be used as a justification for this surgery. The clinical and histological features they consider to be abnormal are, in our opinion, not so. Our reasons are set out below. First, was labia minora hypertrophy really even present? Scant clinical details suggest that fewer than half of their patients met commonly accepted criteria (>4 cm) for the definition of labial hypertrophy. Second, was lymphedema really present? There is no mention of any clinical confirmation, and the authors' histological criteria are based, in our opinion, on completely inadequate controls: 4 genital specimens with no mention of sex or genital sites.2,3 Third, the authors reported the presence of lichenification in 94% of the patients. This important sign of chronic irritation is almost always due to severe itching, rubbing, and scratching. However, no such clinical features were described. The authors defined lichenification histologically as simply the presence of hyperkeratosis and hypergranulosis. This definition is incomplete, as the standard definition also requires the presence of acanthosis and some degree of fibrosis in the superficial stromal tissue. In addition, the same problem with inadequate controls is again present here. Fourth, the authors attempted to relate the finding of sebaceous gland hyperplasia to the development of lymphedema. However, their description is typical of Fordyce “granules” consisting of superficially placed sebaceous lobules, which occur on the labia minora in 75% to 90% of normal women in the reproductive age range.4 Moreover, the reference cited for the relationship between sebaceous gland hyperplasia and lymphedema consists of a single case report of a patient with “sebaceous gland hyperplasia,” a different condition from the diffuse distribution and prominence described in the Barrett and Carlson study.5 Fifth, 3 patients (9%) in the Barrett and Carlson study had recurrence of the labial hypertrophy after labioplasty. Based on this recurrence, the authors suggested that labia minora hypertrophy is potentially an ongoing and progressive medical disorder justifying early intervention up to and including labioplasty. Such a hypothesis runs
© 2014, American Society for Colposcopy and Cervical Pathology
Letters to Editor
counter to our clinical experience and, to be believable, would clearly require long-term prospective studies. Sixth, the authors write that “lymphedema can lead to functional debilitation, recurrent skin infections and even development of malignancy…” [italics ours]. Whereas malignancy is a very rare risk in massive, long-standing lymphedema (e.g., Stewart-Treves syndrome), no such risk has been demonstrated for the nonclinically evident lymphedema that might or might not have been present in the reported patients. We believe that the authors' concern for malignancy in this study is unwarranted and that such potential risk, if it even exists, would be so rare that it should not be a justification, as the authors suggest, for early surgical resection. In conclusion, we believe that the authors have not convincingly demonstrated the presence of lymphedema in patients with normal-appearing but elongated labia minora. We also believe that their conclusions regarding the risks of subsequent medical problems (and especially malignancy) are not warranted. Specifically, we would like to emphasize that, in our opinion, even if lymphedema (and the other histological changes described in this manuscript) are present more often than they are in a suitable control population, they alone cannot be used to justify labioplasty for labia minora that women may perceive as hypertrophic. James Scurry, MD Hunter Area Pathology Service New Lambton Heights NSW, Australia
Claudia Marchitelli, MD Gynecological Department Hospital Italiano de Buenos Aires Buenos Aires, Argentina
Micheline Moyal-Barracco Hôpital Tarnier, Cochin Paris, France
REFERENCES 1. Barrett MM, Carlson JA. A clinicopathological study of labial hypertrophy: signs of lymphedema were universal. J Lower Genit Tract Disease 2014;18:13–20. 2. Carlson JA, Carlson GD, Murphy M, Rohwedder A. Lichen sclerosus exhibiting histologic signs of lymphedema: an essential factor in the pathogenesis of verruciform xanthoma. Arch Dermatol 2012;148:260–2. 3. Paul J, Carlson JA. Lymphangiectases are common underlying warts and in normal peritumoral skin: histological evidence of decreased immune surveillance. Am J Dermatopathol 2011;33:152–60. 4. Margesson LJ. Vulvar disease pearls. Dermatol Clin 2006;24:145–55.
e49
Copyright © 2015 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Letters to Editor 5. Mora M, Boccardo F, Campisini C, Carli C, Ricca R, Fulcheri E. Vulvar sebaceous hyperplasia associated with lymphedema of external genitalia. Int J Dermatol 2010;49:70–4.
