Vulvar itchBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l83 (Published 07 February 2019) Cite this as: BMJ 2019;364:l83
- A Alani, ST6 dermatology trainee, former general practitioner1,
- L McDonald, ST5 dermatology trainee, former general practitioner,1,
- W Abdelrahman, consultant dermatologist2,
- H L Hunter, consultant dermatologist2
- 1Dermatology unit, Royal Victoria Hospital, Belfast, UK
- 2Belfast City Hospital, Belfast Health and Care Trust, Belfast, UK
- Correspondence to A Alani
What you need to know
Suspect inflammatory skin diseases in women with itching in the genital area
A history of using feminine hygiene products, latex condoms, lubricants, or fragrances may suggest irritant contact dermatitis
Look for concomitant skin lesions elsewhere on the body which may provide clues to a diagnosis of seborrhoeic dermatitis, psoriasis, or lichen planus
Erosion of vulval architecture is seen in lichen planus and severe lichen sclerosus
Urgently refer patients with suspicious lesions such as ulceration, lump, or swelling in the vulva, or lesions in the vagina or cervix for biopsy to rule out malignancy
One in 10 women seek help for genital itching at some point in their lifetime.1 Skin conditions affecting the vulva or genital area are usually responsible.
A small survey of general practitioners in England, found that most (67% of 107 participants) saw more than five patients each month with vulvar symptoms, predominantly itching.2 But the true prevalence of symptoms is likely to be underestimated as patients may be embarrassed, and or use over the counter creams and products for symptomatic relief.
This Practice Pointer aims to help non-specialists recognise and treat common dermatological causes of vulvar itch.
What are common dermatological causes of vulvar itch?
Table 1 describes the key clinical features of dermatological vulvar itch.
Irritant contact dermatitis can occur after skin contact with irritating chemicals—for example, detergents, fragrances, and lubricants (box 1). It is a particular problem in women with urinary incontinence.34
Lubricants—spermicides, preservatives, anaesthetics
Toiletries—preservatives or stabilisers—eg, quaternium-15, propylene glycol
Topical treatments—corticosteroids, antimicrobials, anaesthetics, preservatives, or stabilisers
The genital area is often unaffected in patients with atopic dermatitis. However, repeated rubbing and scratching can result in lichen simplex chronicus, characterised by darkened and thickened skin. Lichenification usually affects the hair bearing portion of the labia majora.
Vulvar seborrhoeic dermatitis
An erythematous scaly rash is seen in the genital area. Concomitant characteristic lesions on the scalp, face (eyebrows, glabella, and nasolabial folds), and trunk provide a clue to the diagnosis.
About a third of patients with psoriasis report genital involvement.8 Patients often describe itch, stinging sensation, pain during intercourse, and worsening of symptoms after intercourse. Symmetrical erythematous scaly plaques may be seen in the genital area (fig 1).
Approximately 20% of patients with lichen planus have genital involvement.6 Patients may be asymptomatic or report itch, soreness, burning, and dyspareunia. Scarring, red, erosive, or atrophic areas are localised on the vestibule, labia minora, and clitoris (fig 2). Architectural alterations may result from interlabial or clitoral adhesions. Inspect oral mucosa for networks of fine white lines (Wickham’s striae) which provide a clue to the diagnosis. Ask about dysphagia as this may suggest oesophageal involvement. Complications include scarring and risk of squamous cell carcinoma.3
This is a chronic scarring inflammatory disease that frequently affects the ano-genital skin. Patients may be asymptomatic or report itch, dyspareunia, and poor urinary stream. Genital skin may have atrophic scarring with a “cigarette paper” appearance, which can extend to the perianal area with a classic “figure of eight” distribution39 (fig 3). Severe lichen sclerosus can result in loss of architecture with clitoral resorption, fissuring, and erosions. Involvement of the vagina excludes lichen sclerosus.3 Left untreated, patients may develop scarring and possible malignant change to squamous cell carcinoma.39
What features in the history and examination should I focus on?
Some women may not be comfortable talking about their genital problems or sexual history. Assure them that all information gathered during the consultation is confidential and will be important to diagnose and manage their symptoms. Table 2 lists key points to cover in history.
Opportunistic sexual health screening can help, such as when the patient attends for a pill check, smear, or breast examination. You might say, “Just so you know, I ask these questions to all my adult patients, regardless of age, gender, and marital status. These questions relate to your sexual health and genital skin. Do you have any questions before we start?” This can open the door for more specific questions related to genital symptoms such as pruritus, dyspareunia, and other problems such as sexual dysfunction.
