What are some of the common causes of vulval discomfort and how should you manage them?
Itch and burning in the vulval region, with or without vaginal discharge, is a common presentation in general practice. Many women will describe any vulvovaginal discomfort as “an itch”, and some have already treated themselves several times for what they presume is “another case of thrush”.
Others have a prior diagnosis of a chronic skin problem which they had stopped treating when the itch resolved, due to concerns about long-term use of topical steroids.
Let’s look at two typical presentations, and how we might work through diagnosis and treatment. Both appear similar in the histories given by the patients, but have different diagnoses. We’ll pick up the answers as we go along.
CASE 1
Angie is 30. She presents with a 12-month history of constant “thrush”. She has purchased many tubes of antifungal cream and oral tablets, and is sick of it. She wants you to fix the problem. What is your first step? How would you manage her?
CASE 2
Mary is 55. She presents complaining of itch for the past six months. She says she has been getting some relief from antifungal cream because she thought it was “thrush”, but the effect doesn’t last. She wants something stronger. On examination, she has some shrinkage of the labia minora and pallor of the skin. What is your differential diagnosis? What tests would you do?
History
The following questions must be asked for all vulvovaginal presentations:
1. How long have you had the itch/discharge/pain?
2. Do you have a strong urge to scratch? Do you get temporary relief after scratching the itch? Or is it just sore / burning without the urge to scratch, and is unrelieved when you scratch or rub the area?
3. Have you had it before?
4. Do you have any other skin diseases?
5. Is there a family history of skin disease?
6. Have you ever had any tests to confirm the diagnosis?
7. What have you done to relieve the symptoms (including non-prescription products)?
8. Do you have any other problems with your health?
9. Do you take any medications?
10. Are any of these symptoms/medications new?
Physical examination
The cardinal rule is to always examine the patient. Being unable to make a spot diagnosis isn’t a big problem as a dermatologist referral can be arranged for challenging presentations.
However, missing out on a thorough clinical examination can have serious consequences for the patient and the GP. Vulval cancers may present as an itch and may sometimes resemble a warty lesion, and patients may not always be aware of a vulvovaginal lump beyond simply feeling uncomfortable.
Physical examination, combined with a thorough history, helps to determine which investigations, if any, are required.
Good skin care
Whatever the diagnosis, avoiding soap and other irritants, including excess washing, is the crucial tenet of good skin care. Any perfumed hygiene products, such as scented toilet paper and wipes, should not be used. Pads and panty liners should be worn only while menstruating, and cotton underwear and outer clothing should be worn to allow the skin to breathe.
A cold pack applied to the genital area may help relieve the symptoms while awaiting a diagnosis, while heat will exacerbate the itching.
Topical treatments can be used for as long as needed, keeping in mind that ointments work better for dry skin than creams. Creams work well for weeping skin, but can contain preservatives which may irritate damaged skin.
If the symptoms are not improving at the follow-up appointment, review the diagnosis and consider specialist referral.
The adage “common things are common” certainly applies to vulvovaginal disorders.
Dermatoses
Atopic dermatitis commonly presents with itch, erythema, oedema and fissuring of skin. There’s often a history of the first presentation during childhood, especially on hands, feet and flexural areas. It’s often exacerbated by exposure to water and some chemicals. Skin tends to be dry all over.
Genetic predisposition is a known risk factor, so family history is relevant. Diagnosis is visual, but patch tests can be used to identify the allergens. Patients should be advised to avoid irritants and excess washing. Emollients should be applied liberally, along with the intermittent use of mild to moderate potency topical steroid cream. Antihistamine to control itch may also be helpful in relieving the symptoms of atopic dermatitis.
Allergic dermatitis can present as an acute or a chronic case, commonly with a history of itching and burning. Known allergens include tea tree oil, topical antibiotics, toilet paper, perfumes and preservatives in topical products. Exposure to these allergens triggers a type IV hypersensitivity reaction in susceptible individuals.