Reply to Scurry et al.: Vulvar Lymphangiectasis, an Indicator of Lymph Stasis, Is an Authentic Sign of Abnormal Histopathology in Labiaplasty Specimens To the Editor, e appreciate the criticism of Scurry et al.1 on our retrospective clinicopathologic study.2 Contrary to the opinion of Scurry et al., we maintain that the histopathologic features seen in labial hypertrophy are abnormal and implicate lymphedema in its pathogenesis.3 Our responses to the criticisms follow:
W
WAS LABIAL HYPERTROPHY REALLY PRESENT? Yes, but using elongation as the only criterion would exclude patients with symptomatic but minor labial enlargement. A severity assessment of elongation, asymmetry, and symptoms would more accurately determine the presence of real labial hypertrophy and facilitate planning management.
WAS LYMPHEDEMA “REALLY PRESENT AND IS THE NUMBER OF CONTROLS SUFFICIENT?” In our study, lymphedema is an evident and universal characteristic. However, do the above 3 histopathologic findings correlate with clinical evidence of lymphedema? Besides those 3 factors, we could measure the pliability of the enlarged labia (e.g., soft/supple versus firm/indurated). Lymphedema can be, initially, pitting, soft, and reversible; or later, nonpitting, hard, and irreversible.3 Assessing this factor in patients with labial hypertrophy would be of use if lymphedema is a major factor in its pathogenesis and whether or not this contributes to symptoms. For comparison, the best controls would be biopsies of the labia minora from healthy women. Since this was not a practical alternative, we sought labia minora excision specimens from benign tumors that had a tip of normal perilesional tissue. Our 4 controls ranged in age from 38 to 83 years. We excluded excisions for malignancy because a past study examining perilesional normal skin samples showed greater lymphatic dilation adjacent
e50
Journal of Lower Genital Tract Disease • Volume 19, Number 2, April 2015
to skin cancers,4 which could confound the analysis.
PRESENCE OF LICHENIFICATION—GIVEN “CRITERIA NOT SUFFICIENT FOR DIAGNOSIS” Lichen simplex chronicus is a reaction pattern caused by long-standing, persistent rubbing of the skin with 2 basic histopathologic presentations5; both are found in our study. One is epidermal with marked compact orthokeratosis, prominent hypergranulosis, and slight psoriasiform hyperplasia. The second is epidermal and dermal with distinct compact hyperkeratosis and hypergranulosis but also psoriasiform hyperplasia and coarse collagen bundles arranged in vertical streaks in a thickened papillary dermis.