Examine the skin all over the body to look for coexisting inflammatory rashes—eg, psoriasis or dermatitis.
Ask the patient if they would agree to a genital and speculum examination. Offer a chaperone. Inspect the genital region, vulvar skin, and vestibular tissue. Figure 4 shows the female genital anatomy.
Architectural changes—eg, loss of clitoral hood and erosions may suggest lichen sclerosus.
Atrophic plaques with vaginal involvement suggests lichen planus.
Erythema, scales, plaques, or excoriation marks suggest contact dermatitis.
Thickened skin changes (lichenification) along the mons and labia majora may suggest vulval dermatitis or lichen simplex chronicus
Erythematous shiny plaques along skin folds is more likely psoriasis.11
Use a speculum to visualise the vagina and cervix. A discharge may indicate infection. Vaginal erosions with patchy erythematous friable skin is suggestive of erosive lichen planus. Lesions on the cervix or vagina require further assessment to rule out neoplasia.3711
What investigations to consider?
Diagnosis is largely clinical, and there may be no further investigations needed.
Skin swabs are useful in patients with vaginal discharge to identify infection. Biochemical tests may be relevant in patients with suspected lichen sclerosus and rarely lichen planus because of associated autoimmune diseases (eg, thyroid disease, diabetes).3 Patch testing is useful if allergic contact dermatitis is suspected and symptoms are not settling after adequate treatment.12
How is it treated?
Advise measures to maintain genital hygiene and to avoid scratching as this can worsen the rash. Tight fitting garments may irritate the area, so suggest that the patient avoid these. Cotton undergarments are preferred. Explain possible triggers and suggest avoiding use of irritants such as spermicidal lubricated condoms, soap, shampoo, and bubble baths. Simple emollients can be used as a soap substitute and moisturiser.
Advise good skin care during menses. Cotton pads, tampons, and liners may be preferred. Advise patients to change these frequently to avoid irritating the genital skin. Urinating and rinsing the vulva with cool water after intercourse can help prevent infection.
In patients with severe night itch consider a mild sedating antihistamine—eg, hydroxyzine.35 Improve the skin barrier function with a bland emollient—eg, emulsifying ointment or paraffin based emollients, which are safe and reduce34 symptoms.
Follow general guidance for specific skin conditions. Skin conditions with generalised involvement may require referral to a dermatologist (fig 5).
Little evidence exists on specific management of genital dermatoses. The infographic (fig 6) summarises treatment options and the level of evidence for these. Expert committees recommend potent to very potent topical corticosteroid ointment in persistent cases of eczema and in seborrhoeic dermatitis, genital psoriasis, lichen planus, and lichen sclerosus.38913 These are to be applied daily for 4-8 weeks until symptoms are controlled. Half of a fingertip unit is sufficient to cover the whole genital area. Medicated solution, foams, or gels may be more convenient and effective if pubic hair is present.
Set realistic expectations about treatment—symptoms may recur in most of these conditions. Maintenance treatment with twice weekly application of ointment may be required alongside general care.
Pregnant and lactating women3
Seek specialist advice on treatment options for pregnant and breastfeeding women. Emollients are considered safe to use during pregnancy and lactation. Antihistamines are best avoided; however, if necessary the antihistamines of choice are chloropenamine or diphenhydramine. Topical steroids are safe but should be used minimally and at the lowest potency required to achieve resolution of symptoms. For psoriasis, avoid topical vitamin D analogueues in pregnancy and breastfeeding. Calcineurin inhibitors (tacrolimus, pimecrolimus) are not licensed for use in pregnant or breastfeeding mothers. Topical coal tar is considered safe for short periods of time during pregnancy. Seek specialist advice on treatment options for pregnant and breastfeeding women.
When to refer?
Consider referring patients to a dermatologist or gynaecologist if the cause is unclear or if there is poor response to treatment and symptoms persist after two to three months.347Box 2 lists some situations when referral might be considered. Refer urgently if you suspect vulval carcinoma—eg, the patient has an unexplained vulval lump or ulcer, or where the patient has lesions on the vagina or cervix. These patients usually require a genital smear and biopsy.
