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Histopathologically, vulvar (genital) melanosis exhibits, in most cases, increased melanization of the basal keratinocytes, subepithelial fibrosis, and free melanin and melanophages in the submucosa (right panel) The underlying cause and pathogenesis for vulvar melanosis is unknown, but it appears to be a reactive phenomenon [19] showing features that overlap with post-inflammatory hyperpigmentation, as it is known to occur in the setting of lichen sclerosus [2022] and frequently associated with subepithelial fibrosis, melanophages, and sparse inflammatory infiltrates [23]