Vulvar pruritus

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Chapter 42 VULVAR PRURITUS

Vulvar pruritus can be caused by a number of different conditions ranging from localized diseases to systemic diseases. The age of the woman is very important in the differential diagnosis. In premenopausal women, contact dermatitis, lichen simplex, and candidal vaginitis are common causes of vulvar pruritus. In postmenopausal women, common causes include atrophic vaginitis, lichen sclerosis, vulvar intraepithelial neoplasia, and vulvar cancer. In patients with diabetes, candidal infections are prevalent.

It is often very difficult to diagnose the cause of vulvar lesions. If the diagnosis is unclear, a biopsy should be performed in order to evaluate for malignancy. Most vulvar cancers occur in postmenopausal women; about 10% of these malignancies occur in younger women.

Causes of Vulvar Pruritus

Adenomatous polyps

Allergic contact dermatitis

Atopic dermatitis

Atrophic vaginitis

Bacterial vaginosis

Carcinoid syndrome

Cloacogenic carcinoma

Fox-Fordyce disease

Histiocytosis X

Human immunodeficiency virus (HIV) infection

Hodgkin disease

Hyperthyroidism

Inflammatory bowel disease

Iron deficiency anemia

Irritant contact dermatitis

Lichen sclerosis

Lichen simplex chronicus

Liver disease or biliary disease

Molluscum contagiosum

Multiple myeloma

Mycosis fungoides

Pediculosis pubis

Polycythemia vera

Rectal, anal, or colon cancer

Renal failure or uremia

Seborrheic dermatitis

Squamous cell hyperplasia

Vulvovaginal candidiasis

Vulvar intraepithelial neoplasia

Vulvar carcinoma

Key Historical Features

✓ Constitutional symptoms

• Associated symptoms that may suggest a systemic disease, such as fatigue (caused by malignancy, renal failure, thyroid disease, iron deficiency anemia), unintentional weight loss (caused by diabetes, malignancy), or jaundice (caused by biliary or liver disease)

✓ Gynecologic symptoms and history

• Menopausal status

• Location, duration, and severity of pruritus

• Association of pruritus with menses

• Associated symptoms such as pain, lesions, or vaginal discharge

• Sexual history

• History of sexually transmitted diseases

• History of prior vulvar or gynecologic diseases

• Association with common irritants: medications (see previous list), body fluids, tampons, sanitary napkins, condoms, shaving, waxing, douching, soaps, detergents, clothing dyes, bubble bath, or overzealous cleansing

✓ Gastrointestinal symptoms

• Diarrhea, which may indicate inflammatory bowel disease

• Rectal bleeding, which may indicate colon cancer

✓ Medical history, especially history of diabetes, thyroid disease, renal disease, liver disease, or malignancy

Key Physical Findings

✓ Examination of the vulva for lesions (note color, texture, location)

• Lichen simplex chronicus, which manifests with diffusely erythematous areas

• Lichen planus, which manifests with red ulcerated lesions with white lacy bands

• Psoriasis, which manifests with raised lesions with a silver scale and an erythematous base

• Seborrheic dermatitis, which manifests with symmetric reddish-yellowish lesions with an oily crust, sparing the labia minora

• Lichen sclerosis, which manifests with thin whitish areas of epithelium

• Vulvar intraepithelial neoplasia, which has a variable presentation: white, red, or pigmented lesions that may be an isolated patch or extensive

• Vulvar carcinoma, which has a variable presentation: red or white ulcer or exophytic lesion, usually on the labia majora

• Candida infection, which manifests with red lesions with satellite lesions

• Tinea cruris, which manifests with raised edges and well-demarcated lesions

• Squamous cell hyperplasia, which manifests with areas of thickened epithelium (usually of the clitoris and labia majora)

✓ Speculum examination to evaluate the vagina and cervix for discharge, lesions, or erythema

✓ Examination of the perianal area for any lesions

Suggested Work-Up

Scrapings for fungal culture and microscopy	To evaluate for tinea cruris
Wet-mount preparation of vaginal secretions	To evaluate for bacterial vaginosis or Trichomonas vaginalis infection
Potassium hydroxide (KOH) preparation of vaginal secretions	To evaluate for Candida infection
Colposcopy	To evaluate for vulvar atypia
Biopsy	If the diagnosis is unclear or if neoplasia is suspected

Additional Work-Up

Patch testing	If contact dermatitis is suspected
Serum bilirubin measurement	If biliary disease is suspected
Liver function tests	If liver disease is suspected
Complete blood cell count	If a hematologic disorder is suspected
Serum creatinine measurement	If kidney disease is suspected
HIV test	If HIV infection is suspected or the patient is at risk
Thyroid-stimulating hormone (TSH) measurement	If thyroid disease is suspected
Fasting blood glucose measurement	If diabetes is suspected
Viral culture	To evaluate for herpes if ulcerative lesions are present
Colonoscopy or sigmoidoscopy	If a colonic cause is suspected

FURTHER READING

Bohl TG. Overview of vulvar pruritis through the life cycle. Clin Obstet Gynecol. 2005;48:786-807.

Bornstein J, Pascal B, Abramovich H. The common problem of vulvar pruritus. Obstet Gynecol Surv. 1993;48(2):111-118.

Moses S. Pruritus. Am Fam Physician. 2003;68:1135-1142.

Welsh B, Howard A, Cook K. Vulval itch. Austral Fam Physician. 2004;33:505-510.

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