When to refer
Risk factors for a sexually transmitted infection—refer to a sexual health clinic
Persistent symptoms with poor response to treatment
If the clinical diagnosis is uncertain, clinico-pathological correlation is essential
Recalcitrant chronic disease failing first line treatments
Unusual lump, lesion, ulceration—urgent referral to exclude premalignant or malignant transformation
To exclude an abnormal melanocytic proliferation in pigmented areas, especially in patients with history of lichen sclerosus
In patients with lichen sclerosus or lichen planus, any erosive, hyperkeratotic, erythematous or new warty or papular lesions should be assessed given risk of squamous cell carcinoma
For patch testing in suspected allergic contact dermatitis if symptoms are not settling with treatment
Urinary incontinence—refer to urogenital specialist
Education into practice
What diagnoses would you consider in females presenting with genital itch?
How would you distinguish between these conditions?
When would you consider referring the patient?
Additional educational resources
Information for healthcare professionals
British Association of Dermatologists (BAD) guidelines on lichen sclerosus: www.bad.org.uk/library-media/documents/lichensclerosus_2010.pdf
2016 European guidelines for the management of vulval conditions. Van der Meijden WI, Boffa MJ, ter Harmsel WA, et al. J Eur Acad Dermatol Venereolhttps://www.ncbi.nlm.nih.gov/pubmed/28164373
British Society for the study of vulval diseases. Multidisciplinary specialist society for vulval disease (www.bssvd.org).
Information for patients
British Association of Dermatologists (BAD) patient information leaflets- (www.bad.org.uk/for-the-public/patient-information-leaflets). Provides information for patients on contact dermatitis, lichen planus, female lichen sclerosus, psoriasis, molluscum contagiosum, seborrheic dermatitis, and lichen simplex chronicus.
Leaflet on vulval skin care: www.bad.org.uk/for-the-public/patient-information-leaflets/care-of-vulval-skin
British Society of Sexual Health and HIV (www.bashh.org) provides guidelines and information for patients
Psoriasis and psoriatic arthritis. Arthritis Alliance (www.papaa.org/sites/default/files/Genitals%20final.pdf) provides information for patients with genital psoriasis
Sources and selection criteria
We searched PubMed and Medline for clinically relevant studies from 1988 through to 2018. We searched using the MeSH terms “Genital Psoriasis,” “Genital dermatosis,” “Genital lesions,” “lichen planus,” “lichen sclerosus,” “lichen simplex,” and terms specific to the genital conditions such as “vulval and dermatosis,” “vulval and disease,” “ vulval itch,” “Vulvar itch,” “itchy vulva” including all subheadings. We consulted the Cochrane Library, National Institute for Health and Care Excellence, European Academy of Dermatology and Venereology, British Association of Dermatologists, British Association for Sexual Health and HIV, Royal College of Obstetricians and Gynaecologist for vulval skin disorder guidelines. The overall evidence presented in the article is up to date and supported by the recent European guideline for the management of vulval conditions.
How patients were involved in the creation of this article
A patient kindly shared her experience living with this condition (see Patient perspective). An advocate for patients with atopic dermatitis reviewed this manuscript and indicated how treatment adherence is important. He had useful input into clarifying aspects of the treatment—eg, emollient usage, topical steroids, and antihistamines. He suggested specifying how these treatments are to be used, particularly in relation to menstrual cycles, intercourse, and in the presence of pubic hair, and any considerations for pregnant and lactating women. We have added relevant information on these aspects and have also mentioned additional resources for patients. We thank these individuals for their contribution.
Six years ago, I had a terrible itch that started on the right side of my labia majora. It then spread to my anal passage and it has plagued me ever since. It bothers me constantly, so that I can’t stop thinking about it all the time. I scratch so much it sometimes bleeds and it’s like I can’t NOT scratch, because of how desperately itchy it is. I bought many over-the-counter creams and washes but nothing worked. I had gone through two pregnancies with this itch and I was desperate for a cure!
I went to my general practitioner after many years of being too embarrassed to bring it up. Only now I am finally seeing a specialist about this problem. Learning more about my body private parts, I now know the things that irritate my skin and exacerbate my condition.
The skin specialist has prescribed me strong steroid cream which seems to have calmed things down and I have stocked up on 100% cotton panties, stopped having baths, and bought myself a cleanser that isn’t soap. I know that it will be a constant struggle for me, but thankfully I can have a good night’s sleep at last.
Provenance and peer review: commissioned, based on an idea from the author; externally peer reviewed.
Acknowledgments We would like to thank Sonya Hutchinson, a dermatologist with special interest in vulval dermatology, who reviewed the paper and the evidence presented.
Competing interestsThe BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none
Further details of The BMJ policy on financial interests is here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests