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USMLE First Aid

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• Triple screen Measures the following three levels in the maternal serum:1. AFP2. hCG3. Estriol Low, high, low --> Down SyndromLow, low, low --> Trisomy 18high, n/a, n/a --> neural tube defects
• Gestational hypertension (pregnancy-induced hypertension) BP >140/90 mmHg after 20th week of gestation. - No pre-existing hypertension. - No proteinuria or end-organ damage. Treatment:- α-Methyldopa- Nifedipine- Labetalol- HydralazineDeliver at 37-39 weeks.
• Vaginal tumors Squamous cell carcinoma: Usually 2° to cervical SCC, 1° vaginal carcinoma rare- Clear cell adenocarcinoma: Affects women who had exposure to DES (diethylstilbestrol) in utero. Sarcoma botryoides:- Embryonal rhabdomyosarcoma variant- Affects girls <4 years old- Spindle-shaped cells; desmin ⊕- Presents with clear, grape-like, polypoid mass emerging from vagina.
• Ovarian neoplasms - Most common adnexal mass in women >55 years old- Arise from surface endothelium, germ cells, or sex cord stromal tissue- Majority of malignant tumors are epithelial (serous cystadenocarcinoma is the most common). Risk ↑ with:- Advanced age- Infertility- PCOS- Endometriosis- Genetic predisposition BRCA1/2 mutation, Lynch syndrome, strong family history Risk ↓- Previous pregnancy- OCPs- Breastfeeding- Tubal ligation - Presents with adnexal mass, abdominal distension, bowel obstruction, pleural effusion. - Monitor with CA 125 (endothelial marker)
• Benign ovarian neoplasms Surface epithelium tumors:- Serous cystadenoma: Most common ovarian neoplasm. Lined with fallopian tube-like epithelium. Often bilateral.- Mucinous cystadenoma: Multiloculated, large. Lined by mucus-secreting epithelium.- Endometrioma: Endometriosis within ovary with cyst formation. Presents with pelvic pain, dysmenorrhea, dyspareunia. "Chocolate cyst" – endometrioma filled with dark, reddish-brown blood. Complex mass on ultrasound. Germ cell tumors:- Mature cystic teratoma (dermoid cyst): Germ cell tumor with elements from all 3 layers. Most common ovarian tumor in females 10-30 years old. Can present with pain 2˚ to ovairan enlargement or torsion. A monodermal form with thyroid tissue (struma ovarii) uncommonly presents with hyperthyroidism. Sex cord stromal tumor:- Fibroma: Bundles of spindle-shaped fibroblasts. Meigs syndrome – triad of ovarian fibroma, ascites, hydrothorax. "Pulling" sensation in groin.- Thecoma: Like granulosa cell tumors, may produce estrogen. Usually presents as abnormal uterine bleeding in a postmenopausal woman. Brenner tumor: Resembles bladder epithelium (transitional cell tumor). Solid tumor that is pale yellow-tan and appears encapsulated. "Coffee-bean" nuclei on H&E stain. Usually benign.
• Malignant ovarian neoplasms Surface epithelium tumors:- Serous cystadenocarcinoma: Most common malignant ovarian neoplasms, frequently bilateral. Psammoma bodies.- Mucinous cystadenocarcinoma: Rare malignant mucinous ovarian epithelial tumor. May be metastatic from appendiceal or other GI tumors. Can result in pseudomyxoma peritonei – intraperitoneal accumulation of mucinous material. Germ cell tumors:- Immature teratoma: Aggressive, contains fetal tissue, neuroectoderm. Commonly diagnosed before age 20. Typically represented by immature/embryonic-like neural tissue.- Dysgerminoma: Most common in adolescents. Equivalent to male seminoma but rarer. 1% of all ovarian tumors; 30% of germ cell tumors. Sheets of uniform "fried egg" cells. hCG, LDH = tumor markers.- Yolk sac (endodermal sinus) tumor: Aggressive, in ovaries or testes and sacrococcygeal area in young children. Most common tumor in male infants. Yellow, friable (hemorrhagic), solid mass. 50% have Schiller-Duval bodies (resemble glomeruli). AFP = tumor marker. Sex cord stromal tumros:- Granulosa cell tumor: Most common malignant stromal tumor. Predominantly women in their 50s. Often produces estrogen and/or progesterone and presents with postmenopausal bleeding, sexual precocity, breast tenderness. Histology shows Call-Exner bodies (granulosa cells arranged haphazardly around collections of eosinophilic fluid, resembling primordial follicles). Kruckenberg tumor: GI malignancy that metastasizes to ovary → mucin-secreting signet cell adenocarcinoma. Commonly presents as bilateral ovarian masses. 
