Vulvar Lesions: Common Causes and When to See a Doctor

What counts as a vulvar lesion

The vulva includes the outer and inner lips (labia majora and minora), the clitoris, the mons pubis and the skin around the vaginal and urethral openings. A lesion is any area that looks different from the surrounding skin. Doctors describe lesions by type, because each type points to different causes:

• Ulcers and sores: open, broken skin
• Blisters: small fluid-filled bubbles
• Bumps (papules and nodules): raised, solid spots
• Lumps and cysts: larger swellings under the skin
• Patches and plaques: flat or slightly raised areas of white, red or dark skin

The British spelling is "vulval" and the American spelling is "vulvar". Both mean the same thing.

Common causes of vulvar lesions

Ulcers and blisters

• Genital herpes: the most common cause of genital ulcers. Clusters of small, painful blisters burst to leave shallow sores, often with burning, tingling and painful urination. A first outbreak may come with fever, aches and swollen glands in the groin. Later outbreaks are milder.
• Syphilis: a single, firm, round, usually painless ulcer (chancre) appears about 3 weeks after infection. It heals on its own within weeks, but the infection continues unless treated.
• Non-sexual ulcers (Lipschütz ulcers): large, painful ulcers in girls and young women, often after a viral illness such as mononucleosis or flu. They are not sexually transmitted and heal on their own.
• Behçet's disease: recurring painful mouth and genital ulcers, with eye or joint problems.
• Chancroid: painful ulcers with tender groin glands. Rare in the US.

Bumps and lumps

• Folliculitis and ingrown hairs: small red or pus-filled bumps around hair follicles, common after shaving or waxing. See folliculitis.
• Genital warts: soft, skin-colored or brown bumps, flat or cauliflower-shaped, caused by low-risk types of HPV. Usually painless.
• Molluscum contagiosum: small, firm, pearly bumps with a dimple in the center.
• Bartholin cyst or abscess: a lump at the lower side of the vaginal opening. A cyst is painless. An infected one (abscess) becomes swollen, red and very painful.
• Epidermoid (sebaceous) cysts: small, firm, yellowish lumps under the skin, usually harmless.
• Hidradenitis suppurativa: recurring painful boil-like lumps in the groin and vulva that drain and scar.
• Skin tags, moles and angiokeratomas: usually harmless growths. A changing mole needs checking.

White, red or thickened patches

• Lichen sclerosus: thin, white, crinkled or shiny skin with intense itching, sometimes with tearing and bruising. It is most common after menopause but occurs at any age, including in children. It needs treatment because it can scar and slightly raises the risk of vulvar cancer.
• Lichen planus: painful red erosions or white lacy lines on the vulva and inside the vagina.
• Lichen simplex chronicus: thick, leathery skin from long-term scratching.
• Yeast infection (vulvovaginal candidiasis): red, itchy, sore skin, sometimes with small satellite spots and thick white discharge. See vaginal itching.
• Contact dermatitis: red, itchy or burning skin after exposure to soaps, bubble bath, scented pads, wipes, spermicides or latex.
• Psoriasis: well-defined red patches, usually without the scale seen elsewhere on the body.

Precancer and cancer

• Vulvar intraepithelial neoplasia (VIN): precancerous change, often linked to high-risk HPV. It can look like a raised white, red, gray or dark patch, and often itches.
• Vulvar cancer: uncommon and mostly affects women over 60. Warning signs are a lump, ulcer or thickened patch that does not heal, bleeding not related to periods, and persistent itching or pain.
• Melanoma: a dark, irregular or changing spot.

Telling vulvar lesions apart

Symptoms that often come with vulvar lesions

• Itching: common with yeast infection, lichen sclerosus, contact dermatitis and VIN.
• Burning or pain: herpes, lichen planus, irritation and abscesses. See vulvar pain.
• Painful urination: urine stings when it touches broken skin, especially with herpes.
• Unusual discharge: suggests a vaginal infection.
• Swollen glands in the groin: suggest infection, and less often cancer.
• Pain during sex: common with lichen planus, lichen sclerosus and fissures.