SEBACEOUS HYPERPLASIA—FINDINGS MISTAKEN FOR FORDYCE SPOTS Report of Mora et al.6 underscores the putative relationship between sebaceous hyperplasia, lymphedema, and labial hyperplasia. Moreover, the clinicopathologic findings of labial enlargement, numerous and prominent sebaceous lobules, perisebaceous lymphocytic infiltrates, and lymphedema are strikingly similar to the characteristic features of rosaceous (phymatous) lymphedema.3
RECURRENCE OF LABIAL HYPERTROPHY IS NOT A SIGN OF ONGOING, PROGRESSIVE LABIAL HYPERTROPHY
Why would an anatomic variant “grow back” and be more voluminous than the initial episode like in our 3 patients? In most women with localized vulvar lymphedema, surgery is curative3; those who experience recurrence and progressive growth are obese, have had an episode of cellulitis, and/or exhibit signs of chronic inflammation.3
OVERSTATED RISK FOR COMPLICATIONS DUE TO LABIAL HYPERTROPHY The true risk for complications of labial hypertrophy is unknown. Prospective longterm studies are certainly warranted to characterize the natural history of labial hypertrophy and answer simple questions like “Does elongation, size, and consistency of enlarged labia minora change over time?” In closing, we are not advocates of labiaplasty seeking to “medicalize” labial hypertrophy.1 Our study’s goals were to add additional understanding of labial hypertrophy histopathology and better
characterize its natural history. Whereas retrospective design and number of and types of controls tested are certainly limitations of our study, localized labial lymphedema was our most important study finding. This condition can readily explain many aspects of labial hypertrophy such as asymmetric tissue enlargement and risk for recurrence and continued growth.3 Ultimately, a better understanding of labial hypertrophy, which may require other investigators to reject or reproduce our results, will permit patients and treating physicians to make better-informed decisions. Mary M. Barrett, MD Department of Pathology John Andrew Carlson, MDCM, FRCPC Albany Medical College, MC-81, 47 New Scotland Ave, Albany, NY
REFERENCES 1. Scurry J, Ball R, Bradford J, Heller DS, Marchitelli CE, Margesson L, et al. Labioplasty specimens: when should pathological findings be considered abnormal? J Low Genit Tract Dis 2014. In press. 2. Barrett MM, Carlson JA. A clinicopathologic study of labia minora hypertrophy: signs of localized lymphedema were universal. J Low Genit Tract Dis 2014;18:13–20. 3. Carlson JA. Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous infection, inflammatory dermatoses, and neoplasia: a locus minoris resistentiae. Clin Dermatol 2014;32:599–615. 4. Paul J, Carlson JA. Lymphangiectases are common underlying warts and in normal peritumoral skin: histologic evidence of decreased immune surveillance. Am J Dermatopathol 2011; 33:152–60. 5. Ackerman AB, Chongchitnant N, Sanchez J, Guo Y, Bennin B, Reichel M, et al. Diseases secondary to rubbing and or scratching: lichen simplex chronicus/prurigo nodularis/picker's nodule/erosions/ulcers. In: Ackerman AB, ed. Histologic diagnosis of inflammatory skin disease: an algorithmic method based on pattern analysis. Baltimore, MD: Williams & Wilkins; 1997:304–6. 6. Mora M, Boccardo F, Campisi C, Carli C, Ricca R, Fulcheri E. Vulvar sebaceous hyperplasia associated with lymphedema of external genitalia. Int J Dermatol 2010;49:70–4.
Laser Vaporization of VAIN. A Word of Caution Dear Sir, errotta et al. (“Use of CO2 Laser Vaporization for the Treatment of High-Grade
P
© 2014, American Society for Colposcopy and Cervical Pathology
Copyright © 2015 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
score in vaginal flora evaluation.5,6 In our study, the PCR technique was more sensible than the Nugent score, which is in good agreement with Cartwright et al. and Fredricks et al. To sum up, we compared another PCR-based approach with another microscopy approach (compared to those used by Cartwright et al. and Fredricks et al.), which does not allow direct comparison of the results obtained. Tatiana Rumyantseva, MD Central Research Institute for Epidemiology Moscow, Russian Federation
REFERENCES 1. Rumyantseva TA, Bellen G, Romanuk TN, Shipulina OI, Guschin AE, Shipulin GA, et al. Utility of microscopic techniques and quantitative real-time polymerase chain reaction for the diagnosis of vaginal microflora alterations. J Low Genit Tract Dis 2014 [E-pub ahead of print]. 2. Cartwright CP, Lembke BD, Ramachandran K, Body BA, Nye MB, Rivers CA, et al. Development and validation of a semiquantitative, multitarget PCR assay for diagnosis of bacterial vaginosis. J Clin Microbiol 2012;50:2321–9. 3. Fredricks DN, Fiedler TL, Thomas KK, Oakley BB, Marrazzo JM. Targeted PCR for detection of vaginal bacteria associated with bacterial vaginosis. J Clin Microbiol 2007;45:3270–6. E-pub 2007 Aug 8. 4. Fredricks DN, Fiedler TL, Marrazzo JM. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med 2005;353: 1899–911. 5. Donders GG, Vereecken A, Dekeersmaecker A, Van Bulck B, Spitz B. Wet mount microscopy reflects functional vaginal lactobacillary flora better than Gram stain. J Clin Pathol 2000;53: 308–13. 6. Donders GG, Vereecken A, Salembier G, Van Bulck B, Spitz B. Assessment of vaginal lactobacillary flora in wet mount and fresh or delayed gram's stain. Infect Dis Obstet Gynecol 1996;4:2–6.
