Vulvitis

What is vulvitis?

Vulvitis specifically refers to inflammation of the vulval area. However, the terms vulvitis, vulvovaginitis and vaginitis are used by gynaecologists more or less interchangeably.

Exact figures are not available because the term covers so many different conditions and many women self-treat and do not consult a health professional. Females of all ages are affected, from prepubertal girls to the elderly. It is thought that most women will experience at least one episode in their lifetime and many have recurrent episodes.¹Vulval diseases are still underdiagnosed and undertreated.

The presenting symptoms include:

• Itch.

• Discharge.

• Pain.

• Soreness.

• Dysuria.

• Dyspareunia.

History

It is important to ask about the symptoms above. It is useful to gather information about when the symptoms occur - whether they are constant, intermittent, or cyclical. A personal or family history of skin disease (eg, atopy, psoriasis, eczema) or autoimmune disease (associated with lichen sclerosus) may be significant.

Enquiries should be made about general health and any stress factors. Other information of importance includes current medication, previous treatment (prescribed or purchased), obstetric and gynaecological history and any potential allergens or sensitiser, such as sanitary wear, soap or detergent.

Examination

The examination should be performed in good lighting to assess subtle changes in the skin. A chaperone should be offered.

• As a minimum, the vulva, pubis, and perianal area should be examined. The cervix and vagina should be included if appropriate.

• Other areas of skin should be examined if there are rashes elsewhere. For example, there may be evidence of facial, hand, or flexural dermatitis.

• If the appearance is essentially normal it may be worth proceeding to see whether the pain is localised and provoked by light touch (suggestive of vulvar vestibular disorder) or is more generalised and not provoked by touch (suggestive of vulvodynia).

• The clinical diagnosis may be apparent from the history and examination. Investigations may be required to support the clinician's suspicions.

• Blood tests may include fasting glucose, FBC, and serum ferritin.

• If an infection is suspected, appropriate swabs or cultures should be taken to look for conditions such as candida or bacterial vaginosis.

• If a sexually transmitted infection is suspected, appropriate swabs and/or blood tests should be undertaken.

• Referral to gynaecologists to consider skin biopsy will be required in cases of diagnostic difficulty (or for any skin lesion not responding to a six-week course of treatment).

Most infective causes are due to candidiasis or bacterial vaginosis.¹² However, there are many non-infective causes. Most cases of vulvovaginitis in children have a non-specific aetiology.³

Infection

• Candida, trichomoniasis, bacterial vaginosis.

• Pubic lice, threadworm, scabies.

• Herpes simplex, urinary tract infection (UTI), vulval vestibulitis.

• Group A beta haemolytic streptococcal infection is a relatively uncommon cause of vulvovaginitis in adult women.⁴

Dermatological conditions⁵

• Allergic dermatitis. The most common vulval dermatosis in both adults and children is dermatitis. The majority of these patients are atopic.⁶

• Psoriasis.

• Lichen simplex/planus/sclerosus.

Neoplasia

• Squamous cell carcinoma (90% of cases have vulvitis but this remains a very rare cause of vulvitis with SCCs making up only 4% of gynaecological cancers).⁷

Atrophic

• Genitourinary syndrome of the menopause or GSM (previously known as vaginal atrophy) is thought to affect 70% of peri- and post-menopausal women with symptoms increasing with age. Around 12.5% of pre-menopausal women are also thought to be affected.⁸

• Breastfeeding can also result in lowered oestrogen levels and consequent vulval symptoms, similar to those found in GSM.

Miscellaneous

• Poor hygiene or, more commonly, over-washing with soaps and other products.

• Pregnancy.

• Generalised pruritus.

• Hormonal pH changes associated with the menstrual cycle can lead to pruritus vulvae as increasing pH is known to activate the proteinase-activated receptor-2, which is an itch mediator.⁹

• Idiopathic - uncommon, and only diagnosed when all other causes have been excluded.

• Vulvitis circumscripta plasmacellularis (Zoon's vulvitis). This is a is a rare, benign vulval disorder that presents with erythematous patches and erosions.¹⁰

Miscellaneous pain syndromes

• Vulvodynia - causes chronic vulval and pelvic pain, of unknown aetiology. Vulvodynia is a complex disorder reported by up to 16% of women in the general population.¹¹¹²

• Vulvar vestibulitis syndrome - this is often considered to be a subset of vulvodynia that is characterised by severe pain during attempted vaginal entry (intercourse or tampons insertion), tenderness to pressure localised to the vulvar vestibule and redness of the vulvar vestibule.

Depending on cause this could include:

• Diabetes.

• Immune deficiency states.

• Urinary incontinence.

• Perimenopause, and postmenopausal oestrogen deficiency.

• Faecal incontinence.

• Any cause of generalised pruritus - eg, liver disease, lymphoma.

• Many cases will have an identifiable cause, so accurate diagnosis is an important precursor to management.

• Suspected vulval carcinoma (ie women with an unexplained vulval lump, ulceration, or bleeding) needs urgent referral for an appointment within two weeks as per local and national guidelines.¹³

• Consider referring patients with non-suspicious skin changes and negative microbiology, who have failed to improve with initial treatments, for patch testing, as these cases are often allergic in nature.¹⁴¹⁵

General advice

• All women and girls should be advised to avoid contact of the vulval skin with soap, bubble bath, shampoo, perfumes, personal deodorants, wet wipes, detergents, textile dyes, fabric conditioners, and sanitary wear.

