Vulvar pruritus is a common and distressing condition for patients, and its presentation is often delayed and complicated by home remedies. The true prevalence cannot be accurately estimated. Vulvar pruritus is a symptom, and an underlying cause must be sought and not assumed. This is best accomplished by obtaining a careful history of vulvar care regimens and treatments, performing a detailed physical examination, and considering a broad differential diagnosis. This article provides a practical and clinical approach to the evaluation of vulvar pruritus and then focuses specifically on one common cause, lichen simplex chronicus.
Vulvar pruritus can be caused by a wide spectrum of pathologies, the most common being candidiasis, contact dermatitis, lichen simplex chronicus (LSC), and lichen sclerosus. LSC begins with an inciting itch sensation for which scratching and rubbing yield pleasure and relief, which can trigger a chronic itch-scratch cycle. The tendency toward LSC cannot be cured, but the symptoms generally can be controlled. Prompt treatment with superpotent corticosteroids usually breaks the itch-scratch cycle. Careful attention to irritants and secondary infection prevents this from becoming a significant ongoing problem.
Vulvar pruritus
Vulvar pruritus is a common and distressing condition that affects nearly all women at some point in their lives. Vulvar pruritus describes an itch that feels good when scratched versus an itch that may be described as irritating, prickly, or burning. In the evaluation of vulvar pruritus, true itching is limited to a sensation that produces at least a desire to scratch or rub.
Patients with vulvar pruritus seek care from family practioners, gynecologists, internists, pediatricians, and dermatologists. When patients present themselves for care they are often frustrated by the effect that the pruritus has had on their daily living, and many have already failed multiple home or over-the-counter remedies. Providers are often challenged to diagnose and treat this nonspecific symptom. This is because vulvar pruritus is physiologically complicated by its unique location, emotionally complicated by the impact it has on the patient, and diagnostically complicated and time consuming for the health care provider. This article provides a practical and clinical approach to the evaluation of vulvar pruritus and then focuses specifically on one common cause, LSC.
The location of the vulva at the junction of the urinary, genital, and gastrointestinal tracts, where cutaneous skin transitions to mucosal skin, creates a unique skin surface. The vulva contains glabrous, nonglabrous, and mucosal skin. Local factors including warmth, moisture, and friction can complicate skin conditions by increasing the effect of irritants and prolonging irritant contact time. Moisture and warmth minimize and alter the characteristic presentation of scale, which is often used to differentiate common dermatoses. In addition, the combination of warmth, moisture, and friction create the equivalent of occlusion, which must be considered as a potential complicating factor of treatment with topical corticosteroids.
Skin symptoms of the vulva are often overlooked. Outside of gynecology and pediatrics, the vulva is infrequently examined during routine visits, and a patient is unlikely to have a vulvar examination unless she mentions her symptoms. In addition, the examination of the vulva is difficult, because even the normal appearance of the vulva varies with age and natural skin color. Finally, when examined, signs of vulvar skin disease are often subtle, difficult to distinguish from variations of normal, and atypical compared with classic cutaneous presentations.
Although the findings on physical examination may be subtle to the provider, the impact of vulvar pruritus is anything but subtle to the patient. Vulvar pruritus, or any form of vulvar irritation or discomfort, affects all aspects of a patient’s life including simple activities of daily living, exercise, and sexual encounters, and the psychologic well-being of relationships and self-worth. Often there are underlying fears that the symptoms are caused by undiagnosed cancer, a sexually transmitted infection, poor hygiene, or that there will never be relief. The implications of these fears cannot be overstated.
To further complicate this medical condition, social cues, embarrassment, and the fears noted previously are often obstacles to the patient seeking care. Women often suppose that the cause of their vulvar itching is either a yeast infection or an allergic reaction. Patients commonly invest an extraordinary amount of money in over-the-counter products, and time in hygiene routines that likely exacerbate the symptoms, complicate the history and physical examination, and delay presentation to a medical provider.
In addition to these complicating factors affecting the patient’s presentation of vulvar pruritus, the provider further must overcome many obstacles. The time, equipment, and support required to perform an adequate history and examination can be cumbersome during a routine appointment. After interviewing, the patient must undress, be positioned for adequate exposure, and be examined with suitable lighting and ideally in the presence of a chaperoning assistant. To further confound the evaluation, both the recognition of normal findings and the subtle changes of vulvar disease require experience to appreciate.
