Vulvar mucosal leukoplakia

　　1. Etiology

　　The etiology of this disease is not yet clear and is related to certain systemic factors such as diabetes, endocrine disorders, malnutrition, vitamin deficiency, and so on. Vorobeva et al. found that patients with vulvar leukoplakia and lichen sclerosis have significant functional disorders of the pituitary-ovarian system. Mucosal leukoplakia may also be related to EB virus infection, candidal infection, and so on. There are reports that 22.2% of patients with oral mucosal leukoplakia can be detected with human papillomavirus. p53 gene mutation is one of the causes of abnormal active cell proliferation. Local factors play an important role in the occurrence of vulvar leukoplakia. Local humidity, thermal stimulation, friction, senile atrophy, and other factors can lead to vulvar leukoplakia. Some people have undergone surgery to remove vulvar leukoplakia and transplant skin from other parts of the body to the vulva, and the transplanted skin can develop similar lesions. If the skin of the thigh and the skin of the vulvar lesion site are simultaneously removed and exchanged for skin grafting, the normal thigh skin transplanted to the vulva develops leukoplakia lesions, thus confirming the pathogenic role of the local environment.

　　2. Pathogenesis

　　Vulvar mucosal leukoplakia is mainly a proliferative lesion of mucosal epithelium or epidermis. The normal mucosal epithelium does not have a stratum corneum and granular layer. In leukoplakia, the mucosal epithelium is significantly keratinized, and granular layers of varying thickness appear. When it occurs at the transition site of the vulvar skin and mucosa, there is obvious hyperkeratosis, thickening of the granular layer, and significant hyperplasia of both mucosal and skin epithelium. The stratum spinosum thickens, the epidermal ridges extend downward, and there is varying degrees of infiltration of lymphocytes and a small number of plasma cells in the superficial dermis. The stratum spinosum of vulvar leukoplakia has early dysplasia: some spinocytes have atypicality, with nuclei of inconsistent size, large and deeply stained. The cells are arranged in disorder, irregular in shape, and nuclear division can be seen.

　　Leukoplakia of the vulvar mucosa is mainly a proliferative lesion of the mucosal epithelium or epidermis. The normal mucosal epithelium does not have a stratum corneum and granular layer. In mucosal leukoplakia, the mucosal epithelium is significantly keratinized, and there are granular layers of varying thickness. When it occurs at the transition site of the skin and mucosa of the labia majora, there is obvious hyperkeratosis, thickening of the granular layer, and significant hyperplasia of both mucosal and skin epithelium. The stratum spinosum is thickened, and the epithelial ridges extend downward. There is a varying degree of lymphocytic and a small amount of plasma cell infiltration in the superficial dermis. The prickle cell layer of vulvar leukoplakia has early dysplasia: that is, some prickle cells have atypicality, nuclear size is inconsistent, with large and deeply stained nuclei. The cell arrangement is disordered, irregular in shape, and nuclear division can be seen. About 20% of chronic vulvar mucosal leukoplakia may develop into infiltrative squamous cell carcinoma.

　　Vulvar leukoplakia is manifested as white, thick, infiltrative plaques with clear boundaries. Some may have fissures, small erosions, ulcers. Skin lesions are prone to occur on the vaginal mucosa, mucosa of the urethral orifice, clitoris, the inner and outer sides of the labia minora, and the inner side of the labia majora. It is a single or several irregularly shaped white or milky white patches or plaques with a slightly raised mucosal surface and clear boundaries. A few may not be raised, with unclear boundaries, surface keratinization, roughness, and a hard and tough feeling when touched. If the superficial white keratinized mucosa is scraped off, bleeding at the base is easy, and it usually has an itching sensation, sometimes severe itching, which can cause redness, edema, erosion, or lichenoid changes due to scratching and friction.

　　1. Active prevention and treatment

　　Diseases such as diabetes and endocrine disorders; improve malnutrition, vitamin deficiency, and other conditions; prevent and treat related diseases such as EB virus and Candida albicans infection; pay attention to local hygiene of the vulva, reduce dampness, friction, and heat stimulation, etc.

