Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(1):e2024015 1 Painful Hemorrhage of Vestibular Papillae: A Probably Underreported Complication of Vestibular Papillomatosis Emilio Lopez-Trujillo1, Sonia Segura2, Julia Maria Sánchez-Schmidt1 1 Department of Dermatology, Hospital de Terrassa, Barcelona, Spain 2 Department of Dermatology, Hospital del Mar, Barcelona, Spain Key words: vestibular papillomatosis, dermoscopy, vestibular papillae hemorrhage, female genitalia Citation: Lopez-Trujillo E, Segura S, Sánchez-Schmidt JM. Painful Hemorrhage of Vestibular Papillae: A Probably Underreported Complication of Vestibular Papillomatosis. Dermatol Pract Concept. 2024;14(1):e2024015. DOI: https://doi.org/10.5826/dpc.1401a15 Accepted: May 20, 2023; Published: January 2024 Copyright: ©2024 Lopez-Trujillo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Emilio Lopez-Trujillo, M.D, Department of Dermatology. Hospital de Terrassa, Barcelona. Carr. Torrebonica, s/n, 08227 Terrassa, Barcelona. Telephone: (+34) 619625427 / E-mail: emilio08tr@gmail.com Introduction Vestibular papillomatosis (VP) is a benign condition of the female external genitalia characterized by small projections or bumps on the vestibular area of the vulva, which can be mistaken for genital warts [1]. Some associated symptoms, such as vestibular pruritus or dyspareunia, have been de- scribed as possible complications [2]. Here we report the first known case of painful hemorrhage of vestibular papillae as a complication of VP. Case Presentation A 29-year-old female presented with a 2-day evolution of a rapidly growing, painful reddish lesion on the external la- bia minora. The patient was anxious about a possible ma- lignancy. She had no relevant medical history and did not report previous vulvar pruritus or dyspareunia. The patient had a normal gynecological check-up two weeks before, with negative serology for sexually transmitted infections and negative cervical cytology. She reported no genital trauma and sexual abstinence for the previous 3 months. Physical ex- amination revealed a 3-mm painful erythematous-violaceous papule located at the edge of the left labia minora, accom- panied by multiple uniformly arranged, soft, skin-colored tubular papillae on inner labia, with round tips and separate bases, consistent with a diagnosis of vestibular papillomato- sis ( Figure 1A). Dermoscopy revealed a well-circumscribed red-bluish papule with focal delicate scaling in the outer area and multiple tortuous and linear vessels (Figure 1B). After further history taking the patient recalled tight-fitting clothes as the only causative factor. As a differential diagnosis, papil- lary hidradenoma of the labia minora, vestibular gland cyst, syringomas, condyloma acuminatum, vulvar endometriosis and other tumors that could present with hemorrhage were considered [3]. The patient declined a biopsy of the papular lesion and a conservative approach with close monitoring was de- cided. We advised minimizing external irritants to the gen- ital mucosa (eg avoiding tight clothing, harsh cleaning or 2 Research Letter | Dermatol Pract Concept. 2024;14(1):e2024015 scratching). At the two-week follow-up, the papule had de- creased in size (Figure 1C), was painless upon palpation and showed normal color and appearance, similar to the contig- uous vestibular papules (Figure 1, C and D). Consequently, the diagnosis of self-resolving hemorrhage of a vestibular papilla was established. Conclusions Knowledge of the characteristic appearance and behavior of VP is essential in distinguishing it from other genital lesions [4]. Clinicians must be sensitive to the emotional and psycholog- ical distress that patients may experience and provide appro- priate education and counseling. Dermoscopy proved to be a valuable diagnostic tool in our case of vestibular papilla hemorrhage. The presence of red-bluish coloration, focal superficial desquamation, and vascular engorgement on dermoscopy suggested a traumatic origin of the lesion, leading to papillary hemorrhage. These findings complement the initial description of dermoscopy features of VP by Thakare et al and underscore the utility of dermoscopy in the diagnosis of VP lesions and their compli- cations [5]. This case serves to expand the knowledge base of VP and highlights the importance of considering a complicated ves- tibular papillomatosis in the differential diagnosis of genital lesions. Further studies are needed to better understand the impact of VP complications on the quality of life of the af- fected patients. References 1. Prieto MA, Gutiérrez JV, Sambucety PS. Vestibular papil- lae of the vulva. Int J Dermatol. 2004;43(2):143-144. DOI: 10.1111/j.1365-4632.2004.01863.x. PMID: 15125508. 2. Sarifakioglu E, Erdal E, Gunduz C. Vestibular papillomato- sis: case report and literature review. Acta Derm Venereol. 2006;86(2):177-178. DOI: 10.2340/00015555-0027. PMID: 16648932. Figure 1. Clinical and dermoscopic findings of vestibular papillomatosis complicated with hemorrhage. (A) Painful erythematous vestibular papule with a violaceous hue at the ini- tial visit. (B) Dermoscopy shows a red-bluish finger-like papule, in the context of vestib- ular papillomatosis, with focal superficial scaling in the outer area and multiple tortuous and linear vessels throughout its surface. (C) Complete self-resolution of papillae hemor- rhage, resulting in reduction of its size and normalization of color at two weeks follow-up. (D) Dermoscopy shows multiple pink, soft, uniformly arranged tubular papillae on inner labia, with round tips and separate bases, and confirms hemorrhage resolution. Research Letter | Dermatol Pract Concept. 2024;14(1):e2024015 3 3. Sally R, Shaw KS, Pomeranz MK. Benign “lumps and bumps” of the vulva: A review. Int J Womens Dermatol. 2021;7(4):383-390. DOI: 10.1016/j.ijwd.2021.04.007. PMID: 34621949. PMCID: PMC8484947. 4. Muhammed RT, Afra TP, De D. Vestibular papillomatosis: a nor- mal variation commonly misdiagnosed as genital condylomata. Am J Obstet Gynecol. 2019;220(4):403. DOI: 10.1016/j .ajog.2018.08.025. PMID: 30144403. 5. Thakare SA, Udare S. Importance of Dermoscopy to Diagnose Vulvar Vestibular Papillomatosis vs. Warts. Indian Dermatol Online J. 2020;11(4):680-681. DOI: 10.4103/idoj.IDOJ_463_18. PMID: 32832480. PMCID: PMC7413464.