In summary, vulvar pruritus is a common and distressing condition for patients, and its presentation is often delayed and complicated by home remedies. The true prevalence cannot be accurately estimated. Vulvar pruritus is a symptom, and an underlying cause must be sought and not assumed. This is best accomplished by obtaining a careful history of vulvar care regimens and treatments, performing a detailed physical examination, and considering a broad differential diagnosis.
Patient History
With any vulvar complaint it is imperative to gather a pertinent history. An efficient way to accomplish this uses a patient questionnaire that may be completed by the patient before seeing the provider. Tailoring such a form to one’s own practice facilitates and expedites the patient encounter.
The interview should start with the patient defining her symptom. A patient may struggle to describe her complaint and should be offered a variety of descriptors, such as itch, burn, rawness, pain, tingling, and irritation. Itch, in its most basic form, is a sensation that causes a desire to scratch and for which scratching yields pleasure or relief. The patient who complains primarily of irritation, burning, rawness, soreness, or stinging generally exhibits problems that represent a different differential diagnostic than vulvar pruritus. Some patients describe pain symptoms occurring as a result of rubbing or scratching.
Next, define the location of the pruritus as generalized, limited to a few areas, or localized to the vulva. Some patients hesitate to name or point to the area of involvement and may simply state, “it itches down there.” In these cases, use the physical examination to teach the patient anatomic terms and encourage her to use her hand to show you where and how she scratches the affected skin.
Ask the patient to identify triggers that make the pruritus better or worse, and seek to identify associations, such as vaginal discharge, relation to coitus and menses, contraception, lubrication, and sanitary products. Take time to ask the patient what she thinks the cause is and what may be her fears. Obtain a list of prescribed and over-the-counter treatments, the length of use, and the results of such treatments. Inquire about personal hygiene routines, including cleansers, douches, and use of washcloths, and determine how the products are used and how frequently.
Gather pertinent historical information, including age, allergies, medications, and relevant surgeries, and conduct a directed review of systems. Identify preexisting conditions, such as abnormal Pap smears, genital warts, genital herpes simplex virus infection, herpes zoster, diabetes, allergic rhinitis, asthma, eczema, or psoriasis. Does she have a diagnosis of fibromyalgia, irritable bowel syndrome, interstitial cystitis, or chronic fatigue syndrome? When was her most recent pregnancy and menstrual cycle? Is she postmenopausal? Is there a family history of genitourinary disease?
Physical Examination
The physical examination should include a whole-body mucocutaneous examination, looking for stigmata of skin disease, such as eczema, psoriasis, and lichen planus, which may play a role in vulvar symptoms. A complete genital examination with positioning for adequate exposure and lighting should include examination of the entire anogenital area. Inspect the entire vulva for subtle erythema, swelling, lichenification, and hyperppigmentation or hypopigmentation and the presence of scarring. Have the patient point to her primary area of pruritus. Take a biopsy of any abnormal findings that cannot be defined or are suspicious for malignancy.
Because vaginal disease can have great affect on the vulva, the vaginal mucosa should be included in the examination. A sample of the vaginal secretions should be studied microscopically for the presence of clue cells, lactobacilli, hyphae, pseudohyphae, or budding yeast. As needed, bacterial and fungal cultures should be ordered.
Differential Diagnosis of Vulvar Pruritus
Vulvar pruritus is a symptom that can be caused by any vulvar irritation or inflammation. Because it can be the result of a variety of different conditions, the provider must search for the cause. Vulvar pruritus can be characterized as acute or chronic, or primary or secondary. Vulvar pruritus can be secondary to skin conditions, such as infections, irritants, hormonal changes, infestations, neoplasms, medications, or systemic disease ( Box 1 ).
