Skip to content

Pruritus Vulvae

BASICS

  • Description: Pruritus vulvae is a symptom (vulvar itching/burning) or may be a primary diagnosis only after other etiologies are excluded. “Vulvodynia” or “burning vulva syndrome” may be alternate diagnoses for primary cases.

EPIDEMIOLOGY

  • Any age: Most women experience vulvar pruritus at some point.
  • Young girls: Infectious or hygiene-related etiologies most common.
  • Primary diagnosis: More common in postmenopausal women.
  • Incidence: Exact incidence unknown; underreported.

ETIOLOGY & PATHOPHYSIOLOGY

  • Vulvar tissue: More permeable, easily irritated by:
    • Perfumes, soaps, vaginal hygiene products, topical meds, dyes, body fluids
  • Risk factors: High-risk sexual behavior, immunosuppression, obesity

PREVENTION

  • Avoid irritants (soaps, fragrances, topical products)
  • Wear only cotton underwear
  • Avoid tight-fitting clothing

ASSOCIATED CONDITIONS

  • Infectious: Candida, Gardnerella, Trichomonas, HPV, HSV
  • Dermatologic/Inflammatory: Lichen sclerosus, lichen planus, lichen simplex chronicus, psoriasis, atopic dermatitis, irritant/allergic contact dermatitis
  • Neoplastic: Malignancy, premalignant lesions, extramammary Paget
  • Other: Fecal/urinary incontinence, dermatophytosis, scabies, Pthirus pubis, vulvar vestibulitis, autoimmune progesterone dermatitis
  • Dietary triggers: Methylxanthines (coffee, cola), tomatoes, peanuts

DIAGNOSIS

Diagnosis of Exclusion

  • Exclude all other causes before primary diagnosis is made (vulvodynia/burning vulva syndrome).

History

  • Persistent itching or burning of vulva/perineum
  • Changes in discharge, postcoital bleeding, dyspareunia

Physical Exam

  • Inspect vulva, vagina, perineum, anus (superior labia majora commonly involved)
  • Look for leathery, lichenified, or papillomatous skin
  • Cotton swab test (pain response)
  • Musculoskeletal assessment if persistent pain

Diagnostic Tests

  • Wet mount (NaCl): Gardnerella or Trichomonas
  • KOH: Candida
  • Viral culture/PCR: HSV
  • Directed biopsy: HPV, lichen, malignancy, chronic inflammation (recommended for postmenopausal women and persistent lesions)
  • Colposcopy: With acetic acid or Lugol’s solution
  • Patch test (dermatology): If contact dermatitis suspected

Tissue Biopsies

  • Collect from any ulceration, discoloration, raised/macerated/most symptomatic areas.
  • Most commonly, pathology reveals lichen simplex chronicus, lichen sclerosus, or chronic inflammation.

TREATMENT

General Measures

  • Identify and treat underlying cause.
  • Discontinue all potential irritants.
  • Treat infections (bacterial, fungal).
  • Cool affected area: Cool gel packs (not ice packs), sitz baths, bland emollients

Medication

First Line - Topical steroids: - Triamcinolone 0.1% daily x2–4 weeks, then twice weekly - Hydrocortisone 1–2.5% cream 2–4x/day - Avoid long-term use (skin atrophy risk) - 1st-generation antihistamines (for sleep): - Hydroxyzine 10–100 mg qHS - Doxepin 10 mg qHS - 2nd-generation antihistamines: little benefit

Second Line - SSRI: Citalopram 20–40 mg (for refractory cases) - Calcineurin inhibitor: Pimecrolimus 1% cream

ISSUES FOR REFERRAL

  • Persistent symptoms: refer to gynecologist or gynecologic oncologist for further workup
  • Biopsy-proven or suspected malignancy: gynecologic oncology
  • Patch testing for contact dermatitis: dermatology

ADDITIONAL THERAPIES

  • Sacral neuromodulation device
  • Laser therapy
  • GnRH analogues
  • Naltrexone

ONGOING CARE

  • Frequent reevaluation, repeat cultures and biopsies if needed
  • Persistent or refractory cases: multidisciplinary referral

DIET

  • Avoid:
    • Coffee, cola, other caffeinated drinks
    • Tomatoes
    • Peanuts

PATIENT EDUCATION

  • ACOG Patient Resources: https://www.acog.org
  • National Vulvodynia Association: https://www.nva.org

PROGNOSIS

  • Most controlled with conservative measures and topical steroids

COMPLICATIONS

  • Underlying malignancy

ICD-10 CODE

  • L29.2 Pruritus vulvae
  • N94.819 Vulvodynia, unspecified

CLINICAL PEARLS

  • Pruritus vulvae is common, but diagnosis of exclusion
  • Always biopsy any ulcer, discoloration, raised, macerated, or highly symptomatic area to rule out malignancy
  • Conservative therapy is initial mainstay
  • Delay in diagnosis can impact sexual comfort and quality of life