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 described as possible complications [ 2 ] . Here we report the first known case of painful hemorrhage of vestibular papillae as a complication of VP.
A 29-year-old female presented with a 2-day evolution of a rapidly growing, painful reddish lesion on the external labia minora. The patient was anxious about a possible malignancy. 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 examination revealed a 3-mm painful erythematous-violaceous papule located at the edge of the left labia minora, accompanied by multiple uniformly arranged, soft, skin-colored tubular papillae on inner labia, with round tips and separate bases, consistent with a diagnosis of vestibular papillomatosis ( 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, papillary 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 decided. We advised minimizing external irritants to the genital mucosa (eg avoiding tight clothing, harsh cleaning or scratching). At the two-week follow-up, the papule had decreased in size ( Figure 1C ), was painless upon palpation and showed normal color and appearance, similar to the contiguous vestibular papules ( Figure 1, C and D ). Consequently, the diagnosis of self-resolving hemorrhage of a vestibular papilla was established.
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 psychological distress that patients may experience and provide appropriate 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 complications [ 5 ] .
This case serves to expand the knowledge base of VP and highlights the importance of considering a complicated vestibular 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 affected patients.
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