Background Vulvar complaints are among the most frequent causes for a woman to visit a healthcare provider. The diseases of this area of the body may be a challenge to diagnose. In this study, we assess epidemiologic and clinical data of patients in an outpatient vulvar clinic in the dermatology department of a tertiary hospital. MethodsWe performed an observational retrospective study of patients who attended our consultation service for vulvar diseases at the Dermatology Division at Hospital das Cl ınicas da Faculdade de Medicina da USP during a 4-year period. Data were obtained by patient medical records and by phone.Results During the 4-year period under study, a total of 136 patients were treated in the outpatient service specialized in vulvar care. All patients were included in the study. The most frequent diagnoses were lichen sclerosus et atrophicus (64.7%), lichen planus (8.8%), and vitiligo (8%). We registered that 26.7% of the patients showed extravulvar involvement.Conclusions Women with vulvar diseases need specific care, considering not only genital aspects but also all skin changes. In this context, the dermatologist is a very well trained professional to take good and complete care of these patients. However, ideally vulvar clinics should have a multidisciplinary team.

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A 53-year-old male presented with lichenified and excoriated plaques mainly on the hands, forearms and face that had been present since the previous year ( Figure 1). Past medical history was denied. The patient works as a furniture refinisher, using "peroba-rosa" wood (Aspidosperma polyneuron), and denied other possible allergens. A skin biopsy showed spongiotic dermatitis. Patch testing with the Brazilian Contact Dermatitis Group Standard Series 1 was performed, and showed positive reactions to Myroxylon pereirae 10% (balsam of Peru) on day (D) 2 and D4. The patient also had a positive reaction to dust of "peroba-rosa" applied as wood dust wetted with distilled water in an 8-mm aluminium chamber. 136CABEZAS ARTEAGA ET AL. DISCUSSIONThe diagnosis of allergic contact dermatitis is based on a combination of the clinical presentation, a meticulous history, and the results of patch testing. In our patient, the confirmed contact allergen was the wood of A. polyneuron, an exotic hardwood used in construction and furniture, 2 related to the patient's job. A. polyneuron Mueller Argoviensis (Apocynaceae) is a native tree of Brazil, and is typical of the Atlantic forest. 2 The wood of this species has high commercial value. In the literature, there is a series of reports of cases of contact allergy to Aspidosperma sp., found in the wood of an "orange stick" used for manicuring, and in the keyboard of an organ. Jemec and Hausen tested the strong sensitizing potential of this Brazilian wood in guinea-pigs. 3 Our patient also had a positive patch test reaction to M. pereirae. Possible cross-sensitization between trees could be explained by the composition of woods and barks. Aspidosperma sp. contains alkaloids, coumarins, quinones, steroids, triterpenoids, and essential oils. 4 M. pereirae consists of an aromatic liquid derived from the tree bark of Myroxylon balsamum that contains cinnamic aldehyde, cinnamic alcohol, eugenol, isoeugenol, vanillin, benzoic acid, and farnesol. Roesyanto et al reported a rate of 27.2% of combined sensitization to wood tars, fragrance mix and M. pereirae in a population of 1833 patients with proven allergic contact dermatitis. 5 The description of which essential oils are found in hardwoods could give an understanding of the allergen that causes the cross-sensitization. Quinone has already been described as a common allergen among exotic woods. 6,7Continuous exposure to an allergen may produce chronic symptoms. It is important to emphasize the utility of the chemical knowledge of plants. Also, a positive patch test reaction to balsam of Peru may be an important clue regarding wood allergy, although identification of the cross-reacting agent was not possible. Finally, patch testing with suspected woods should be performed in woodworkers, to enable subsequent avoidance of the allergens. ACKNOWLEDGEMENTSWe thank the biologist Mr Ricardo Spina, who assisted in the investigation.

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