• Asherman syndrome Adhesions and/or fibrosis of the endometrium. - Presents with ↓ fertility, recurrent pregnancy loss, abnormal uterine bleeding, pelvic pain. - Often associated with dilation and curettage of intrauterine cavity.
• Leiomyoma (fibroid) Benign smooth muscle tumor. Malignant transformation to leiomyosarcoma is rare. - Most common tumor in females. - Often presents with multiple discrete tumors.- ↑ incidence in African Americans.- Peak occurance at 20-40 years of age - Estrogen sensitive – tumor size ↑ in pregnancy and ↓ with menopause. - May be asymptomatic, cause abnormal uterine bleeding, or result in miscarraige.- Severe bleeding may lead to iron deficiency anemia. - Whorled pattern of smooth muscle bundles with well-demarcated borders.
• Endometrial hyperplasia Abnormal endometrial gland proliferation usually caused by excess estrogen stimulation. - ↑ risk for endometrial carcinoma- Nuclear atypia is greater risk factor than complex (vs simple) architecture. - Presents as postmenopausal vaginal bleeding. Risk factors: - Anovulatory cycles- Hormone replacement therapy- PCOS- Granulosa cell tumor
• Benign breast tumors Fibroadenoma:- Most common in women <35 years old- Small, well-defined, mobile mass- ↑ size and tenderness with ↑ estrogen (eg, pregnancy, prior to menstruation)- Risk of cancer is usually not increased Intraductal papilloma:- Small fibroepithelial tumor within lactiferous ducts, typically beneath areola- Most common cause of nipple drainage (serous or bloody)- Slight (1.5-2x) ↑ risk for cancer Phyllodes tumor:- Large mass of connective tissue with cysts and "leaf-like" lobulations- Most common in 5th decade- Some may become malignant
• Inflammatory breast processes Fat necrosis:- Benign, usually painless, lump due to injury to breast tissue- Calcified oil cyst on mammography- Necrotic fat and giant cells on biopsy- Up to 50% of patients may not report trauma Lactational mastitis:- Occurs during breastfeeding- ↑ risk of bacterial infection through cracks in nipple- S aureus is most common pathogen- Treat with antibiotics and continue breastfeeding
• Malignant breast tumors - Commonly postmenopausal.- Usually arise from terminal duct lobular unit.- Most often located in upper-outer quadrant of breast. - Amplification/overexpression of estrogen/progesterone receptors or c-erbB2 (HER-2, an EGF receptor) is common- Triple negative (ER ⊝, PR ⊝, HER-2⊝) more aggressive - Axillary lymph node involvement indicating metastasis is the most important prognostic factor in early-stage disease.  Risk factors:- ↑ estrogen exposure- ↑ total number of menstrual cycles- Older age at 1st live birth- Obesity (↑ estrogen exposure as adipose tissue converts androstenedione to estrone)- BRCA1 and BRCA2 gene mutations- African American ethnicity (↑ risk for triple ⊝ breast cancer)
• Noninvasive malignant breast cancer Ductal carcinoma in situ:- Fills ductal lumen- Arises from ductal atypia- Often seen early as microcalcifications on mammography- Early malignancy without basal membrane penetration Comedocarcinoma:- Ductal, central necrosis- Subtype of DCIS Paget disease:- Results from underlying DCIS or invasive breast cancer- Eczematous patches on nipple- Paget cells = intraepithelial adenocarcinoma cells
• Invasive breast cancer Invasive ductal carcinoma:- Firm, fibrous, "rock-hard" mass with sharp margins and small, glandular, duct-like cells- Tumor can deform suspensory ligaments → dimpling of skin- Classic morphology: "stellate" infiltration- Most common (~75% of all breast cancers) Invasive lobular carcinoma:- Orderly row of cells ("single file") due to ↓ E-cadherin expression- Often bilateral with multiple lesions in the same location Medullary carcinoma:- Fleshy, cellular, lymphocytic infiltrate- Good prognosis Inflammatory breast cancer:- Dermal lymphatic invasion by breast carcinoma- Peau d'orange (skin texture resembles orange peel due to edema leading to tightening of Cooper's suspensory ligament)- Neoplastic cells block lymphatic drainage- Poor prognosis (50% survival at 5 years)- Often mistaken for mastitis or Paget disease
• Cryptorchidism Undescended testis (one or both); impaired spermatogenesis (since sperm develop best at temperatures <37° C). - Can have normal testosterone levels (Leydig cells are mostly unaffected by temperature).- Associated with ↑ risk of germ cell tumors.- Prematurity ↑ risk of cryptorchidism. - ↓ inhibin B, ↑ FSH, ↑ LH- Testosterone ↓ in bilateral cryptorchidism, normal in unilateral
• Testicular torsion Rotation of testicle around spermatic cord and vascular pedicle.- Commonly presents in males 12-18 years old. - Characterized by acute, severe pain, high-riding testis, and absent cremasteric reflex. Treatment:- Surgical correction (orchiopexy) within 6 hours, manual detorsion if surgical option unavailable in timeframe- If testis is not viable, orchiectomy- Orchiopexy, when performed, should be bilateral because the contralateral testis is at risk for subsequent torsion.
