Pruritis Vulvae

Question 1

Definition of prutritis vulvae

Answer 1

Itching of the vulva (including the mons pubis, labia majora, labia majora, labia minora, clitoris, perineum and external openings of the urethra and vagina).

Question 2

Incidence and most comon cause

Answer 2

• Pruritis is the most common disorder of the vulva- 1 in 10 women seek help for this symptom
• Vulvovaginal candidiasis is considered by some to be the most common cause of vulval pruritus. It is estimated 75% of women will have at least one episode of vulvovaginal candidiasis in their lifetime

Question 3

Causes of pruritis vulvae

Answer 3

• Dermatological conditions: Atopic dermatitis, allergic contact dermatitis (fragrances, topical antibiotics etc.), irritant contact dermatitis, psoriasis (scale is less common due to moisture and friction of skin folds), lichen simplx, lichen planus, lichen sclerosis
• Infections: Candidiasis, trichomoniasis, bacterial vaginosis, threadworm, genital HSV, pubic lice, scabies
• Pre-malignant and malignant disease: Vulval intraepithelial neoplasia (VIN), malignant neoplasms of the vulva (SCC, extramammary Paget disease)
• Hormonal changes: Atrophic vulvovaginitis, pregnancy
• Gastrointestinal disease: irritable bowel syndrome, Crohn’s disease, ulcerative colitis, other inflammatory bowel disease, and anal fissures may lead to prolonged contact of stool with the vulval skin due to faecal incontinence or poor perianal hygiene. May also be caused by urinary or faecal incontinence
• Any cause of generalised pruritis (drug reactions, systemic disease, psychological problems, stress)

Question 4

Complications of pruritis vulvae (and underlying conditions)

Answer 4

• May arise from the underlying cause of the pruritis vulvae (e.g sexual dysfunction, increased risk of neoplasia- SCC in lichen sclerosis, planus and VIN)
• May arise from persistence of symptoms- Poorer QOL, psychological problems (loss of self-esteem, relationship problems, depression and anxiety), sexual dysfunction, sleep disturbance, lichen simplex (plaques resulting from itch-scratch cycle)

Question 5

Important aspects of history taking in pruritis vulvae

Answer 5

• Confirm that the woman is experiencing vulval itch, not vulval pain
• Location, duration, and onset of symptoms
• Extragenital itch may indicate a more generalised problem, lichen sclerosus is normally confined to the vulva (lichen planus may affect the vagina, skin, hair, nails as well as genital and oral mucous membranes)
• Acute onset is associated with allergic contact dermatitis or vulvovaginal candidiasis
• Nocturnal vulval itching may indicate threadworm infestation
• Trigger factors (sexual activit, menses, exercise, friction, heat, moisture)
• Any associated symptoms
• Use of hygiene products and practices
• Medical history (including factors that may predispose- incontinence GI, atopy, gynaecological)

Question 6

Investigations for pruritis vulvae

Answer 6

• Diagnosis is often clinical and further investigation may not be necessary
• A high vaginal swab should be taken if there is vaginal discharge, signs of infection or suspicion of candidiasis
• Bloods including FBC, ferritin, TFTs, renal function, LFTs, BG

Question 7

Management of contact dermatitis (causing purirtis vulvae)

Answer 7

• Identify and remove exposure to irritants (soaps, fragrances, condoms, lubricants)
• For mild itching, consider prescribing a mild potency topical corticosteroid ointment, such as hydrocortisone 1% for 7-10 days
• Stronger potency corticosteroids (such as betamethasone or mometasone) may be used if symptoms are moderate or severe
• Treat co-existing infection with a combination cream corticosteroid/antifungal, or corticosteroid/antibacterial, or oral antibiotic if required.
• A sedative antihistamine such as hydroxyzine may be helpful if there is sleep disturbance, or a low dose of a tricyclic antidepressant such as amitriptyline or doxepin

Question 8

Treatment of seborrheic dermatitis causing pruritis vulvae

Answer 8

Ketoconazole cream once or twice a day for at least 4 weeks

Question 9

Management of an unknown cause of pruritis vulvae

Answer 9

• 2 week wait if vulval neoplasm is suspected
• The aim of treatment is to provide symptomatic relief, reduce inflammation, restore the skin barrier and prevent and/or treat secondary infection.
• Offer symptomatic treatment with an emollient (GIVE TO ALL WOMEN)
• Consider a mildly anxiolytic antihistamine (hydroxyzine) or low dose TCA
• Consider prescribing a short trial (1–2 weeks) of low potency topical corticosteroids (hydrocortisone 1% ointment).
• Consider prescribing a combination corticosteroid/antifungal, or corticosteroid/antibacterial if a co-existing infection is suspected

Question 10

General advice for women with pruritis vulvae

Answer 10

• Shower rather than bath, and to clean the vulval area (a maximum of once a day) with a simple, unscented emollient as a soap substitute — over cleaning may aggravate vulval symptoms
• Keep nails short to avoid skin damage
• Wash with water only, or with soap (avoid contact with cleaning products)
• Avoid tight-fitting garments or synethic closthes