Contact dermatitis of the vulva is common, with irritant contact dermatitis occurring more frequently than allergic contact dermatitis. Patients with chronic vulvar dermatoses are at greater risk and should continually be reassessed for possible contact dermatitis. Comprehensive and specific questioning about hygiene practices and product use is necessary to elicit a history of contactant use. Patch testing is required to identify relevant contact allergens, the most common of which include medicaments, preservatives, and fragrances. Patient education and follow-up are essential in optimizing treatment and preventing recurrence of vulvar contact dermatitis.
Inflammatory dermatoses and cutaneous infections commonly affect the vulva. Cultural taboos, embarrassment, and fear may prevent women from reporting vulvar pruritus, pain, and cutaneous eruptions to their health care providers. As a result, women often self-medicate using a myriad of over-the-counter and/or herbal remedies. Vulvar disease is often multifactorial. Diagnosis of vulvar diseases can be challenging because of the effect of local factors (moisture, friction), clinical manifestations, which differ from nongenital cutaneous sites, and the frequent concomitant presence of multiple diagnoses. Lack of knowledge by practitioners causes underrecognition and misdiagnosis of vulvar disorders, which leads to repeated failure to improve despite use of multiple medications.
Whether self-induced or iatrogenic, contact dermatitis frequently complicates vulvar disorders. Contact dermatitis results from exposure to exogenous agents, either irritants or allergens. Irritant contact dermatitis (ICD) affects the vulva more often than allergic contact dermatitis (ACD). Acute, subacute, and chronic forms exist. Subacute and chronic contact dermatitis, either allergic or irritant, typically present with eczematous changes ranging from mild erythema to lichenified, thick erythematous plaques with excoriation, fissures, and weeping. Severe, acute contact dermatitis may be bullous, erosive, and extremely painful.
The vulva is particularly susceptible to ICD and ACD. Vulvar skin has been shown to react more intensely to some irritants (eg, benzalkonium chloride, maleic acid) than forearm skin; however, vulvar skin may not be more susceptible than other skin areas to all irritants. The barrier function of vulvar skin is compromised by moisture (urine, vaginal discharge), enzymes (stool residua), friction, and heat, all of which constitute the normal vulvar environment. Estrogen is integral in maintaining the strength and integrity of vulvar tissues. Estrogen deficiency, as occurs during premenarche, oral contraceptive use, postpartum, lactation, and menopause, decreases the barrier function of the vulvar epithelium. Persistent contact with urine can alone cause irritant dermatitis, widely recognized as diaper dermatitis in infants. Urinary incontinence, secondary to pelvic floor muscle weakness and laxity, severely affects up to 20% of women aged 80 years and older. Obesity and limitations in physical mobility, which reduce the ability to touch and visually inspect the vulva, can significantly impede a patient’s ability to keep the vulva clean and dry. Additional risk factors for vulvar contact dermatitis include preexisting dermatosis, occlusion (from natural skin folds, sanitary napkins), poor nutritional status, overzealous hygiene practices, and concomitant microbial infections (ie, candidiasis, infectious diarrhea).
ICD of the vulva is more common than ACD. Both types of contact reactions may occur simultaneously and have overlapping features clinically and histologically. Contact dermatitis should be considered early in the evaluation of patients with chronic vulvar symptoms (pruritus, irritation) with or without abnormal findings on examination. In patients with other vulvar dermatoses, contact reactions should be suspected in patients who do not respond appropriately to therapy. Vulvar contact dermatitis may result from direct application, inadvertent transfer from other body sites, local exposure to products excreted in the urine and/or feces after oral consumption, and systematized contact reactions. This article addresses the most common causes of ICD and ACD affecting the vulva and provides practical recommendations for evaluation and management.
Irritant Contact Dermatitis
ICD is common, although the exact prevalence remains unclear. ICD results from cutaneous exposure to substances that cause direct cytotoxicity to keratinocytes without prior sensitization. Irritants can remove surface lipids and water-holding substances, damage cell membranes, and denature keratins and other proteins.
Severe, acute ICD is equivalent to a caustic burn and manifests as erythema, edema, and vesicles, which evolve quickly into erosions and superficial ulcerations ( Fig. 1 ). Subacute and chronic irritant reactions present with poorly demarcated erythematous patches and plaques with variable scale and excoriations. Patients may complain of burning, rawness, stinging pain, and/or itching. Severe irritant dermatitis can progress to punched-out ulcers with elevated, indurated borders (erosive diaper dermatitis of Jacquet) or erythematous to violaceous pseudoverrucous papules and nodules (granuloma gluteale infantum). These clinical presentations are well recognized in infants with chronic diaper dermatitis but may also occur in adults. Significant pain and dysuria may occur in the context of vulvar erosions. Irritant reactions may also manifest as stinging and burning in the absence of identifiable skin changes.
Greater concentrations of a given irritant are more likely to cause dermatitis. Common classes of irritants include acids, alkalis, surfactants, solvents, oxidants, and enzymes. More specifically, urine, feces, sweat, topical medications, overzealous cleansing practices, and feminine hygiene products cause irritant contact reactions ( Box 1 ). Strong irritants usually cause immediate symptoms, which facilitate correlation between the culprit product and disease. Weaker irritants cause more subtle changes and are therefore less often suspected.
Body Fluids
- •
Abnormal vaginal discharge
- •
Feces (enzymes)
- •
Semen
- •
Sweat
- •
Urine (ammonia)
- •
Excessive bathing
Feminine hygiene products
- •
Depilatories
- •
Douches
- •
Feminine hygiene wipes
- •
Lubricants
- •
Panty liners
- •
Sanitary napkins/pads
- •
Heat
- •
Heating pads
- •
Hair dryer
- •
Medications
- •
Alcohol-based creams and gels
- •
Bichloroacetic acid, trichloroacetic acid
- •
Cantharidin
- •
Fluorouracil
- •
Imiquimod
- •
Phenol
- •
Podophyllin
- •
Propylene glycol
- •
Spermicides (foaming agents, emulsifiers)
- •
Soaps and detergents (including bubble baths)
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