• Varicocele Dilated veins in pampiniform plexus due to ↑ venous pressure.- Most common cause of scrotal enlargement in adult males.- Most often on left side because of ↑ resistance of flow from left gonadal vein into left renal vein.- Can cause infertility because of ↑ temperature. - Diagnosed by standing clinical exam/Valsalva maneuver (distension on inspection and "bag of worms" on palpation; augmented by Valsalva) or ultrasound with Doppler (does not transilluminate). Treatment: consider surgical ligation or embolization if associated with pain or infertility
• Extragonadal germ cell tumors Arise in midline locations. In adults, most commonly in retroperitoneum, mediastinum, pineal, and suprasellar regions. In infants and young children, sacrococcygeal teratomas are most common.
• Scrotal masses Benign scrotal masses present as testicular masses that can be transilluminated (vs solid testicular tumors). Congenital hydrocele:- Common cause of scrotal swelling in infants, due to incomplete obliteration of processus vaginalis.- Most spontaneously resolve by 1 year old.- Transilluminating swelling. Acquired hydrocele:- Scrotal fluid collection 2° to infection, trauma, tumor.- If bloody → hematocele. Spermatocele:- Cyst due to dilated epididymal duct or rete testis.- Paratesticular fluctuant nodule.
• Seminoma Malignant testicular germ cell tumor.- Most common testicular tumor- Does not occur in infancy - Painless, homogenous testicular enlargement - Large cell in lobules with watery cytoplasm and "fried egg" appearance - ↑ placental AFP - Highly radiosensitive- Late metastases, excellent prognosis
• Yolk sac tumor (endometrial sinus tumor) Aggressive malignant germ cell tumor of testes, analogous to ovarian yolk sac tumor. - Yellow, mucinous - Schiller-Duval bodies resemble primitive glomeruli. - ↑ AFP is highly characteristic. - Most common testicular tumor in boys <3 years old.
• Choriocarcinoma Rare malignancy of trophoblastic tissue (cytotrophoblasts, syncytiotrophoblasts).- Can develop during or after pregnancy in mother or baby.- No chorionic villi present. - ↑ frequency of bilateral/multiple theca-lutein cysts.- Presents with abnormal ↑ β-hCG, shortness of breath, hemoptysis.- Hematogenous spread to lungs ("cannonball metastases") and brain.- May produce gynecomastia, symptoms of hyperthyrodism (hCG is structurally similar to LH, FSH, TSH).
• Benign prostatic hyperplasia Common in men >50 years old. - Characterized by smooth, elastic, firm nodular enlargement (hyperplasia not hypertrophy) of periurethral (lateral and middle) lobes, which compress the urethra into a vertical slit. - Not premalignant. - Often presents with ↑ frequency of urination, nocturia, difficulty starting and stopping urine stream, dysuria.- May lead to distension and hypertrophy of bladder, hydronephrosis, UTIs- ↑ free prostate-specific antigen (PSA). Treatment:- α1-antagonists (terazosin, tamsulosin), which cause relaxation of smooth muscle- 5α-reductase inhibitors (eg, finasteride)- PDE-5 inhibitors (eg, tadalafil)- Surgical resection (eg, TURP, ablation)
• Prostatic adenocarcinoma Common in men >50 years old. - Arises most often from posterior lobe (peripheral zone) of prostate gland. - Most frequently diagnosed with ↑ PSA and subsequent needle core biopsies. - Prostatic acid phosphatase (PAP) and PSA may be useful tumor markers (↑ total PSA with ↓ fraction of free PSA). - Osteoblastic metastases in bone may develop in late stages, as indicated by lower back pain and ↑ serum ALP and PSA.
