Management strategy

Pruritus vulvae describes a symptom that may be both psychologically distressing and socially embarrassing. An underlying etiology should be sought by obtaining a thorough history and performing a mucocutaneous physical examination. Secondary pruritus vulvae may be caused by infections, dermatoses, systemic diseases, and malignant or premalignant lesions (Box 200.1). Appropriate treatment should be instituted.

If no etiology is identified, then symptomatic relief is the goal of therapy. The tenets of treatment are to interrupt the itch–scratch cycle, restore the skin barrier, and minimize impact on quality of life.

The mainstay of treatment of pruritus vulvae is to identify and remove all suspected local irritants and allergens (Boxes 200.2 and 200.3). The patient should be instructed to discontinue all local products, including soaps, personal hygiene products, sanitary pads, medications (complementary/alternative, non-prescription, and prescription), and occlusive/synthetic clothing. The patient should bathe with lukewarm (not hot) water, pat (not rub) dry, wipe from front to back, change underpants daily, and launder clothing using a double rinse cycle. The patient may resist these measures, as they may believe in the need to have a ‘clean’ vulva and that natural secretions and odors are offensive or the cause of their symptoms. The patient may develop elaborate hygiene regimens that contribute to local irritation and contact sensitivity and may confound or be the primary cause of persistent pruritus. Toilet (tissue) paper and commercial wipes may contribute to local irritation. Furthermore, both may contain allergens such as formaldehyde, benzalkonium chloride, and fragrance that could contribute to persistent pruritus. Urine, stool, sweat, and cervical or vaginal secretions may contribute to local irritation. Urinary incontinence and contact with stool should be addressed. Cotton washcloths, cool Sitz baths and use of fragrance-free feminine hygiene products should be advocated.

The use of barrier petrolatum and zinc-based ointments, used to prevent diaper rash in both children and adults, helps to seal in moisture and protect the affected skin. In low-estrogen states (postpartum, peri- and postmenopause), the use of topical or systemic estrogen helps restore vaginal and vulvar mucosal barrier function.

Systemic or topical corticosteroids are used to reduce inflammation. Ointment-based formulations are preferred. Topical preparations may contribute to allergic or irritant contact dermatitis as can the corticosteroid itself. Corticosteroid ointment, used sparingly, should be applied once or twice a day. Close clinical supervision is necessary to limit secondary changes such as striae, folliculitis, and atrophy. Systemic agents are used to treat infections and to provide symptomatic relief of pruritus in order to limit complications of local agents. Intralesional triamcinolone acetonide injection and systemic corticosteroids may be effective for recalcitrant pruritus.

Although corticosteroids reduce pruritus, they are often not sufficient to interrupt the itch–scratch cycle. Nightly sedating antihistamines such as hydroxyzine or doxepin are recommended. For daytime pruritus, a low-dose selective serotonin reuptake inhibitor (SSRI) is advised.

Specific investigations