BASICSMaeve K. Hopkins, MA, MD • Michael P. Hopkins, MD, MEd
BASICS
DESCRIPTION
• Pruritus vulvae is a symptom, as well as a primary diagnosis:
– The symptom may indicate an underlying pathologic process.
– Only when no underlying disease is identified may this be used as a primary diagnosis.
• Pruritus vulvae as a primary diagnosis may also be more appropriately documented as vulvodynia (see “Vulvodynia” topic) or burning vulva syndrome.
EPIDEMIOLOGY
Symptoms may occur at any age during a woman’s lifetime.
• Young girls most commonly have infectious or hygiene etiology.
• The primary diagnosis is more common in postmenopausal women.
Incidence
The exact incidence is unknown, although most women complain of vulvar pruritus at some point in their lifetime.
ETIOLOGY AND PATHOPHYSIOLOGY
Vulvar tissue is more permeable than exposed skin due to differences in structure, occlusion, hydration, and susceptibility to friction. It is particularly vulnerable to irritants (1)
• Perfumes
• Soaps
• Laundry detergent
• Douches
• Toilet paper
• Sanitary napkins
RISK FACTORS
• High-risk sexual behavior
• Immunosuppression
• Obesity
GENERAL PREVENTION
• Attention should be paid to personal hygiene and avoidance of possible environmental factors.
• Tight-fitting clothing should be avoided.
• Only cotton underwear should be worn.
COMMONLY ASSOCIATED CONDITIONS
• Infectious etiology
– Vaginal or vulvar candida
– Gardnerella vaginalis
– Trichomonas
– Human papillomavirus
– Herpes simplex virus
• Vulvar vestibulitis
• Lichen sclerosis
• Lichen planus
• Lichen simplex chronicus (squamous cell hyperplasia)
• Malignant or premalignant conditions
• Psoriasis
• Fecal or urinary incontinence
• Dermatophytosis
• Parasites: scabies, phthrius pubis
• Extrammmary Paget’s
• Dietary: methylxanthines (e.g., coffee, cola), tomatoes, peanuts
• Autoimmune progesterone dermatitis: perimenstrual eruptions
• Irritant or allergic contact dermatitis
• Atopic dermatitis
DIAGNOSIS
Pruritus vulvae is a diagnosis of exclusion.
HISTORY
• Persistent itching
• Persistent burning sensation over the vulva or perineum
• Change in vaginal discharge
• Postcoital bleeding
• Dyspareunia
PHYSICAL EXAM
• Visual inspection of the vulva, vagina, perineum, and anus
– Superior surfaces of the labia majora—extending from mons to the anal orifice are most involved.
– Vulvar skin is leathery or lichenified in appearance.
– Papillomatosis may be a sign of chronic inflammation.
• Light touch identification of affected areas
• Cotton swab–applied pressure to vestibular glands
DIAGNOSTIC TESTS & INTERPRETATION
• Sodium chloride: Gardnerella or Trichomonas
• 10% potassium hydroxide: Candida
• Viral culture or polymerase chain reaction (PCR): herpes simplex virus
• Directed biopsy: human papillomavirus, lichen, malignancy
• Colposcopy with acetic acid or Lugol solution of vagina and vulva
Follow-Up Tests & Special Considerations
• A patch test may be performed by a dermatologist to assist in identifying a causative agent if contact dermatitis is suspected.
• Exam-directed tissue biopsies are essential in the postmenopausal population to rule out malignancy.
Diagnostic Procedures/Other
Biopsies should be collected from any ulceration, discoloration, raised areas, macerated areas, and the area of most intense pruritus.
Test Interpretation
• Only in the absence of pathologic findings can the primary diagnosis of pruritus vulvae be made.
• In one study, a specific clinicopathologic diagnosis was obtained in 89% of patients by using the most recent 2006 International Society for the Study of Vulvar Diseases (ISSVD) classifications (2).
TREATMENT
Identify the underlying cause or disease to target treatment
• Stop all potential irritants.
• Eliminate bacterial and fungal infection.
• Cool the affected area: Use cool gel packs (not ice packs, which may cause further injury).
• Sitz baths and bland emollients to soothe fissured or eroded skin
First Line
• 1st-generation antihistamines (3)[C]
– Hydroxyzine: Initiate with 10 mg before bedtime (slow increase up to 100 mg).
– Doxepin: Initiate with 10 mg before bedtime (slow increase up to 100 mg).
– 2nd-generation antihistamines are of little benefit.
• SSRIs (3)[C]
– Citalopram 20 to 40 mg in the morning may be helpful for daytime symptoms.
• Topical steroids (4)[C]
– Triamcinolone 0.1% applied daily for 2 to 4 weeks, then twice weekly
– Hydrocortisone 1–2.5% cream applied 2 to 4 times daily (5)
– Avoid long-term use due to risk of atrophy.
