Vulval Itch Is Common, and Generally the Differential

Itch • THEME Vulval itch ulval itch is common, and generally the differential BACKGROUND Vulval itch is common. Patients V diagnosis is fairly straightforward. In both children and presenting with this symptom can have a long adults, the most frequently seen vulval dermatoses are history involving visits to several general 1 practitioners. Self diagnosis as thrush is common, dermatitis, psoriasis and lichen sclerosus. In both age and inappropriate use of over-the-counter groups, the majority of patients with dermatitis are antifungal preparations can lead to further atopic.1,2 Streptococcal vulvovaginitis is seen only in the irritation and distress. Excoriation, rubbing, paediatric group, whereas chronic vulvovaginal candidi- maceration, secondary infection and the effects of asis is an oestrogen dependent condition and is only topical applications frequently complicate matters. seen postpuberty.2 Belinda Welsh, OBJECTIVE This article identifies the common Eczema and dermatitis causes of vulval itch in adults and children, and MBBS, MMed, FACD, is consultant Eczema and dermatitis are synonymous terms. highlights key features of the diagnosis and dermatologist, management of these conditions. Vulval pain Whitening and thickening of the skin develops with St Vincent’s Hospital, syndromes are beyond the scope of this article chronic rubbing and scratching and is termed lichen Melbourne, Skin and and are therefore not discussed. simplex chronicus. Dermatitis is the most common Cancer Foundation, Carlton, Dermatology/ 1 DISCUSSION The cause of vulval itch can often cause of chronic vulval itch. Major categories of der- Vulval Conditions be multifactorial, but with careful assessment, a matitis include atopic dermatitis, irritant contact Clinic, Mercy Hospital primary diagnosis can be reached in most cases. A dermatitis, allergic contact dermatitis, and seborrhoeic for Women, East Melbourne, and is in good history requires patience, and gentle direct dermatitis. Multiple causative factors are often present private practice, Sunbury, questioning, as patients often feel uncomfortable in the one patient. Victoria. discussing their problems and may not disclose self applied remedies. Care should be taken Table 1. Potential irritants to vulval skin Anne Howard, during examination, as vulval rashes may be MBBS, FRACP, FACD, subtle. All postpubertal patients should have a low is consultant Chemical Physical dermatologist, Western vaginal swab to diagnose candidiasis rather than Hospital, Footscray, Skin treating empirically. and Cancer Foundation, Retained sweat Sanitary pads, Carlton,Dermatology/ Vaginal secretions Tampon strings Vulval Conditions Urine Tight clothing, Clinic, Mercy Hospital for Women, East Soaps, gels, bath oils, synthetic underwear Melbourne, and is in bubblebath Toilet paper private practice, Disinfectants, tea tree oil Overzealous Footscray, Victoria. Douches, perfumes cleansing, scrubbing Kathy Cook, Lubricants, spermicides Shaving, plucking hair MBBS, FRACOG, Medicaments, especially Prolonged sitting is obstetrician and antifungal creams gynaecologist, Depilatory creams Dermatology/Vulval Conditions Clinic, Mercy Semen Hospital for Women, East Melbourne, Victoria. Reprinted from Australian Family Physician Vol. 33, No. 7, July 2004 4 505 Theme: Vulval itch may be a background of atopy (eczema, asthma, Table 2. Potential allergens hayfever) (Table 1). In the early stages, candida is often diagnosed (by the patient, friends or a GP) and topical Anaesthetics Benzocaine (common), lignocaine (rare) creams applied that are irritant in themselves, thereby Antibacterial agents Neomycin, chlorhexidine, tea tree oil compounding the problem. Urinary and faecal inconti- Preservatives Ethylenediamine, parabens, propylene, glycol, nence can worsen eczema, as can heat, friction and chlorocresol, lanolin stress. Allergic reactions are less common, but need to Contraceptives Condoms, spermicides, diaphragm be considered if there is poor response to treatment3 Clothing Dyes (Table 2). Cosmetics Perfumes, deodorants Sanitary products Sanitary pads Clinical features Other medicaments Antifungals These conditions present similarly with itch being the Semen predominate symptom. Burning will occur if the mucosal surface is involved and fissures can lead to pain and dyspareunia. Clinical signs need to be sought carefully as they may be subtle, such as interlabial erythema or small skin splits (Figure 1). Poorly defined erythema, with or without scale, may extend onto the pubis and thighs. Thickening and whitening of the skin (lichenification) (Figure 2, 3) with multiple small excoria- tions can be seen in more severe longstanding cases. Unlike lichen sclerosus, normal anatomy is preserved and the vagina