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What ARE Those Little White Bumps?

One of the most frequent concerns expressed on our WebMD GYN message board, and our “Friends Talking” message boards relates to “bumps” or “pimples” on the vulva. Usually these lesions have just been noticed, rather than being present for a long time. So let’s consider what some of the causes might be.

Occasionally a woman will refer to the raised lesion as a “cyst”. Cysts are a common occurrence, and can arise most any place on the body. In the area of the vulva a cyst is usually created by a blocked sweat (“apocrine”) or skin (“sebaceous gland”) gland. For example, if a hair follicle gets blocked it can fill with the debris of exfoliated/shed skin cells which causes the lining of the follicle to get distended. This is similar to what happens when one develops a “white head” pimple on the face. On the genitals, such cysts are called “epithelial inclusion cysts”.

If the cyst continues to enlarge to a size greater than a half inch, it can incised with a sterile instrument and drained in a sterile fashion. While some women attempt to “squeeze” a cyst to extrude the “cheese-like” skin-cell debris, this is not a good idea. Normal skin bacteria can enter through the break in the skin and set up an infection.

There are some specific genital sites where drainage ducts can get blocked and create cysts. These are named after the area in which they occur:

  • Skene’s duct cysts are located on either side of the urethra. These may be treated with warm moist soaks–or can require incision and drainage.
  • Vaginal cysts of embryonic origin typically are not a recent blocked duct opening. Rather they are a cyst which developed in utero. These are treated with surgical excision if they continue to grow in size over time.
  • Bartholin’s duct cysts can develop on either side of the lower portion of the labia majora. These can grow to be the size of walnuts and usually are noticed because of a rapid increase in size and tenderness. Three times per day warm soaks or sitz baths are tried first, followed by incision and drainage if needed. Bartholin’s cysts tend to reoccur. If this happens the cyst may be surgically opened and the sides sewn open (like keeping a purse permanently open) to be sure no fluid or skin cells accumulate. This procedure is called “marsupialization.”

There are two conditions where clogged sweat glands can create bumps on the vulva:

  • Fox Fordyce is an itchy type of skin lesion which can range in size from small papules to cyst sized bumps. They may also be found on the lower abdomen and thighs. Keratin or skin debris clogs the apocrine/sweat glands, thus it is not a bacterial infection which requires antibiotics. It may be treated with a steroid cream or phototherapy.
  • Hiradenitis suppurativa, by contrast, is a clogged sweat gland which often has a secondary bacterial infection associated with the bumps. This condition does not itch, but can be very painful if deep, infected cysts or nodules form. These areas tend to leave a shiny scar of darkened skin. Somewhat more common in women who have acne, these lesions are often treated with acne-type approaches such as oral or topical antibiotics, or even oral Accutane. Steroids and birth control pills have also been tried. If there are large hardened nodules, or draining fistulas (tracts for pus to travel from one nodule to another), the area can be surgically treated

While on the subject of infections we should mention some of the most common vulvar infections which can create bumps or pimples:

  • Folliculitis is the most common cause of irritated or tender, raised lesions. Common skin bacterias such as staph or strep get into a hair follicle through a tiny break in the skin (eg bikini shave nicks). The area of infection can remain a small “folliculitis” or it can increase in size to become a “furuncle.” A larger, or deeper, infected skin abscess is called a “carbuncle.” Depending upon the size and degree of infection, incision/drainage or antibiotics may be utilized as treatments.
  • Skene’s duct, or Bartholin’s duct, abscesses might require antibiotics if a bacterial infection takes advantage of the cyst formed in the clitoral or labial area.

Sometimes the infection is viral rather than bacterial:

  • Molluscum contagiosum is caused by a pox virus. The bumps on the vulva or thighs are small, fleshy, and round often with a small indentation in the middle of the round lesion–like a bellybutton. These bumps tend to regress in time even without treatment. For cosmetic purposes they can be removed by freezing/cryo.
  • Human papilloma virus (HPV) subtypes 6 and 11 cause the visible genital warts which look like little cauliflowers. These rough to touch, raised growths can expand in size and number–especially in times of a suppressed immune system (eg pregnancy, illness, etc.). HPV lesions can be treated with applications of bi or trichlorocetic acid, freezing/cryo, or an immune system enhancing cream (“Aldara”).
  • Herpes simplex virus (HSV) is more often linked to an itching, burning area which might be slightly raised. It can look like a bug bite in its early stages, but within several days it becomes an open ulcer or cut in the skin–not a bump.

There are a number of medical conditions which can produce bumps which are not related to clogged ducts or infections:

  • Acanthosis nigricans produces velvety, dark raised areas on the vulva, armpits, and neckline. It is linked with insulin resistance, the metabolic change found in polycystic ovarian syndrome (“PCOS“).
  • Neurofibromatosis creates nodular areas all over the body, not just the vulva. This is an uncommon, genetically transmitted disorder.
  • Angiokeratomas as the name implies are created by small blood vessels. When there are dilated capillaries grouped together dark red to purple raised spots are visible. There may not be any symptoms until friction to the capillaries causes bleeding. Treatment is by freezing/cryo or surgical removal.

Lastly there are “normal” findings which a woman may suddenly discover:

  • Skin tags, or even remnants of the hymenal ring around the vaginal opening, can be mistaken for bumps. As one might expect these are soft and fleshy with irregular
    shapes.
  • Papillomatosis is frequently mistaken for genital warts, but is a normal variation in the vaginal/vulvar anatomy. If genital warts look like a cauliflower, these look like stalks of asparagus–more fingerlike than raised bumps.

Given the multitude of possible causes of bumps or lesions in the genital area it is important to have them examined by a GYN or other healthcare provider to ensure proper treatment. For more in-depth information you can visit this WebMD site targeted to healthcare personnel. 

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