• In addition, they should use a non-soap cleanser and wear loose cotton clothing.

• Partners should avoid use of spermicidally-lubricated condoms.¹⁶

• Patients should be given accurate and clear written information to reinforce these measures.

Pruritus vulvae of unknown cause

In the absence of a specific diagnosis, or whilst waiting for results, the following treatments can be tried. Most are based on the empirical experience of experts, as there is little published evidence:

• Emollients can be used as an adjunct to other treatments and are suitable for easing itching in almost all types of vulval disease; they can be used in addition to most other therapies. They can also be used as a soap substitute or moisturiser. There is wide patient variability and lack of comparative evidence, so the choice of preparation can be left to individual preference. If topical steroids are used as well, the emollient should be used first and the steroid 10-20 minutes later. This ensures the skin is moisturised and avoids spread of the steroid to normal skin.

• Sedating oral antihistamines appear to work by promoting sedation rather than blocking the action of histamine. Sedative antidepressants have been used with similar benefit.

• Low-potency topical corticosteroids (eg, hydrocortisone 1% ointment) can be considered as a short trial (1-2 weeks). Potent steroids should be avoided, as they can affect surface features and confuse the diagnosis should subsequent specialist referral be required. Specialist referral is indicated if there is no response to steroids.

• Topical oestrogen should be used in most women with symptoms of vulvitis. Unless there is a history of breast cancer, when specific advice should be sought, genitourinary syndrome of the menopause is so common that this is a very reasonable treatment.

This will depend on the underlying condition and the results of investigations. Topical corticosteroids are the mainstay of treatment for inflammatory vulval disorders. Ointments are better tolerated than creams, as they are less likely to cause stinging.

Potent steroids should only be used if the prescriber is confident in the diagnosis. Starting potent steroids for lichen sclerosus is reasonable in general practice but should always be accompanied by a referral to a specialist.

Infection

Vulval and vaginal infections should be treated with the appropriate antibiotic, antifungal, antiviral, or other antimicrobial agent. Treatment should generally await the swab results in order to reduce the risks of over-treatment.

Dermatological conditions

• Contact dermatitis - this is mainly centred on irritant avoidance, with topical corticosteroid treatment as a secondary measure to relieve itching.

• Seborrhoeic dermatitis and psoriasis - these are usually treated with judicious use of topical corticosteroids (sometimes combined with an antibacterial or anticandidal agent). Ketoconazole shampoo can be used as body wash for seborrhoeic dermatitis.

• Lichen simplex can be treated with topical betamethasone for 1-2 weeks to break the itch-scratch cycle.

• Lichen sclerosus and lichen planus usually respond to short-term regular potent or superpotent topical corticosteroids. Women with lichen sclerosus and lichen planus have a small risk (2-5%) of developing carcinoma, so long-term annual follow-up may be suggested. There is little evidence for this. Where it is recommended this should be carried out in specialist gynaecology clinics and not in general practice. Although the evidence is not clear, it is thought that treatment of vulval lichen sclerosus and vulval lichen planus is likely to reduce the risk of squamous cell carcinoma.¹⁷

Genitourinary syndrome of the menopause

Management of GSM is via the use of local vaginal and vulval oestrogens, along with non-hormonal lubricants or moisturisers, coupled with maintenance of sexual activity if possible. It is important to recognise that, unlike with other menopausal symptoms, GSM symptoms do not usually improve over time (and tend to deteriorate) and therefore long-term treatment is usually required.¹⁸

Zoon's vulvitis

This normally responds to high-potency topical steroids.¹⁹ Successful treatment with platelet-rich plasma has been reported.²⁰

In both the conditions below, examination and investigations are usually normal:

• Vulvodynia - the predominant symptom is chronic, poorly localised vulval burning or pain. The exact aetiology is unclear but the condition shares some features with neuropathic pain syndromes. An approach to the diagnosis and management of a woman presenting with vulvodynia should address the biological, psychological and social/interpersonal factors that contribute to this condition.²¹

• Vulvar vestibular syndrome - this is also known as vestibulitis, vestibular pain syndrome, vestibulodynia, and localised vulval dysaesthesia. Altered pain perception is the major feature of this syndrome. Management is often challenging. A number of treatments have been tried, including Xylocaine® gel, pelvic floor retraining with biofeedback, low-dose tricyclic antidepressants, newer neuropathic pain agents, and cognitive behavioural therapy. Surgery for this condition exists, with success rates of 60% to 90%. However, surgery is recommended only in cases that have failed to respond to traditional treatments.²²

Referral is indicated if:

• There is an unexplained vulval lesion or vulval bleeding due to ulceration.

• Sexually transmitted infection is suspected and there is no capacity for the clinician to do screening tests, or where a sexually transmitted infection is confirmed, requiring sexual health management and contact tracing.

• A dermatological diagnosis is suspected but there is no response to treatment.

• Contact allergy is suspected and patch testing is required.

• An underlying cause has not been identified and symptoms do not respond to simple advice or a short trial of topical steroids.

• Night-time pruritus can lead to sleep loss and reduce quality of life. Threadworms should always be considered in this symptom.

• If correctly diagnosed, most underlying causes can be successfully treated.

• Failure to diagnose serious underlying conditions, such as neoplasia, can be fatal.

• Most cases of pruritus resolve once the correct diagnosis is made and appropriate treatment instituted.

• The prognosis will depend on the underlying condition causing the vulvitis.