is normal. Tinea should be considered in Figure 2. Vulval dermatitis with lichenification of the differential diagnosis of dermatitis. Toenail and foot the labia minora due to chronic rubbing involvement is a helpful clue. Management Figure 1. Vulval dermatitis Principles of management is that of most vulval diseases and includes: • patient education and environmental modification (see Patient education page 517 this issue) – this is of vital importance as control rather than cure is usually the realistic aim. Washing without soap should be emphasised • treatment of any secondary infection • management of incontinence • the use of bland, nonirritating moisturiser (eg. Figure 4. Psoriasis in an adult aqueous cream, petroleum jelly) • if moderate to severe, a potent topical steroid such as methylprednisolone aceponate is recommended Figure 3. Dermatitis with prominent initially once per day (maximum of 1 month) until lichenification involving the groin symptoms settle. Application frequency can be crease reduced (ie. every second day, 3 times per week) as Aetiology symptoms improve. Follow with 1% hydrocortisone 1–2 times per day for maintenance if required, and Irritant reac- • cycling back to the more potent steroid may be nec- tions are essary for flare-ups. common on the vulva, Psoriasis and there Psoriasis is also common in the vulva (Figure 4) and Figure 5. Psoriasis in a child 5063 Reprinted from Australian Family Physician Vol. 33, No. 7, July 2004 Theme: Vulval itch can be easily mistaken for dermatitis. It is generally not biopsy. Although not itself considered a nearly as itchy as dermatitis, except in children (Figure 5). premalignant condition, longitudinal Diagnostic clues include a family history of psoriasis studies suggest a roughly 4% (reports and evidence of psoriatic lesions elsewhere on the skin range from 1–11%) lifetime risk of the (postauricular erythema and scale, natal cleft, nail development of squamous cell carci- pitting). Clinically, psoriasis tends to be symmetrical, noma within affected skin in patients well defined and a beefy, red colour compared to der- with vulval lichen sclerosis.8 matitis. The classic scale of psoriasis is absent. The aims of treatment are: Psoriasis often requires more aggressive and pro- • control of symptoms such as itch, longed treatment. Weaker potency steroids are usually soreness, and dyspareunia Figure 6. Lichen sclerosus with prominent insufficient to induce a response. Moderate to potent • minimisation of scarring and alteration purpura, whitening and resorption of the labia minora and burying of the clitoris topical steroids such as methyl prednisolone aceponate of normal vulval architecture, and 0.1% can be used once per day for 3–4 weeks fol- • lifelong 12 monthly surveillance for lowed by weak tar preparations such as 3% liquor picis squamous cell carcinoma of the vulva. carbonis (LPC) in aqueous cream, and/or 1% hydrocor- Potent topical steroids are the mainstay of treat- tisone for maintenance. Concurrent infection will ment in adults and children and response is usually worsen the psoriasis, therefore it is important this is rapid (Figure 7a, b). Betamethasone diproprionate identified and treated. Any condition not responsive to 0.05% ointment in optimised vehicle is used initially corticosteroids requires biopsy to exclude diseases twice per day for 1 month, then daily for 2 months, such as extramammary Paget disease and Langerhan gradually tapered to an ‘as needs’ basis, ideally only cell histiocytosis. 1–2 times per week. If symptoms flare-up, candida and bacterial swabs should be performed to Lichen sclerosus exclude co-existent pathology. Lichen sclerosus (previously known as lichen sclerosus et atrophicus) is an uncommon inflammatory skin Vulvovaginal candidiasis Figure 7a. Florid lichen sclerosus disease of unknown cause. It has a predilection for More than 50% of women over 25 years of age pretreatment genital skin, and although seen in both sexes, is more have had one episode of acute vulvovaginal candidia- commonly reported in women.4 It can affect all age sis. It is generally easily recognised and treated. groups with reported onset from 6 months of age to However, there is a small subset of women (less late adulthood. Lichen sclerosus has been reported in than 5%) who suffer repeated or intractable clinical association with a number of autoimmune conditions.5 candidiasis. Vulvovaginal candidiasis is considered Patients diagnosed with lichen sclerosus, however, do recurrent when at least four discrete episodes occur not seem to be at continued excessive risk of develop- in 1 year or at least three in 1 year that are not ing autoimmune disease, so an exhaustive search for related to antibiotic therapy.9 these diseases is not mandated. The vast majority

Load more