• Important genes of embryogenesis Sonic hedgehog gene: Produced at base of limbs in zone of polarizing activity. Involved in patterning along anteroposterior axis and CNS development. Mutation can cause holoprosencephaly. Wnt-7 gene: Produced at apical ectodermal ridge (thickened ectoderm at distal end of each developing limb). Necessary for proper organization along dorsal-ventral axis. Fibroblast growth factor (FGF) gene: Produced at apical ectodermal ridge. Stimulated mitosis of underlying mesoderm, providing for lengthening of limbs. Homeobox (Hox) genes: Involved in segmental organization of embryo in craniocaudal direction. Code for transcription factors. Hox mutations → appendages in wrong locations. - Assist in development of the axial and appendicular skeleton, central nervous system, gut, and urogenital tract.- Mutations in HOXA13 can cause hand-foot-genital syndrome, a rare dominantly inherited condition characterized by distal limbs defects, such as hypoplastic first digits, and Müllerian fusion abnormalities (eg, uterus didelphys), which can cause miscarriages.
• Twinning Dizygotic ("fraternal") twins arise from 2 eggs that are separately fertilized by 2 different sperm (always 2 zygotes) and will have 2 separate amnionic sacs and 2 separate placentas (chorions)- 2/3rds of all pregnancies Monozygotic ("identical") twins arise from 1 fertilized egg (1 egg + 1 sperm) that splits in early pregnancy. The timing of cleavage determines chorionicity and amnionicity.- Cleavage 0-4 days: Dichorionic diamniotic (25%)- Cleavage 4-8 days: Monochorionic diamniotic (75%)- Cleavage 8-12 days: Monochorionic monoamniotic- Cleavage 13+ days: Monochorionic monoamniotic (Conjoined)
• Umbilical cord - Umbillical arteries (2) – return deoxygenated blood from fetal internal iliac arteries to placenta.- Umbillical vein (1) – supplies oxygenated blood from placenta to fetus; drains into IVC via liver or via ductus venosus- Single umbilical artery (2-vessel cord) is associated with congenital and chromosomal anomalies.- Umbillical arteries and veins are derived from allantois.
• Aortic arch derivatives 1st – Part of maxillary artery (branch of external carotid) 2nd – Stapedial artery and hyoid artery. 3rd – Common carotid artery and proximal part of internal carotid artery. 4th - On left, aortic arch; on right, proximal part of right subclavian artery. 6th - Proximal part of pulmonary arteries, and (on left only) ductus arteriosus Right recurrent laryngeal nerve loops around right subclavian artery.Left recurrent laryngeal nerve loops around aortic arch distal to ductus arteriosus.
• Uterine (Müllerian duct) anomalies Septate uterus: Common anomaly. Incomplete resorption of septum. ↓ fertility and early miscarriage/pregnancy loss. Treat with septoplasty. Bicornuate uterus: Incomplete fusion of Müllerian ducts. ↑ risk of complicated pregnancy, early pregnancy loss, malpresentation, prematurity. Uterus didelphys: Complete failure of fusion → double uterus, cervix, vagina. Pregnancy possible.
• Descent of testes and ovaries Gubernaculum: Band of fibrous tissue.- Male remnant: Anchors testes within scrotum- Female remnant: Ovarian ligament + round ligament of uterus Processus vaginalis: Evagination of peritoneum.- Male remnant: Forms tunica vaginalis- Female remnant: Obliterated
• Estrogen Potency: estradiol > estrone > estriol Source:- Ovary (granulosa cells): 17β-estradiol- Placenta: Estriol- Adipose tissue: Estrone via aromatization Function:- Development of genitalia and breast, female fat distrubution- Growth of follicle, endometrial proliferation, ↑ myometrial excitability- Upregulation of estrogen, LH, and progesterone receptors; feedback inhibition of FSH and LH; then LH surge; stimulation of prolactin secretion- ↑ transport proteins, SHBG; ↑ HDL; ↓ LDL Pregnancy:- 50-fold ↑ in estradiol and estrone- 1000-fold ↑ in estriol (indicator of fetal well-being) Estrogen receptors expressed in cytoplasm; translocate to nucleus when bound to estrogen.