How vulvar lesions are diagnosed

A clinician will ask when the lesion appeared, whether it hurts or itches, whether it has happened before, about sexual partners, new products and medicines, and your skin history. They will examine the vulva, sometimes with a magnifying light (colposcope).

Tests depend on what they find:

• Swab from a sore or blister for herpes PCR testing
• Blood tests for syphilis and HIV, plus tests for chlamydia and gonorrhea
• Swab of discharge for yeast and other vaginal infections
• Skin biopsy: a tiny sample taken under local anesthetic. It is the only way to confirm lichen sclerosus, VIN or cancer, and is recommended for any lesion that is persistent, unusual, or not responding to treatment.

Treatment for vulvar lesions

Treatment depends entirely on the cause, so avoid self-treating repeatedly without a diagnosis.

• Herpes: antiviral tablets shorten outbreaks. Daily suppressive treatment helps frequent recurrences.
• Syphilis: penicillin injections cure it. Partners need testing.
• Warts: prescription creams, freezing (cryotherapy) or removal.
• Yeast infection: antifungal creams, pessaries or tablets.
• Lichen sclerosus and lichen planus: strong steroid ointment, used as directed, then maintenance treatment and yearly checks.
• Bartholin abscess: drainage, sometimes with a small catheter or a minor procedure to prevent recurrence.
• VIN and cancer: removal by surgery or laser, with specialist follow-up.

Home care while you wait to be seen

• Wash with plain warm water only. Avoid soap, bubble bath, douches and scented products.
• Wear loose cotton underwear and avoid tight clothing.
• Pat dry rather than rubbing.
• For painful sores, pour lukewarm water over the area while passing urine, or sit in a shallow lukewarm bath.
• Use a plain barrier ointment such as petroleum jelly to protect sore skin.
• Avoid sex until sores have healed and you have a diagnosis.

Preventing vulvar lesions

• Use condoms and dental dams to reduce the risk of herpes, syphilis and warts. They do not fully protect against skin-to-skin infections.
• Get the HPV vaccine, which prevents most genital warts and HPV-related precancer.
• Go for regular STI testing if you have new partners.
• Avoid irritating products, and shave in the direction of hair growth with a clean razor.
• Check your vulva with a mirror now and then, so you notice changes early.

Frequently asked questions

What are common causes of vulvar lesions?

The most common causes are ingrown hairs and folliculitis, cysts, yeast infections, skin irritation from products, genital herpes and genital warts. Less common but important causes include syphilis, lichen sclerosus, lichen planus, precancerous changes (VIN) and vulvar cancer. The look of the lesion and whether it hurts help narrow it down.

Are vulvar lesions always an STI?

No. Many vulvar lesions are not sexually transmitted. Ingrown hairs, cysts, yeast infections, contact dermatitis, lichen sclerosus and non-sexual ulcers after a viral illness are all common. Testing is the only reliable way to know, so see a clinician for any new sore or ulcer.

What does a cancerous lesion on the vulva look like?

Vulvar cancer often appears as a lump, a thickened or raised patch, or an ulcer that does not heal. It may be white, red, pink or dark. Persistent itching, pain or bleeding not related to periods are other signs. Any lesion lasting more than 2 to 3 weeks should be checked and may need a biopsy.

What causes white patches on the vulva?

The most common cause is lichen sclerosus, which makes the skin thin, white and crinkly, with intense itching. Other causes include lichen simplex chronicus from scratching, vitiligo, which causes painless color loss, and less often precancerous changes. A biopsy may be needed to confirm the cause.

Is a painless sore on the vulva serious?

It can be. A single painless, firm ulcer is the classic sign of syphilis, and painless lumps or patches can be warts, molluscum or, rarely, precancer or cancer. Painless does not mean harmless, so have any new sore examined, especially if it does not heal within 2 to 3 weeks.