Allergic dermatitis is diagnosed through the association of the symptoms with the allergen within a clear timeline. Acute cases usually present with erythema and burning, while chronic cases may present with itch and lichenification. Treatment is usually focused on ceasing the exposure to the allergens.
Irritant contact dermatitis commonly presents with a history of itch and burning. Acute cases may present with erythema and burning associated with the irritant in a timeline, while chronic cases may have itch and lichenification. Irritant contact dermatitis is caused by prolonged exposure to irritants such as soap, feminine sprays, synthetics and sanitary pads or liners.
Treatment is aimed at ceasing the exposure to the irritant. Personal reasons for excessive cleaning, if involved, should be explored. A short course of a potent topical steroid ointment, tapering to a lower potency and reduced frequency of application, should relieve the symptoms of irritant contact dermatitis.
Psoriasis
Common symptoms of genital and flexural psoriasis are itching, fissuring, burning and pain. Clinical appearance in the genitals is different from the usual psoriatic skin, with little or no scaling and a shiny erythematous surface. Genetic predisposition is a known factor, with 50% of the patients having a family history of psoriasis. The cases are triggered post-acute infection or exposure to chemicals, including some medications.
Treatment includes the use of emollients and low to moderate strength topical steroids.
Infections
Candida infection classically presents with erythema and a thick white discharge. Non-albicans candida infections can present with less erythema and less discharge, and may be sore rather than itchy. Vulval skin may have deep-seated candida infection with a long-term itch. About 5% of women experience recurrent candida infections.
Candida infection is caused by C albicans in 95% of the cases, with the remaining 5% due to other candida species. It is not considered a sexually-transmitted infection. The diagnosis is by microscopy and culture, and sensitivity should be requested for non-albicans species, as these may be resistant to azoles. Repeat culture should be done for recurring symptoms to confirm candidiasis.
If swabs do not reveal candida and the diagnosis is unknown, skin biopsy is indicated to exclude a deep-seated candida infection within the skin.
The first or occasional episode of candida can be treated with a single dose fluconazole 150mg, and / or up to six days vaginal azole cream. However, single dose azole vaginal cream is not effective for recurrent infections. Recurrent C albicans may need long courses of treatment, for weeks or even months. Non-albicans species may respond to Nystatin vaginal cream or boric acid 600mg vaginal pessaries for 14 to 28 days.
This is where we find the answer to Angie’s problem
This is a common presentation. Establishing the diagnosis is the most important first step. Angie needs a vaginal and a vulval swab for microscopy and culture, to establish whether she has candida and whether it is C albicans or C non-albicans.
Whether or not she has candida on initial testing, the test should be repeated next time she has symptoms. This can sometimes be best addressed by giving the patient a take-home swab for self-testing when symptoms recur, along with advice to make an appointment to discuss the result.
Recurrent candida needs longer courses of both oral and topical antifungal treatment. Non-albicans species are often resistant to azoles and should have resistance testing if there is no response to initial treatment. Women who have recurrent candida should also be tested for diabetes, especially if they are post-menopausal. Some presentations should also be tested for HIV, depending on relevant history.
Tinea presents with itch and the presence of a red lesion with a well-defined scaly margin and central clearing in the perineum, pubic region, groin, buttocks or upper thigh. It’s often associated with infection on the feet. It’s caused by a range of dermatophytes.
The diagnosis is arrived it by skin scraping in 10% KOH for hyphae, and /or culture. Topical azole cream for two to four weeks is effective for treatment of tinea.
Herpes simplex presents with pain and multiple small blisters in a crop close together, which may coalesce into larger single erosion and small shallow erosions. The herpes simplex infection is caused by Herpes simplex virus 1 or 2, and is diagnosed by Herpes simplex PCR (not serology). Treatment is with valaciclovir or famciclovir, with the dose dependent on whether the outbreak is initial or recurrent.
