An irritating, recurring itch
VULVAL pruritus is a common symptom resulting from infectious or noninfectious causes.
Vulval pruritus can occur at any age and may be associated with vaginal discharge, which should be sampled and sent for examination to exclude a specific vaginal cause.
Associated symptoms may include irritation, burning, erythema, dysuria and dyspareunia.
Erroneous self-diagnosis of ‘thrush’ is common and use of over-the-counter products may exacerbate the condition; some women develop a contact dermatitis following chronic use of topical antifungal therapy.
With persistent symptoms over a period of time there is a cycle of itch, scratch, fissuring and secondary infection.
Many women are embarrassed to discuss their problem, leading to symptoms that may have persisted for many years — older women are often reluctant to mention this complaint.
Common causes of vulval and/or vaginal itching include:
• Infection — trichomonas, genital warts, candidiasis and chlamydia
• Menopause — results in thinning of the vaginal wall and less lubrication
• Dry Skin — needs moisture in order to stay supple, and retaining moisture while ageing
• Chemical irritants such as soaps, bubble baths, washing detergents, fabric softeners, feminine sprays, scented sanitary towels and toilet paper, ointments, creams, and contraceptive foams or gels.
Candidiasis is a common condition in the reproductive years, with symptoms including vulvovaginal itching or burning and stinging or burning while urinating or during sex.
It is associated with a thick, white discharge with a ‘cottage cheese’ appearance and yeasty smell. There is redness or swelling of the vagina and vulva and fissuring may be present on the labial skin, perineum or perianal areas. Less than 5% have recurrent or intractable infections, that is, three or more infections per year unrelated to antibiotic therapy.
Candidiasis is commonly caused by Candida albicans, however other species such as C. glabrata, which is often resistant to commonly used antifungals, may be found.
The condition may be triggered by hormone therapy, antibiotic therapy, diabetes, pregnancy and chronic illnesses, and may occur in the premenstrual phase of the menstrual cycle.
Treatment includes antifungal therapies, both topically and orally, with recurrent infections requiring long-term therapy. Boric acid intravaginal capsules are prescribed for the treatment of non-Candida albicans species.
Referral to a dermatologist or gynaecologist with expertise in vulval conditions is necessary for recurrent resistant infections.
Lichen sclerosus (LS), a skin condition that can occur at any age, is most commonly seen on the genital skin and does not involve the vagina. The skin is often pale or whitish with plaque formation, fissuring, shrinking and loss of the labia minora and narrowing of the introitus. The anogenital region is most commonly involved but other skin sites can be affected. Currently 3—5% of women with vulval LS will develop vulval cancer.
Diagnosis is by skin biopsy. Management is aimed at symptom relief and includes vulval hygiene and use of potent topical steroids.
Regular review to exclude any malignancy is important. Effective treatment will reduce itch and loss of normal anatomy, prevent vulval intraepithelial neoplasia and invasive cancer.
Psoriasis is characterised by red scaly skin plaques over many areas of the body including the genitalia. It occurs around the labia majora, and perianal and postanal areas, as well as up into the natal cleft.
Vulval hygiene is important, and initial treatment is topical ointments including steroids.
This condition can occur as either an acute reaction with itching, burning and blisters or a slow reaction with redness, burning and swelling. It is often caused by irritants such as creams, ointments, soaps, sanitary pads and clothing. To manage, remove irritants, commence vulval hygiene recommendations and steroid cream.
To diagnose, it is important to determine the duration of symptoms and what treatments have already been used. Examination of the vagina and vulva is essential to assess the site of the irritation for a rash, redness, pallor or fissuring. A vaginal swab should be taken to exclude specific infections, especially candidiasis, and discharge should be sent for investigation. A biopsy should be taken for all other skin conditions.
Hygiene advice for patients
- Use water or a soap substitute only (bathing the vulva with water and a small amount of bicarbonate of soda is often soothing in severe cases)
- Avoid irritants such as shampoos, bubble baths or other bath or perfumed products
- Wear only cotton underwear, preferably washed in a pure soap
- Avoid tight clothes such as jeans or pantyhose
- Use unscented toilet paper
Jean Hailes for Women’s Health is a national, not-for-profit organisation focusing on clinical care, innovative research and practical educational opportunities for health professionals and women. www.jeanhailes.org.au