Management of VIN depends on multiple factors. For VIN 1, treatment is generally avoided (e.g., persistent lesions; cosmetic concerns). For patients with VIN 2 or 3, treatment is usually recommended, although observation is initially reasonable for women who have recently completed a course of corticosteroids, who are temporarily immunocompromised or who are pregnant. Spontaneous regression of untreated VIN 3 has been reported, particularly among young women with multifocal disease (Jones, 2000). Current treatments for VIN, although numerous, have largely resulted in suboptimal outcomes. Response rates have been poor and relapse rates high. Recurrence rates following many medical or surgical therapies range from 39% following local excision and 70% following laser ablation to 90% in some studies of 5-flourouracil (Stanley, 2003). Finally, the resultant physical and psychological morbidity associated with such therapies can be profound.

In the end, agents that enhance or induce strong cell-mediated immune responses likely hold the greatest promise not only for control of HPV-related disease but also for reduction of future recurrences. Photodynamic therapy (PDT) appears to act as such an immunomodulator. PDT, using photosensitizers such as aminolevulinic acid, has demonstrated complete clearance rates of 66% for condyloma and 57% for high-grade VIN. Topical 5% imiquimod, another immunomodulator, acts by activating macrophages and dendritic cells to release IFN-alpha and other proinflammatory cytokines. These cytokines in turn lead to activation of the appropriate antigen-specific immune response. Imiquimod’s efficacy in the treatment of genital warts is well-documented, and in a number of recent trials, its use has been associated with encouraging results in the treatment of VIN 2/3 (Le, 2007). In a recent randomized, controlled trial, Mathiesen (2007) and colleagues documented a complete response in 18 of 21 (81%) of those using imiquimod as compared to none of 10 on placebo. Referral of patients with vulvar cancer to gynecologic oncologists for surgical treatment, and/or radiation therapy and chemotherapy, is appropriate.