Syphilis can often be silent, but the patient may notice a single painless ulcer in the primary phase, with a maculopapular rash involving the palms and soles in the secondary stage. The infection is caused by Treponema pallidum and can be diagnosed by swab from the ulcer for PCR, as well as serology at any time. Positive serology always warrants treatment if there is no history of previous treatment, or there is a risk of reinfection.
Penicillin is the drug of choice for treatment of syphilis. Single dose benzathine penicillin is effective in primary and secondary syphilis, and three doses one week apart are given for syphilis of more than two years’ duration.
Infestations
Scabies usually presents with itch due to local or generalised irritation, which is worse at night. It’s caused by an infection with Sarcoptes scabei (mite) and transmitted by close body contact and fomite spread. Genital lesions are often papular, rather than linear, burrows. The diagnosis is by direct observation of the burrows, papules and follicles on breast, genitalia, wrists and finger webs.
Permethrin 5% from the neck down provides effective treatment. It’s applied and left for eight hours overnight before washing it off. The whole family, all household members and sexual partners should be treated. Clothes, towels and bedding should be washed. The treatment should be repeated in one week.
Pubic lice: This itchy infection is caused by Pthiris pubis (crab louse) and transmitted by close body contact. Eggs of the lice are cemented to pubic hair, but this is less common these days due to the current fashion for pubic hair removal. The crab louse may be seen in pubic hair and the nits can be observed attached to pubic hair. Red spots on the skin may result from louse bite.
Treatment is by the application of Permethrin 1% to affected areas of skin, and washing off in ten minutes. The whole family, household members and sexual partners should be treated and clothes, towels and bedding should be washed.
Beware the person with delusional parasitosis, who returns with repetitive complaints that the parasite is still present. This person needs psychiatric help rather than topical treatments and should be referred appropriately.
Lichens
Lichens are the skin lesions which are best biopsied to establish a definitive diagnosis prior to commencing steroid creams.
Lichen simplex arises as a result of the itch /scratch / itch cycle. The skin is thickened and pale. The diagnosis is usually clinical, but biopsy can confirm the tentative diagnosis. To treat, oral antihistamine and moderate potency topical steroid ointment are used daily for two to three weeks, and then tapered off.
Lichen sclerosus is a visual diagnosis made on areas of whiteness, atrophy or hyperkeratosis, and purpura. The most abnormal-looking area should be biopsied to exclude VIN. The first diagnosis is bimodal (in children and middle aged women) and an itch may or may not be present. The cause is unknown, but lichen sclerosis probably has an autoimmune basis.
Treatment is with a potent topical steroid ointment daily until the pallor resolves, then tapered to a weekly maintenance dose if possible. Lichen sclerosus needs annual review due to the risk of skin cancer associated with Lichen sclerosus.
This is where we find the answer to Mary’s problem
Mary may have a problem with candida, but this is unusual in post-menopausal women unless they have diabetes or other immunosuppressive conditions. Mary’s story is a typical presentation of lichen sclerosus which is best confirmed by taking a biopsy.
Lichen planus has an unknown, but possibly autoimmune cause. It presents as mildly itchy dusky purple patches, painful dark red mucosal patches and white lacy lines on the mucosa. Lichen planus may involve the mouth and the oesophagus, as well as the genital area.
The diagnosis is by biopsy, which may not be specific (reported as lichenoid reaction). Treatment is by a potent topical steroid which may require compounding. If the response to topical steroid cream is poor, the patient should be referred to a vulval specialist.
Katherine Brown is Clinical Associate Professor Medicine, Westmead Clinical School, University of Sydney
Resources:
www.australianstiguidelines.gov.au
www.ashm.org.au Contact Tracing Guidelines
Brown K (Chapter 21) in Sexual Health Medicine: A Clinical Approach. Russell D, Bradford D and Fairley CK Eds. 2nd Edition. 2011. IP Communications Pty Ltd