Labioplasty Specimens: When Should Pathological Findings Be Considered as Abnormal? To the Editor arrett and Carlson1 recently reported the histological findings occurring in 34 labia minora labioplasties of 31 women with labia minora hypertrophy. Their review of the medical records indicated that all patients apparently had excessive, but normal-appearing, labia minora tissue. Approximately half of the patients presented
B
with aesthetic concerns and approximately 30% had discomfort; itching was not mentioned. They found that all the labia histologically demonstrated lymphedema, 94% demonstrated lichenification, and 60% showed sebaceous gland hyperplasia. Their study comes during an explosion of aesthetic reduction labioplasties. The Barrett and Carlson manuscript “medicalizes” what we believe to be normal variation in labial size and appearance and, as a result, is likely to be used as a justification for this surgery. The clinical and histological features they consider to be abnormal are, in our opinion, not so. Our reasons are set out below. First, was labia minora hypertrophy really even present? Scant clinical details suggest that fewer than half of their patients met commonly accepted criteria (>4 cm) for the definition of labial hypertrophy. Second, was lymphedema really present? There is no mention of any clinical confirmation, and the authors' histological criteria are based, in our opinion, on completely inadequate controls: 4 genital specimens with no mention of sex or genital sites.2,3 Third, the authors reported the presence of lichenification in 94% of the patients. This important sign of chronic irritation is almost always due to severe itching, rubbing, and scratching. However, no such clinical features were described. The authors defined lichenification histologically as simply the presence of hyperkeratosis and hypergranulosis. This definition is incomplete, as the standard definition also requires the presence of acanthosis and some degree of fibrosis in the superficial stromal tissue. In addition, the same problem with inadequate controls is again present here. Fourth, the authors attempted to relate the finding of sebaceous gland hyperplasia to the development of lymphedema. However, their description is typical of Fordyce “granules” consisting of superficially placed sebaceous lobules, which occur on the labia minora in 75% to 90% of normal women in the reproductive age range.4 Moreover, the reference cited for the relationship between sebaceous gland hyperplasia and lymphedema consists of a single case report of a patient with “sebaceous gland hyperplasia,” a different condition from the diffuse distribution and prominence described in the Barrett and Carlson study.5 Fifth, 3 patients (9%) in the Barrett and Carlson study had recurrence of the labial hypertrophy after labioplasty. Based on this recurrence, the authors suggested that labia minora hypertrophy is potentially an ongoing and progressive medical disorder justifying early intervention up to and including labioplasty. Such a hypothesis runs
© 2014, American Society for Colposcopy and Cervical Pathology
Letters to Editor
counter to our clinical experience and, to be believable, would clearly require long-term prospective studies. Sixth, the authors write that “lymphedema can lead to functional debilitation, recurrent skin infections and even development of malignancy…” [italics ours]. Whereas malignancy is a very rare risk in massive, long-standing lymphedema (e.g., Stewart-Treves syndrome), no such risk has been demonstrated for the nonclinically evident lymphedema that might or might not have been present in the reported patients. We believe that the authors' concern for malignancy in this study is unwarranted and that such potential risk, if it even exists, would be so rare that it should not be a justification, as the authors suggest, for early surgical resection. In conclusion, we believe that the authors have not convincingly demonstrated the presence of lymphedema in patients with normal-appearing but elongated labia minora. We also believe that their conclusions regarding the risks of subsequent medical problems (and especially malignancy) are not warranted. Specifically, we would like to emphasize that, in our opinion, even if lymphedema (and the other histological changes described in this manuscript) are present more often than they are in a suitable control population, they alone cannot be used to justify labioplasty for labia minora that women may perceive as hypertrophic. James Scurry, MD Hunter Area Pathology Service New Lambton Heights NSW, Australia
