Reviewer’s report
Title: 
Vulvar Crohn’s Disease in an adolescent diagnosed after unsuccessful
surgical treatment: A case report
Version: 
0 
Date: 
17 Jun 2021
Reviewer: 
Francesca Cisotto
Reviewer's report:
The manuscript of Kim et collegues (Vulvar Crohn's Disease in an adolescent
diagnosed after unsuccessful surgical treatment: a case report), presents a case
report of a 18-year-old woman with perineal pain and recurring labia major
abscess. Many differential diagnoses have been considered and confirmation of
Vulvar Crohn's disease (VCD) was made after clinical, imaging and
histopathological evaluation.
After treatment with azathioprine 50 mg daily and mesalazine1 g three times
daily, vulvar lesions resolved after 6 weeks.
Vulvar Crohn's disease (VCD) is a rare extraintestinal cutaneous manifestation
of Crohn's disease. The clinical presentation of VCD was variable but vulvar
swelling, vulvar ulceration, pain and local erythema were the most commonly
presenting symptoms, with or without GI symptoms. The histopathology almost
invariabily demonstrated non-caseating vulvar granulomas.
VCD diagnosis and therapeutic management are challenging and to our
knowledge, no consensus guidelines are available.
Correct diagnosis is the key and it is based on a clinical-pathologic correlation.
Nonetheless histopathological analysis is required to support diagnosis and
imaging techniques (in particular ultrasonography, MRI and enterography) to
identify eventual abscesses or fistulas. 
I appreciate the case report exposure, all important informations are reported,
figures are appropriate and useful to follow the diagnostic work-up.
In the Discussion I suggest to stress the importance of pelvic MRI and anorectal
endoscopic ultrasound that could rule out a possible underlying rectovaginal
fistula complex and provide and advice towards diagnosis.
A combination of topical and systemic therapy (with immunosuppressive agents
and tumor necrosis factors alpha inhibitors) is often required. Surgery should be
reserved for patients in which lesions refractory to medical therapy are found.
In my opinion the authors should consider the possible correlation between VCD
and vulvar malignancies. Indeed a small percentage of patients with VCD were
diagnosed with high-grade dysplasia or carcinoma. The correlation remains
uncertain, but the possibility of a dysplasia related to inflammatory 
environment
or immunosuppressive therapy has to be considered. Increased gynecological
surveillance in patients with VCD may be beneficial. 
I suggest to consider this paper DOI: 10.1097/DAD.0b013e31820a2635
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