Review of Atlas of Vulvar Pathology. 3rd ed. by EJ Wilkinson, IK Stone

François Milette1

1 Centre Hospitalier Pierre-Boucher, Longueuil, Canada

Citation: Milette F. Review of Atlas of Vulvar Pathology. 3rd ed. by EJ Wilkinson, IK Stone. Dermatol Pract Concept. 2014;4(2): 17.

Copyright: ©2014 Milette. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Corresponding author: François Milette M.D., Centre Hospitalier Pierre-Boucher, Longueuil, Canada. Email:

The cover

Figure 1. Wilkinson EJ, Stone IK. Atlas of Vulvar Pathology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2012. ISBN: 1451132182.274 pages. List price: $164.99.

Review by François Milette

This atlas of vulvar disease (sic) is the result of a collaboration between a gynecologist and a pathologist who benefited from the advice of a colleague, Dr. Ann Church, dermatologist and dermatopathologist.

The difficulties inherent to the dialogue between clinicians and pathologists are apparent in that two different classifications of the diseases discussed in the book are given: “one which the reader can search under specific disease headings and another in which the clinical presentation is the guide,”as stated in the preface.

The second classification based on clinical presentation is the one on which the structure of the whole book is based. It includes the following categories, a chapter being devoted to each successively: (1) Cysts; (2) Maculae; (3) Papillae; (4) Papules; (5) Plaques; (6) Tumors, benign; (7) Ulcers; (8) Verrucae; (9) Vesicles/bullae; (10) Pediatrics; (11) Trauma; (12) Tumors, malignant; and (13) Vulvodynia and vestibulodynia.

The logic of this classification is certainly questionable, as the various categories are neither exclusive nor complete. Moreover, lesions are distributed in these various categories and chapters in a bizarre and completely arbitrary manner. Malignant melanoma, for instance, is classified in the chapter about papules and not in the chapter on malignant tumors. A melanoma certainly can present as a papular lesion, but it can also occur as a macule, a plaque or an ulcer and it certainly is a malignant tumor. Another evident flaw in this classification is exemplified by verrucous carcinoma, which is addressed in the chapter on verrucae as if it were not the malignant neoplasm that it is.

The “specific disease headings” referred to in the preface are dispersed almost randomly throughout the book. Moreover, this histologic classification, although purportedly referring to specific headings, is presented as only a “cross-reference” to the clinical presentation classification and it, too, is flawed (for example, lichen planus is classified as a “non-neoplastic epithelial disorders” and not as the non-infectious inflammatory disorder that it is).

This having been said concerning the general organization of this book, if one can overcome the reservations induced by the limitations apparent in the table of contents, one will discover a very good chapter devoted to the anatomy, macroscopic and microscopic, of the vulva and to a practical discussion of the general approach to vulvar problems.

Following this introduction to vulvar problems, the following chapters, enumerated earlier, are each introduced by an algorithm, the algorithmic nature of which is not always evident. For instance, the ulcer algorithm on page 121 is only a list of confirmatory tests of presumed diagnoses and not, as one would expect, a tool for evaluation of a vulvar ulcer (Figure 2.)

Figure 2. Ulcer algorithm, page 121, Atlas of Vulvar Pathology.

Following the algorithm, each chapter presents various lesions that are discussed in a constant and well-structured succession of paragraphs devoted to: (1) Definition; (2) General features; (3) Clinical presentation; (4) Adjunctive studies; (5) Differential diagnosis; (6) Microscopic features; (7) Clinical behavior and treatment; and (8) Progressive therapeutic options.

As a pathologist, I was somewhat deceived by the relatively superficial treatment of histology. In the discussion of psoriasis, for instance, the stereotypical histopathology of the disease is presented and little attention is given to the fact that vulvar psoriasis is most often not stereotypical histologically and therefore is often difficult to diagnose. This may lead to a false impression of facility in the mind of the student.

Some definitions given in this book are questionable. For example, seborrhea (seborrheic dermatitis) is as a chronic inflammatory disease associated with a characteristic distribution in areas of sebum production, particularly the face and scalp defined (page 90). In fact, the microscopic description on page 100 is a much better definition: Seborrheic dermatitis is a spongiotic dermatitis affecting the hair follicle.  Seborrheic dermatitis has nothing to do with sebum production and the term seborrheic is a misnomer in the context of this dermatitis. Therefore the legend to figure 6.24: “Note the loss of pubic hair related to excess sebum production,” states a falsity.

The therapeutic options are presented in a progressive way, thus aiding a student and the patient to plan therapy adapted to the severity of the clinical condition.

Last, I must add a word concerning the images in this book. The quality of the clinical photographs are excellent and in fact much better than that of the microphotographs. This is probably because the authors are primarily clinicians.

Do you like atlases? Personally, I have often been deceived by atlases and have concluded that they are more useful to their authors than to their readers. The present book is no exception. Nevertheless it certainly has value either as an introduction to vulvar diseases for residents in gynecology, dermatology or pathology or as a synthetic review of vulvar pathology for the practicing clinician or pathologist.