Claudia Marchitelli, MD Gynecological Department Hospital Italiano de Buenos Aires Buenos Aires, Argentina
Micheline Moyal-Barracco Hôpital Tarnier, Cochin Paris, France
REFERENCES 1. Barrett MM, Carlson JA. A clinicopathological study of labial hypertrophy: signs of lymphedema were universal. J Lower Genit Tract Disease 2014;18:13–20. 2. Carlson JA, Carlson GD, Murphy M, Rohwedder A. Lichen sclerosus exhibiting histologic signs of lymphedema: an essential factor in the pathogenesis of verruciform xanthoma. Arch Dermatol 2012;148:260–2. 3. Paul J, Carlson JA. Lymphangiectases are common underlying warts and in normal peritumoral skin: histological evidence of decreased immune surveillance. Am J Dermatopathol 2011;33:152–60. 4. Margesson LJ. Vulvar disease pearls. Dermatol Clin 2006;24:145–55.
e49
Copyright © 2015 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Letters to Editor 5. Mora M, Boccardo F, Campisini C, Carli C, Ricca R, Fulcheri E. Vulvar sebaceous hyperplasia associated with lymphedema of external genitalia. Int J Dermatol 2010;49:70–4.
Reply to Scurry et al.: Vulvar Lymphangiectasis, an Indicator of Lymph Stasis, Is an Authentic Sign of Abnormal Histopathology in Labiaplasty Specimens To the Editor, e appreciate the criticism of Scurry et al.1 on our retrospective clinicopathologic study.2 Contrary to the opinion of Scurry et al., we maintain that the histopathologic features seen in labial hypertrophy are abnormal and implicate lymphedema in its pathogenesis.3 Our responses to the criticisms follow:
W
WAS LABIAL HYPERTROPHY REALLY PRESENT? Yes, but using elongation as the only criterion would exclude patients with symptomatic but minor labial enlargement. A severity assessment of elongation, asymmetry, and symptoms would more accurately determine the presence of real labial hypertrophy and facilitate planning management.
WAS LYMPHEDEMA “REALLY PRESENT AND IS THE NUMBER OF CONTROLS SUFFICIENT?” In our study, lymphedema is an evident and universal characteristic. However, do the above 3 histopathologic findings correlate with clinical evidence of lymphedema? Besides those 3 factors, we could measure the pliability of the enlarged labia (e.g., soft/supple versus firm/indurated). Lymphedema can be, initially, pitting, soft, and reversible; or later, nonpitting, hard, and irreversible.3 Assessing this factor in patients with labial hypertrophy would be of use if lymphedema is a major factor in its pathogenesis and whether or not this contributes to symptoms. For comparison, the best controls would be biopsies of the labia minora from healthy women. Since this was not a practical alternative, we sought labia minora excision specimens from benign tumors that had a tip of normal perilesional tissue. Our 4 controls ranged in age from 38 to 83 years. We excluded excisions for malignancy because a past study examining perilesional normal skin samples showed greater lymphatic dilation adjacent
e50
Journal of Lower Genital Tract Disease • Volume 19, Number 2, April 2015
to skin cancers,4 which could confound the analysis.
PRESENCE OF LICHENIFICATION—GIVEN “CRITERIA NOT SUFFICIENT FOR DIAGNOSIS” Lichen simplex chronicus is a reaction pattern caused by long-standing, persistent rubbing of the skin with 2 basic histopathologic presentations5; both are found in our study. One is epidermal with marked compact orthokeratosis, prominent hypergranulosis, and slight psoriasiform hyperplasia. The second is epidermal and dermal with distinct compact hyperkeratosis and hypergranulosis but also psoriasiform hyperplasia and coarse collagen bundles arranged in vertical streaks in a thickened papillary dermis.
