Patient education

Women with chronic vulvovaginal symptoms require education regarding the nature of their condition, therapy, expectations as to rapidity of improvement, and expectations as to duration of therapy required. Patients should be taught about their disease, causes, and the options for therapy. Most often, the conditions producing chronic vulvovaginal symptoms are unfamiliar to patients, so that written information can be crucial to understanding and successful management. Patient handouts on the more common diseases are found in Appendix 4. Part of patient education is reassurance regarding sexual transmission, infertility, risk of malignancy, absence of human immunodeficiency virus (HIV), or other dangerous accompanying diseases.

Attention to psychosexual issues

An overriding factor in the management of chronic vulvovaginal symptoms is the usual anxiety and depression of patients, and the resulting psychosexual issues. In general, chronic pain or itching produces anxiety and depression and is worsened by this psychological dysfunction. Chronic vulvovaginal symptoms are especially anxiety-provoking due to patient concerns about potential issues of sexually transmitted disease, fertility, and malignancy. Self-esteem, sexual functioning, and intimate relationships suffer and compound symptoms. Inattention to the psychosexual aspects of vulvovaginal disease prevents optimal response to therapy.

In addition to reassurance, antidepressant therapy, and psychological counseling, couple counseling to include sex therapy is often crucial in producing maximal improvement.

Avoidance of irritants

The local environment of anogenital skin produces unique issues. Chronic symptoms are usually multifactorial. Prolonged moisture from sweat, urine, and normal and abnormal vaginal secretions, friction of skin folds, and heat combine to increase the risk of intermittent trivial but annoying infections, heavy colonization of normal organisms, and irritant contact dermatitis. The clinician should evaluate for any contributing factors both on the vulva and within the vagina. Specifically, irritant contact dermatitis from overwashing, an atrophic vagina from estrogen deficiency, and secondary infections should be evaluated for and addressed. A handout which specifically lists irritating activities to avoid can be extremely useful for patients who may find a drastic change in habits psychologically difficult (Table A3.2). Many women have focused on their vulvovaginal symptoms, arranging their lives, activities, diet, and choice of clothing all in the context of their genital symptoms. Therefore, minimizing daily care often helps to relieve anxiety as well. For a woman with isolated vulvovaginal symptoms, the choice of detergent and fabric softener is unimportant. Double-rinsing underwear serves no purpose. The color and the fabric of panties are unimportant unless the patient finds that particular types of underwear are uncomfortable. Low-yeast diets, avoidance of sugar, and eating or douching with yogurt or lactobacilli provide no substantiated benefits.

Table A3.2 Common Irritants

Not only do overuse of medications and hygiene measures by patients worsen symptoms, but clinician-prescribed therapies frequently cause or exacerbate symptoms. For example, antibiotics or corticosteroids can precipitate yeast, and creams contain alcohols and preservatives that can sting with application and produce an irritant dermatitis. Therefore, ointments are generally preferred over creams. When reasonable, oral therapy is favored over topical medication in order to avoid these problems. Patients who require vaginal corticosteroids, vaginal estrogen, or antibiotics, and particularly those who receive a combination of these agents, are at a high risk for secondary candidiasis. These patients benefit from initial preventive medication, most often in the form of weekly fluconazole 150 mg.

Patients who have flares of their symptoms should be re-evaluated. Often, the flare is produced by a new problem, and a telephone diagnosis is substandard care.

First aid for acute symptoms and flares

Patients with severe itching or burning due to inflammation, redness, erosion, ulceration, excoriation, or infection often need immediate first aid for comfort while awaiting effects of specific therapy (Table A3.3). In addition to reassurance and patient education, there are nonspecific measures that can improve symptoms in the short term.

Table A3.3 First Aid

The first item to address is the possibility of an intercurrent infection. Women should not receive empiric therapy, but only treatment for confirmed infection. Patients should be cultured if the index of suspicion is high, but microscopic confirmation is lacking.

Tepid or cool tap-water soaks are often helpful for itching and pain. These can be achieved in a bathtub with a temperature that is comfortable, soaking for 10–15 minutes two or three times a day. For those women unable to use tub soaks, a sitz bath in a shallow pan can be used. A less satisfactory alternative is the application of wet towels to the area. Women with fissures, erosions, or ulcers may experience stinging when water first touches the skin. However, this is usually short-lived, and the soaks provide some degree of comfort. As the cells of the epidermis are hydrated and swell, fissures and cracks close temporarily, decreasing the sensation of irritation. Soaks are short-term therapy only, because the chronic use of frequent soaks dissolves natural oils and overall dries the skin, as well as producing maceration in normally moist areas.

Following soaks, the skin should be patted dry gently, and the moisture sealed in immediately with the application of a bland emollient such as petrolatum (Vaseline petroleum jelly). Although historically avoided by gynecologists, there are several studies that incidentally exhibit the benefit of petrolatum on pain and irritation in the course of evaluating the effects of testosterone¹. Petrolatum is a cost-effective emollient that contains no irritants, allergens, preservatives, or stabilizers. Women who are incontinent or have diarrhea often benefit from a barrier paste that protects surrounding skin. Although messy, zinc oxide paste or Desitin applied liberally and regularly protects the skin from alkaline urine and, especially, liquid feces.

Itching and pain are also improved by cold. Ice packs, or crushed ice wrapped in a soft towel and applied to the vulva, frequently provide short-term comfort. Ice should not be applied directly to the vulva because of risk of frostbite.

Topical anesthetics are useful in some patients. Benzocaine (Vagisil) is an extremely effective anesthetic, but it is a highly allergenic agent, and it is often compounded with irritants such as resorcinol, which exacerbate inflammatory skin disease. Prescription lidocaine jelly 2% is soothing and variably effective. Lidocaine ointment 5% is more potent and equally safe, but it frequently produces burning with application. Prescription lidocaine cream 4% (ElaMax) or Emla (lidocaine with prilocaine) are more potent, but cause redness and burning in most patients. Pramoxine is found in some over-the-counter anesthetics (Summer’s Eve Anti-itch gel), and it is quite safe but less effective.

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A Systematic Approach to the Dermatoses of Pregnancy The Papular and Pruritic Dermatoses of Pregnancy Pemphigoid (Herpes) Gestationis Physiologic Skin Changes of Pregnancy Vaginitis Disorders of Pigmentation

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