• Human placental lactogen (hPL) Also known as chorionic somatomammotropin.Source: Syncytiotrophoblast of placenta  Stimulates insulin production; overall ↑ insulin resistance → ↑ glucose levels in the maternal circulation; glucose freely crosses the placenta and is continuously consumed by the fetus for energy. Maternal lipolysis is also increased by hPL, with the resulting free fatty acids and ketones providing energy to the mother (preserving glucose and amino acids for the fetus). Gestational diabetes can occur if maternal pancreatic function cannot overcome the insulin resistance.
• Adenomyosis Extension of endometrial tissue (glandular) into uterine myometrium.  - Caused by hyperplasia of basal layer of endometrium. - Presents with dysmenorrhea, menorrhagia, uniformly enlarged, soft, globular uterus. - Treatment: GnRH agonists, hysterectomy or excision of an organized adenomyoma.
• Endometritis Inflammation of endometrium associated with retained products of conception following delivery, miscarriage, abortion, or with foreign body (eg, IUD). - Retained material in uterus promotes infection by bacterial flora from vagina or intestinal tract. - Chronic endometritis characterized by presence of plasma cells on histology. Treatment: gentamicin + clindamycin +/- ampicillin
• Gynecomastia Breast enlargement in males due to ↑ estrogen compared with androgen activity. Causes:- Physiologic in newborn, pubertal, and elderly males- Cirrhosis- Hypogonadism (eg, Klinefelter syndrome)- Testicular tumors- Drugs (spironolactone, cimetidine, finasteride, ketoconazole)
• Fibrocystic changes (breast) Pathology in terminal duct lobular unit.Most common in premenopausal women >35 years old. - Present with premenstrual breast pain or lumps; often bilateral and multifocal.- Nonproliferative lesions include simple cysts (fluid-filled duct dilation, blue dome), papillary apocrine change/metaplasia, stromal fibrosis.- Risk of cancer is usually not increased. Subtypes:- Sclerosing adenosis – acini and stromal fibrosis, associated with calcifications. Slight (1.5-2x) ↑ risk for cancer.- Epithelial hyperplasia – cells in terminal ductal or lobular epithelium. ↑ risk of carcinoma with atypical cells.
• Penile pathology Peyronie disease: Abnormal curvature of the penis due to fibrous plaque within tunica albuginea. Associated with erectile dysfunction. Can cause pain, anxiety. Consider surgical repair once curvature stabilizes. Distinct from penile fracture (rupture of corpora cavernosa due to forced bending). Ischemic priapism: Painful sustained erection lasting >4 hours. Associated with sickle cell disease (RBCs block venous drainage of corpus cavernosum), medications (eg, sidenafil, trazodone). Treat immediately with corporal aspiration, intracavernosal phenylephrine, or surgical decompression to prevent ischemia. Squamous cell carcinoma: Precursor in-situ lesions include Bowen disease (in penile shaft, presents as leukoplakia), erythroplasia of Queyrat (carcinoma in situ of the glans, presents as erythroplakia), Bowenoid papulosis (carcinoma in situ of unclear malignant potential, presenting as reddish papules). Associated with uncircumcised males and HPV. More common in Asia, Africa, South America.
• Testicular non-germ cell tumors 5% of all testicular tumors. Mostly benign.(Germ cell tumors (95%) include: seminoma, choriocarcinoma, yolk sac tumor, teratoma, embryonal carcinoma) - Leydig cell tumor: Golden brown color. Contains Reinke crystals (eosinophilic cytoplasmic inclusions). Produces androgens and estrogens → gynecomastia in men, precocious puberty in boys. - Sertoli cell tumor: Androblastoma from sex cord stroma. - Testicular lymphoma: Most common testicular cancer in older men. Not a 1˚ cancer; arises from metastatic lymphoma to testes. Aggressive.