Dermatoses
* Irritant contact dermatitis
* Allergic contact dermatitis
* Lichen simplex chronicus
* Lichen sclerosus
* Lichen planus
* Psoriasis
Seborrheic dermatitis
Plasma cell vulvitis
Dermatographism
Papular acantholytic dyskeratosis
Infectious causes
Fungal: * candidiasis, tinea cruris
Bacterial: group A streptococcus, Staphylococcus aureus , Trichomonas vaginalis , Neisseria gonorrhea , Chlamydia trachomatis
Viral: herpes simplex virus, human papilloma virus, molluscum contagiosum
Infestations: scabies, lice, enterobiasis
Neoplasms
* Vulvar intraepithelial carcinoma
* Extramammary Paget disease
Syringomas
Mammary-like gland adenomas (hidradenoma papilliferum)
Langerhans cell histiocytosis
Basal cell carcinoma
* More common causes
The most common causes of vulvar itching are infection and skin disease. Vulvar pruritus can be caused by infections, such as vulvovaginal candidiasis, trichomonas, gonorrhea, Chlamydia , and bacterial vaginosis. In addition to pruritus, these infections often are associated with abnormal vaginal discharge. When abnormal vaginal discharge accompanies vulvar pruritus a work-up including potassium hydroxide (KOH) and wet mount are required. Bacterial, fungal, and viral cultures also may be necessary.
Vulvovaginal candidiasis is the most common cause of acute-onset vulvar pruritus, and it is the most common cause of vulvar pruritus diagnosed by gynecologists ( Fig. 1 ). Presumptive diagnosis and empiric treatment must be avoided in women with chronic vulvovaginal pruritus, however, because many genital skin problems are mistakenly attributed to candidiasis.
It is important to look for candidiasis in every itchy patient and confirm infection by microscopy or culture. Vulvovaginal candidiasis caused by Candida albicans commonly is associated with an itching and burning sensation and a thick, white, curd-like discharge that is worse premenstrually. Non-albicans Candidiasis is usually asymptomatic, but can produce irritation, burning, and soreness. Candidiasis is not just a primary problem, but also occurs as a superinfection when topical corticosteroids and oral antibiotics are used to treat underlying conditions. Additionally, be aware that treatment with antifungal imidazole creams can cause a secondary irritant contact dermatitis (ICD), complicating the clinical picture.
Less commonly, such infections as herpes simplex virus, human papilloma virus, and molluscum contagiosum may provoke a sensation of itch. Note, however, that herpetic infections more commonly cause a burning pain, and human papilloma virus and molluscum are most likely to be asymptomatic. Consider perineal streptococcal disease secondary to group A streptococci, especially in pediatric patients. Dermatophyte infections of anogenital skin are uncommon in women, and usually accompanied by involvement of the feet and toenails; a fungal preparation of scale from affected vulvar skin shows dermatophytosis.
The most likely skin diseases to present as vulvar pruritus include LSC; irritant and allergic contact dermatitis (ACD); lichen sclerosus; tinea cruris (much more common in men); lichen planus; psoriasis; and seborrheic dermatitis. As noted previously, characteristic scale seen on other parts of the body is commonly minimized or absent on the vulva because of moisture, which makes it difficult to distinguish these dermatoses by physical examination. Classic lesions identified elsewhere on a full-body skin examination can assist in narrowing the differential diagnosis. LSC is an important cause of primary vulvar pruritus and may complicate any of the other vulvar dermatoses. Therefore, it is discussed separately in detail later.
Contact dermatitis can be caused by irritants or allergens ( Fig. 2 ). Vulvar skin is notably more sensitive to irritants and allergens than skin elsewhere on the body because of occlusion, hydration, and susceptibility to friction. Acute ICD occurs minutes to hours after exposure secondary to a strong irritant, such as urine or medications including trichloroacetic acid or podophylotoxin. Much more common is the chronic form of ICD, where the cumulative effect of repeated, low-grade irritation causes damage to the skin barrier. Overwashing, application of irritating hygiene products, lubricants, douches, and urinary and fecal incontinence (secondary to any variety of lower bowel disorders) can cause vulvar irritation and pruritus. In response, some patients develop extensive hygiene routines secondary to fears of odor or infection, which further exacerbate the problem. Treatment of ICD consists of avoiding all irritants. It is important to inquire about incontinence, hygiene products, and cleansing habits and to give patients educational instructions on how to clean the vulvar area without causing irritation.
