Vulval Fissures and Granuloma: Causes, Symptoms, and UK Management

Vulval fissures are thin, linear splits in the skin of the vulva, most commonly appearing in the posterior commissure (the area just below the vaginal opening) or within the skin folds of the labia. Because this area is rich in nerve endings, even a microscopic fissure can cause significant stinging, burning, and discomfort, especially during intercourse, wiping after urination, or physical exercise.

A vulval granuloma, specifically a pyogenic granuloma or a granuloma fissuratum, is a small, fleshy, red growth that may develop at the site of persistent irritation or a non-healing fissure. These growths are benign (non-cancerous) but can bleed easily if bumped or rubbed. In the UK, these conditions are often managed by GPs, though complex cases may be referred to a specialist vulval clinic run by dermatologists or gynaecologists, in line with British Society for the Study of Vulval Disease (BSSVD) guidance.

Fissuring is rarely a standalone condition; it is usually a symptom of a compromised skin barrier or an inflammatory process. Common triggers include:

• Dermatitis: Irritant or allergic contact dermatitis caused by soaps, wipes, or detergents can weaken the skin, leading to cracks.
• Lichen Sclerosus: An inflammatory condition that causes the skin to become thin, white, and fragile, making it highly prone to linear splitting.
• Atrophic Vaginitis: Common during menopause, the lack of oestrogen causes the vulval and vaginal tissues to thin and lose elasticity.
• Chronic Candidiasis: While thrush usually causes a discharge, chronic or recurrent infections can lead to swelling and 'friable' skin that splits easily.
• Mechanical Stress: Friction during sexual activity or tight clothing can trigger fissures if the skin is already dry or inflamed.

Management of vulval fissures focuses on two goals: providing immediate symptom relief and treating the root cause. According to NICE CKS guidance on vulval conditions, the first step is often 'vulval hygiene' and skin protection:

Topical Treatments

If the fissure is caused by an inflammatory condition like eczema or lichen sclerosus, a GP may prescribe a potent topical corticosteroid ointment. For fissures related to menopause, topical oestrogen creams can help restore skin thickness and elasticity. Barrier creams, such as plain white soft paraffin, can protect the area from the irritating effects of urine.

Self-Care Measures

• Soap Substitutes: Avoid all perfumed soaps and shower gels. Instead, use an emollient wash or plain water.
• Loose Clothing: Wear breathable cotton underwear and avoid tight trousers to reduce friction.
• Pat Dry: Never rub the vulval area with a towel; gently pat it dry after washing.
• Avoid Irritants: Stop using wet wipes, feminine deodorants, or scented sanitary products.

Many women find vulval symptoms difficult to discuss, leading to delays in treatment. If you have a persistent split in the skin that has not healed within two weeks, or if you notice a new lump like a granuloma, you should speak to a GP online or in person.

An online GP consultation provides a private, calm environment to discuss your symptoms and medical history. Through OnlineDoctor24, a GP can review your history, offer advice on soap substitutes and barrier creams, and, if appropriate, issue a prescription for treatments such as steroid ointments or antifungal creams. If the GP suspects a condition like lichen sclerosus or if a lesion looks atypical, they can provide a referral for a physical examination or a biopsy at a local clinic to ensure an accurate diagnosis.

A vulval granuloma often appears as a bright red, 'raspberry-like' bump. It is important to distinguish this from other common vulval lumps such as Bartholin's cysts, sebaceous cysts, or vulval warts (caused by HPV). While a granuloma is typically an inflammatory response to a fissure or irritation, any new or changing lump on the vulva must be assessed by a healthcare professional to rule out malignancy, particularly in post-menopausal women. In the UK, the 'two-week wait' pathway is used for any suspicious vulval lesions to ensure rapid specialist assessment.