• Neonatal abstinence syndrome Complex disorder involving CNS, ANS, and GI systems. Secondary to maternal opiate use/abuse. Risk factors for maternal substance abuse during pregnancy include poor mental health, poor prenatal care, low SES, lack of family support, HCV.Universal screening for substance abuse is recommended in all pregnant patients. Newborn presentation:- Uncoordinated sucking reflexes- Irritability- High-pitched crying- Tremors- Tachypnea- Sneezing- Diarrhea- Possibly seizures Treatment: Opioid therapy (eg, morphine, methadone)
• Urethral injury Suspect if blood seen at urethral meatus. Urethral catheterization is relatively contraindicated. Anterior urethral injury:- Bulbar (spongy) urethra- Mechanism: Perineal straddle injury- Blood accumulates around penis, in the scrotum. If Buck fascia is torn, urine escapes into perineal space (lower abdominal wall).- Blood at urethral meatus and scrotal hematoma Posterior urethral injury:- Membranous urethra- Mechanism: Pelvic fracture- Urine leaks into retropubic space- Blood at urethral meatus and high-riding prostate
• Mittelschmerz Transient mid-cycle ovulatory pain - Classically associated with peritoneal irritation (eg, follicular swelling/rupture, fallopian tube contraction)- Can mimic appendicitis
• Abnormal uterine bleeding Characterized as either heavy menstrual bleeding (HMB) or intermenstrual bleeding (IMB). - Structural causes: Polyp, adenomyosis, leiomyoma, malignancy/hyperplasia- Non-structural causes: Coagulopathy, ovulatory, endometrial, iatrogenic
• Child development - Infant (0-12 months) Motor: - Primitive reflexes disappear – Moro (by 3 months), rooting (by 4 months), palmar (by 6 months), Babinski (by 12 months)- Posture – lifts head up prone (by 1 month), rolls and sits (by 6 months), crawls (by 8 months), stands (by 10 months), walks (by 12-18 months)- Picks – passes toys hand to hand (by 6 months), pincer grasp (by 10 months)- Points to objects (by 12 months) Social:- Social smile (by 2 months)- Stranger anxiety (by 6 months)- Separation anxiety (by 9 months) Verbal/cognitive:- Orients – first to voice (by 4 months), then to name and gestures (by 9 months)- Object permanence (by 9 months)- Oratory – says "mama" and "dada" (by 10 months)
• Child development - Toddler (12-36 months) Motor:- Cruises, takes first steps (by 12 months)- Climbs stairs (by 18 months)- Cubes stacked – number = age (yr) x 3- Cutlery – feeds self with fork and spoon (by 20 months)- Kicks ball (by 24 months) Social:- Recreation – parallel play (by 24-36 months)- Rapprochement – moves away from and returns to mother (by 24 months)- Realization – core gender identity formed (by 36 months) Verbal/cognitive:- Words – 200 words by age 2, 2-word sentences
• Child development - Preschool (3-5 years) Motor:- Drive – tricycle (3 wheels at 3 years)- Drawings – copies line or circle, stick figure (by 4 years)- Dexterity – hops on one foot (by 4 years), uses buttons or zippers, grooms self (by 5 years) Social:- Freedom – comfortably spends part of day away from mother (by 3 years)- Friends – cooperative play, has imaginary friends (by 4 years) Verbal/cognitive:- Language – 1000 words by age 3 (3 zeros), uses complete sentences and prepositions (by 4 years)- Legends – can tell detailed stories (by 4 years)
• Diagnosing disorders of sex hormones Testosterone ↑, LH ↑ – Defective androgen receptor Testosterone ↑, LH ↓ – Exogenous steroids, testosterone-secreting tumor Testosterone ↓, LH ↑ – Hypergonadotropic hypogonadism (1°) Testosterone ↓, LH ↓ – Hypogonadotropic hypogonadism (2°)
• Placental aromatase deficiency Inability to synthesize estrogens from androgens. - Masculinization of female (46,XX DSD) infants (ambiguous genitalia). - ↑ serum testosterone and androstenedione. - Can present with maternal virilization during pregnancy (fetal androgens cross the placenta).
• Bartholin cyst and abscess Due to blockage of Bartholin gland duct causing accumulation of gland fluid. - May lead to abscess 2˚ to obstruction and inflammation. - Usually in reproductive-age females. - Associated with N gonorrhoeae infections.
• Lichen sclerosus Thinning of epidermis with fibrosis/sclerosis of dermis.  - Porcelain-white plaques with a red or violet border.- Skin fragility with erosions. - Most common in postmenopausal women. - Benign, but slightly increased risk for SCC.
• Lichen simplex chronicus Hyperplasia of vulvar squamous epithelium. - Presents with leathery, thick vulvar skin with enhanced skin markings due to chronic rubbing or scratching. - Benign, no risk of SCC.

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