Vulvar Dermatitis

Background

• Vulvovaginal skin conditions causing pruritus, irritation, pain, and/or dyspareunia are described broadly as vulvar dermatoses.
• Common pruritic vulvar dermatoses include contact dermatitis (allergic or irritant), lichen sclerosus, lichen planus, lichen simplex chronicus, and psoriasis.
• Vulvar irritants that can lead to dermatoses include:
  • physiologic factors, such as abnormal vaginal discharge, urine, sweat, semen, and saliva
  • hygiene-related factors and products, such as excessive bathing, soaps, bubble bath, bath salts, shampoo, conditioner, laundry detergents, tea tree oil, and vaginal hygiene products
  • medications, including topical anesthetics, topical corticosteroids, topical antibacterials, and topical antimycotics
  • other irritants such as condoms, contraceptive creams, jellies, foams, nonoxynol-9, lubricants, dyes, emollients, heating pads, and constrictive clothing

Evaluation

• Diagnosis is based on the clinical appearance of affected vulvovaginal tissue during an anogenital exam, supported by biopsy findings when indicated.
• As part of the exam, a vaginal specimen should be obtained and evaluated for vaginal pH, Candida yeast growth on culture to rule out vulvovaginal candidiasis, and microscopic evidence of infection - see Vulvovaginitis for additional information.
• Consider patch testing if allergic contact dermatitis is suspected.
• Consider biopsy if the diagnosis is uncertain and other dermatologic conditions should be ruled out.

Management

• For treatment of vulvar contact dermatitis:
  • The mainstay of management is to identify and avoid any precipitating allergen or irritant.
  • For mild-to-moderate cases, treatment with either triamcinolone acetonide 0.1% ointment or clobetasol propionate 0.05% ointment is recommended.
  • Oral therapy with corticosteroids can be considered for severe dermatitis refractory to topical clobetasol propionate 0.05% twice daily for 4 weeks.
  • See Contact dermatitis for additional information on treatment of nongenital contact dermatitis.
• For treatment of anogenital lichen sclerosus:
  • Early diagnosis and treatment is encouraged to reduce complications of lichen sclerosus.
  • Skin care with soap substitutes, emollients for moisturization, and avoidance of contact irritants is suggested.
  • Ultrapotent topical corticosteroid is the recommended treatment for vulvovaginal lichen sclerosus, typically topical clobetasol propionate 0.05% ointment is applied nightly for 4 weeks, then alternate nights for 4 weeks, then twice weekly for 4 weeks and it may improve symptoms of genital lichen sclerosus in women.
  • Mometasone furoate 0.1% may be similarly effective as clobetasol 0.5% ointment in women with vulvar lichen sclerosus.
  • An ongoing maintenance regimen of twice-weekly applications of an ultrapotent or moderate-strength corticosteroid can be considered in women who respond to topical steroids; long-term compliance may improve clinical outcomes and decrease the risk of squamous cell carcinoma.
  • For patients unresponsive to 12 weeks of topical steroids, other options may be considered, including:
    • topical calcineurin inhibitors
    • topical retinoids
    • injectable corticosteroids such as triamcinolone or dexamethasone
    • systemic therapies
    • surgery for complications such as stenosis due to scarring or adhesions that inhibit urinary or sexual functioning, or for treatment of coexisting carcinoma
    • fat grafting and adipose-derived stem cells in cases of atrophy
  • Patients with anogenital lichen sclerosus should be evaluated in follow-up every 6-12 months to monitor disease activity and screen for malignant changes.
  • See Lichen sclerosus for additional information on treatment of nongenital lichen planus.
• For treatment of genital lichen planus:
  • There is overall limited evidence of efficacy for most treatments of lichen planus, but options include topical ultrapotent corticosteroid (clobetasol propionate 0.05%) and aloe vera gel.
  • See Lichen planus for additional information on treatment of nongenital lichen planus.
• For treatment of lichen simplex chronicus:
  • The goal of management is to stop the "itch-scratch cycle", which can be achieved through:
    • behavioral modifications including removal of possible triggers of pruritus, such as rough or irritating fabrics, tight clothes, skin cleansers, or other physical irritants
    • treatment of underlying atopic dermatitis, psoriasis, vulvovaginal infections, or other underlying conditions
    • use of cooling packs or over the counter anti-itch menthol-containing products for symptomatic relief of pruritus
    • counseling and treatment for psychological conditions such as depression or increased anxiety may lead to increased or habitual scratching
  • Medications to reduce skin inflammation and pruritus may include:
    • topical corticosteroids, commonly given as first-line treatment
      • High-potency agents such as clobetasol 0.05% or halobetasol 0.05% ointment can be considered for initial short-term management.
      • Lower-potency agents, such as mometasone 0.1% ointment may be an option for less severe symptoms.
    • sedating oral antihistamines at bedtime, such as hydroxyzine 10 mg (up to 50 mg if necessary) orally 2 hours before bedtime, or doxepin 10-25 mg orally 2 hours before bedtime
    • intralesional triamcinolone 60-80 mg (in consultation with specialist) if persistent symptoms after topical steroid or severe symptoms
    • other medications, such as:
      • topical capsaicin 0.025%-0.1%
      • lidocaine 2% jelly
      • topical calcineurin inhibitors (pimecrolimus 1% cream or tacrolimus 0.1% ointment)
      • topical aspirin/dichloromethane solution (appears to reduce pruritus in lichen simplex chronicus)
      • gabapentin (reported to reduce pruritus and lesions in patients with lichen simplex chronicus or prurigo nodularis)
  • Other management options for patients with severe lichen simplex chronicus refractory to other treatments may include:
    • acupuncture
    • transcutaneous electrical nerve stimulation
    • ultraviolet phototherapy
    • botulinum toxin A injection