　　2. Prognosis

　　Some scholars report that 10% of patients with leukoplakia of the vulvar mucosa eventually develop vulvar cancer. The literature states that the incidence of mucosal leukoplakia cancer is 4% to 6% (Rook, 1996). Wang Jibai (1991) reported that among 85 cases of vulvar leukokeratosis and mucosal leukoplakia, 7 cases transformed into squamous cell carcinoma, with an incidence rate of 8.2%. Su et al. (1995) used immunohistochemical technology to detect the relationship between p53 gene protein expression and vulvar cancer, among which there were 17 cases of vulvar squamous cell carcinoma, 34 cases of mucosal leukoplakia, and normal skin from the abdomen and lower leg, as well as adjacent tissue of vulvar cancer, were used as controls for observation. The positive rate of p53 gene mutation protein in vulvar cancer was 52.9% (9/17 cases), and in mucosal leukoplakia was 14.7% (5/34 cases). The expression rate of p53 gene mutation protein in vulvar cancer and precancerous lesions is higher than that in vulvar mucosal leukoplakia, thus p53 gene mutation is one of the reasons for the abnormal active proliferation of cells.

　　The diagnosis of leukoplakia of the vulvar mucosa, in addition to clinical manifestations, also requires essential related examination methods. Common examinations include the following:

     1. Vaginal secretion examination and microbiological examination to exclude infectious diseases.

　　2. Conduct histopathological examination for the benefit of diagnosis and differential diagnosis.

　　Vulvar leukoplakia is a common gynecological disease, mainly characterized by itching. In the past, various vulvar lesions with symptoms of itching, combined with skin and mucosal whitening, thickening, or atrophy, were collectively called vulvar leukoplakia. Vulvar leukoplakia is often caused by various types of vulvar atrophy, vulvar heat, chronic irritation and itching, certain nutrient deficiencies, allergic reactions, metabolic disorders, and nervous and mental factors, all of which may be causes of the disease. Therefore, this disease is also known as vulvar white lesions and vulvar atrophy.

　　One: Foods to eat

　　1. Eat more foods with anti-vulvar tumor and leukoplakia effects, such as sesame, almond, wheat, barley, loofah, black chicken, cuttlefish, amphisbaena, pig pancreas, chrysanthemum, umeboshi, peach, litchi, Portulaca oleracea, chicken blood, eel, abalone, crab, sea cucumber, sardine, clam, tortoise shell.

　　2. To relieve pain, eat sea cucumber, red, lobsters, clams, sea cucumber, tiger fish, beetroot, mung bean, radish, chicken blood.

　　3. To relieve itching, eat amaranth, cabbage, mustard, taro, kelp, seaweed, chicken blood, snake meat, pangolin.

　　4. To enhance physique and prevent metastasis, eat Tremella, Auricularia,香菇,猴头菇, chicken gizzards, sea cucumber, Coix seed, walnut, crab, lizard, needlefish.

　　Two: Foods to avoid

　　1. Avoid smoking, drinking, and spicy刺激性 foods.

　　2. Avoid greasy, fried, moldy, and preserved foods.

　　3. Avoid foods that cause boils, such as rooster, goose, etc.

　　4. Avoid seafood and刺激性, allergenic foods when there is severe itching.

　　5. Avoid warm and spicy foods such as mutton, chives, ginger, pepper, cassia, etc. when there are ulcers and bleeding.

　　One: Traditional Chinese medicine treatment method for vulvar mucosal leukoplakia:

　　1. Formula 1 [Medicines] 15 grams of Phellodendron amurense, 15 grams of Atractylodes macrocephala, 30 grams of Cnidium Monnieri, 30 grams of Sophora flavescens, 12 grams of Schizonepeta tenuifolia, 6 grams of芍药, 6 grams of Carthamus tinctorius, 20 grams of Astragalus membranaceus.

　　[Preparation] Boil the medicine into a decoction, remove the dregs and reserve for later use.

　　[Usage] Take the medicine liquid when it is suitable in temperature, sit in the bath, twice a day, each dose of medicine can be used 2-4 times. If the patient is allergic to Cnidium Monnieri, Sophora flavescens, and芍药, they can change to 30 grams of Dictamnus dasycarpus, 20 grams of Spatholobus suberectus, and 6 grams of Salvia miltiorrhiza; for atrophic type, add 10 grams of Curcuma zedoaria. In addition, external medicine should be applied, for hyperplastic type use Vaginal ointment I, for atrophic type use Vaginal ointment II, and for mixed type, the two medicines should be alternated. After Chinese medicine sitz bath, apply locally, twice a day. This formula is suitable for vulvar white lesions with damp-heat in the liver meridian and blood stasis.

　　[Source] Shaanxi Journal of Traditional Chinese Medicine, 1988; (7): 302.

　　[Note] (1) Children with vulvar atrophy often use Vaginal ointment I, or hydrocortisone, Chinese medicine sitz bath, the dosage of medicine should be adjusted according to age, if ineffective, use ointment II.

　　(2) Vaginal ointment I: consists of 20% cod liver oil ointment 20 grams, dexamethasone 10 grams, and 1 tablet of 5-fluorouracil or hydrocortisone ointment; Vaginal ointment II: consists of 20% cod liver oil ointment 15 grams, testosterone propionate 150 milligrams, sometimes with 1 tablet or half a tablet of 5-fluorouracil.

　　2. Formula 2 [Medicines] 30 grams of Cnidium Monnieri, 30 grams of Sophora flavescens, 30 grams of Forsythia suspensa, 20 grams of Angelica sinensis, 20 grams of Lonicera japonica, 6 grams of Borneol (added later).

　　[Preparation] Boil the medicine into a decoction for later use.

　　[Usage] Take a sitz bath with the herbal decoction. Twice a day, for 20-30 minutes each time, one dose per day. After the sitz bath, apply 0.1‰ estrogen cream to the affected area. A course of treatment is 2 weeks, for the treatment of vulvar leukoplakia.}

　　[Source] Journal of Integrated Traditional Chinese and Western Medicine, 1989; (12): 775.

　　[Note] (1) During treatment, keep the vulva clean, avoid washing with soap, and prevent scratching.

　　(2) Avoid spicy foods.

　　(3) Change clothes frequently and wash them.

　　3. Formula 3 [Herbs] Herba Epimedii 30g, Herba Epimedii 30g, Periplaneta sinensis 15g.

　　[Preparation] Boil the herbs to make the decoction for later use.

　　[Usage] Take the herbal decoction while hot and fumigate and wash the affected area, twice a day, for the treatment of vulvar leukoplakia.

　　[Source] Comprehensive Book of External Treatment of Chinese Herbs.

　　Secondly, Western treatment methods for vulvar mucosal leukoplakia

　　Appropriate treatment of mucosal leukoplakia can prevent further deterioration in 97% of cases.

　　1. Active treatment of accompanying diseases, control blood sugar, correct endocrine disorders and malnutrition, supplement vitamins, etc.

　　2. Local treatment: Keep the vulva clean and dry, avoid excessive washing with soap, etc. Local use of herbal decoctions with cooling, detoxifying, and drying properties. When itching is obvious, topical corticosteroid hormones such as hydrocortisone ointment or butylhydrocortisone cream can be used locally. When itching is particularly severe, topical halometasone (sicorten) cream or ointment and clobetasol (Tremefur) cream or ointment can be used, with good effects. Keratotic hyperplastic lesions can be treated locally with 0.025% to 0.05% tretinoin cream or 2.5% fluorouracil cream. Fluorouracil cream can block the conversion of uracil deoxyribonucleotide to thymine deoxyribonucleotide, inhibit DNA synthesis, and prevent the proliferation, division, and differentiation of tumor cells, thus it can be locally applied to treat precancerous skin lesions and malignant skin lesions.

　　3. The surgical removal of mild atypical hyperplasia of the vulvar leukoplakia can be completely cured and alleviated through integrated traditional Chinese and Western medicine treatment, and it is not necessarily developed into squamous cell carcinoma. Therefore, it is first necessary to determine the degree of atypical change in vulvar leukoplakia, which usually requires regular follow-up observations while integrating traditional Chinese and Western medicine treatment. For those who do not heal for a long time, surgery is the exact indication for vulvar leukoplakia only when there is obvious atypicality in the keratinocytes and a tendency to develop into in situ carcinoma.