The association between human papillomavirus vulval skin infection and vulval intra-epithelial neoplasia is strong. Vulval skin carcinogenesis is, however, multifactorial. Both human papillomavirus oncogenic subtype infection and p53 mutations are likely to contribute to the risk of malignant transformation of normal epithelium. The long-term cumulative risk of developing vulval squamous carcinoma following the diagnosis of high-grade vulval intra-epithelial neoplasia is thought to be approximately 6% per decade, but observational data supporting this are mostly non-population based and retrospective. Surgical treatment may reduce this risk, but the rates of recurrence and treatment-related morbidity are high. Surveillance should therefore be discussed as an alternative. New treatments being researched include photodynamic therapy, human papillomavirus vaccines, immunotherapy, immune modulators and gene therapy. The advantages of these new modalities over surgery is the potential to preserve body image and sexual functioning while targeting more generalized epithelial molecular dysfunction.