– One randomized, controlled trial showed no difference between topical triamcinolone and placebo cream (6).
Second Line
Calcineurin inhibitors such as topical pimecrolimus 1% cream applied BID for 3 weeks (7)[B]
• May lead to an 80% reduction of pruritus
ISSUES FOR REFERRAL
• Persistent symptoms should prompt additional investigation and referral to a gynecologist or gynecologist oncologist.
• Gynecology oncology referral for proven or suspected malignancy
• Dermatology referral for patch testing to evaluate for contact dermatitis
ADDITIONAL THERAPIES
• GnRH analogue
ONGOING CARE
• Frequent evaluation, repeat cultures, and biopsies are necessary for cases resistant to treatment.
• Refractory cases may require referral to gynecologist or gynecology oncology for further management.
DIET
Dietary alterations include avoidance of the following:
• Coffee and other caffeine-containing beverages
• Tomatoes
• Peanuts
PATIENT EDUCATION
• American Congress of Obstetricians and Gynecologists: www.acog.org
• National Vulvodynia Foundation: www.nva.org
PROGNOSIS
Conservative measures and short-term topical steroids control most patients’ symptoms.
COMPLICATIONS
Malignancy
REFERENCES
1. Farage M, Maibach HI. The vulvar epithelium differs from the skin: implications for cutaneous testing to address topical vulvar exposures. Contact Dermatitis. 2004;51(4):201–209.
2. Kelecki KH, Adamhasan F, Gencdal S, et al. The impact of the latest classification system of benign vulvar diseases on the management of women with chronic vulvar pruritus. Indian J Dermatol Venereol Leprol. 2011;77(3):294–299.
3. Margesson LJ. Overview of treatment of vulvovaginal disease. Skin Therapy Lett. 2011;16(3):5–7.
4. Weichert GE. An approach to the treatment of anogenital pruritus. Dermatol Ther. 2004;17(1):129–133.
5. Pincus SH. Vulvar dermatoses and pruritus vulvae. Dermatol Clin. 1992;10(2):297–308.
6. Lagro-Janssen AL, Sluis S. Effectiveness of treating non-specific pruritus vulvae with topical steroids: a randomized controlled trial. Eur J Gen Pract. 2009;15(1):29–33.
7. Sarifakioglu E, Gumus II. Efficacy of topical pimecrolimus in the treatment of chronic vulvar pruritus: a prospective case series—a non-controlled, open-label study. J Dermatolog Treat. 2006;17(5):276–278.
8. Kelly RA, Foster DC, Woodruff JD. Subcutaneous injection of triamcinolone acetonide in the treatment of chronic vulvar pruritus. Am J Obstet Gynecol. 1993;169(3):568–570.
9. Woodruff JD, Babaknia A. Local alcohol injection of the vulva: discussion of 35 cases. Obstet Gynecol. 1979;54(4):512–514.
10. Ovadia J, Levavi H, Edelstein T. Treatment of pruritus vulvae by means of CO2 laser. Acta Obstet Gynecol Scand. 1984;63(3):265–267.
ADDITIONAL READING
• Banerjee AK, de Chazal R. Chronic vulvovaginal pruritus treated successfully with GnRH analogue. Postgrad Med J. 2006;82(970):e22.
• Boardman LA, Botte J, Kennedy CM. Recurrent vulvar itching. Obstet Gynecol. 2005;105(6):1451–1455.
• Bohl TG. Overview of vulvar pruritus through the life cycle. Clin Obstet Gynecol. 2005;48(4):786–807.
• Caro-Bruce E, Flaxman G. Vulvar pruritus in a postmenopausal woman. CMAJ. 2014;186(9):688–689.
• Farage MA, Miller KW, Ledger WJ. Determining the cause of vulvovaginal symptoms. Obstet Gynecol Surv. 2008;63(7):445–464.
• Foster DC. Vulvar disease. Obstet Gynecol. 2002;100(1):145–163.
• Petersen CD, Lundvall L, Kristensen E, et al. Vulvodynia. Definition, diagnosis and treatment. Acta Obstet Gynecol Scand. 2008;87(9):893–901.
• Sener AB, Kuscu E, Seckin NC, et al. Postmenopausal vulvar pruritus—colposcopic diagnosis and treatment. J Pak Med Assoc. 1995;45(12):315–317.
CODES
ICD10
• L29.2 Pruritus vulvae
• N94.819 Vulvodynia, unspecified
CLINICAL PEARLS
• Most women complain of pruritus vulvae at some point in their lifetime.
• Pruritus vulvae is a diagnosis of exclusion once other causes of itching have been ruled out.
• Exam-directed biopsies from any ulceration, discoloration, raised areas, macerated areas, and the area of most intense pruritus are essential to rule out malignancy.
• Initial treatment is conservative.