SEBACEOUS HYPERPLASIA—FINDINGS MISTAKEN FOR FORDYCE SPOTS Report of Mora et al.6 underscores the putative relationship between sebaceous hyperplasia, lymphedema, and labial hyperplasia. Moreover, the clinicopathologic findings of labial enlargement, numerous and prominent sebaceous lobules, perisebaceous lymphocytic infiltrates, and lymphedema are strikingly similar to the characteristic features of rosaceous (phymatous) lymphedema.3
RECURRENCE OF LABIAL HYPERTROPHY IS NOT A SIGN OF ONGOING, PROGRESSIVE LABIAL HYPERTROPHY
Why would an anatomic variant “grow back” and be more voluminous than the initial episode like in our 3 patients? In most women with localized vulvar lymphedema, surgery is curative3; those who experience recurrence and progressive growth are obese, have had an episode of cellulitis, and/or exhibit signs of chronic inflammation.3
OVERSTATED RISK FOR COMPLICATIONS DUE TO LABIAL HYPERTROPHY The true risk for complications of labial hypertrophy is unknown. Prospective longterm studies are certainly warranted to characterize the natural history of labial hypertrophy and answer simple questions like “Does elongation, size, and consistency of enlarged labia minora change over time?” In closing, we are not advocates of labiaplasty seeking to “medicalize” labial hypertrophy.1 Our study’s goals were to add additional understanding of labial hypertrophy histopathology and better
characterize its natural history. Whereas retrospective design and number of and types of controls tested are certainly limitations of our study, localized labial lymphedema was our most important study finding. This condition can readily explain many aspects of labial hypertrophy such as asymmetric tissue enlargement and risk for recurrence and continued growth.3 Ultimately, a better understanding of labial hypertrophy, which may require other investigators to reject or reproduce our results, will permit patients and treating physicians to make better-informed decisions. Mary M. Barrett, MD Department of Pathology John Andrew Carlson, MDCM, FRCPC Albany Medical College, MC-81, 47 New Scotland Ave, Albany, NY
REFERENCES 1. Scurry J, Ball R, Bradford J, Heller DS, Marchitelli CE, Margesson L, et al. Labioplasty specimens: when should pathological findings be considered abnormal? J Low Genit Tract Dis 2014. In press. 2. Barrett MM, Carlson JA. A clinicopathologic study of labia minora hypertrophy: signs of localized lymphedema were universal. J Low Genit Tract Dis 2014;18:13–20. 3. Carlson JA. Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous infection, inflammatory dermatoses, and neoplasia: a locus minoris resistentiae. Clin Dermatol 2014;32:599–615. 4. Paul J, Carlson JA. Lymphangiectases are common underlying warts and in normal peritumoral skin: histologic evidence of decreased immune surveillance. Am J Dermatopathol 2011; 33:152–60. 5. Ackerman AB, Chongchitnant N, Sanchez J, Guo Y, Bennin B, Reichel M, et al. Diseases secondary to rubbing and or scratching: lichen simplex chronicus/prurigo nodularis/picker's nodule/erosions/ulcers. In: Ackerman AB, ed. Histologic diagnosis of inflammatory skin disease: an algorithmic method based on pattern analysis. Baltimore, MD: Williams & Wilkins; 1997:304–6. 6. Mora M, Boccardo F, Campisi C, Carli C, Ricca R, Fulcheri E. Vulvar sebaceous hyperplasia associated with lymphedema of external genitalia. Int J Dermatol 2010;49:70–4.
Laser Vaporization of VAIN. A Word of Caution Dear Sir, errotta et al. (“Use of CO2 Laser Vaporization for the Treatment of High-Grade
P
© 2014, American Society for Colposcopy and Cervical Pathology
Copyright © 2015 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
