Pruritus vulvae - Clinicals, Diagnosis, and Management

General Gynecology

Clinicals - History

Fact Explanation
Persistent itching of the vulva Patients may complain that itching is persistent may even disturb their sleep. Persistent itching of the vulva
Patients may complain that itching is persistent may even disturb their sleep.
History of vaginal discharge Vulvovaginal candidiasis is a common reason for pruritus vulvae. . There could be an associated curd like whitish discharge. History of vaginal discharge
Vulvovaginal candidiasis is a common reason for pruritus vulvae. . There could be an associated curd like whitish discharge.
Abdominal discomfort, Itchiness around anus, irritability, behavioural changes and past history of threadworm infection. Threadworm infection is also one of the causes which can induce vulval itching. However most patients with threadworm infestation has no symptoms. Abdominal discomfort, Itchiness around anus, irritability, behavioural changes and past history of threadworm infection.
Threadworm infection is also one of the causes which can induce vulval itching. However most patients with threadworm infestation has no symptoms.
History of genital lice, scabies or contact history with an infected person Local infestation with genital lice , such as Phthirus pubis or Sarcoptes scabiei may present as pruritus vulvae. History of genital lice, scabies or contact history with an infected person
Local infestation with genital lice , such as Phthirus pubis or Sarcoptes scabiei may present as pruritus vulvae.
Rash in vulval area Vulval dermatoses such as lichen sclerosus , , , vulval dermatitis, lichen planus , vulval psoriasis , also leads to pruritus vulvae. Rash in vulval area
Vulval dermatoses such as lichen sclerosus , , , vulval dermatitis, lichen planus , vulval psoriasis , also leads to pruritus vulvae.
Ulcer or growth in vulval area. Vulval intraepithelial neoplasia and vulval carcinoma can present as pruritus vulvae. , Ulcer or growth in vulval area.
Vulval intraepithelial neoplasia and vulval carcinoma can present as pruritus vulvae. ,
History of urinary or fecal incontinence Frequent wetness and irritation around vulva due to urinary/ fecal incontinence can lead to persistent itching. History of urinary or fecal incontinence
Frequent wetness and irritation around vulva due to urinary/ fecal incontinence can lead to persistent itching.
Yellowish discoloration of eyes, generalized oedema, loss of weight, loss of appetite or a history of liver failure Liver failure or obstructive jaundice may induce pruritus , but this is usually generalized rather than localized. Yellowish discoloration of eyes, generalized oedema, loss of weight, loss of appetite or a history of liver failure
Liver failure or obstructive jaundice may induce pruritus , but this is usually generalized rather than localized.
Generalized oedema, malaise, reduced urine output or a history of renal failure Renal failure causes uraemia . This is another systemic illness and this also leads to generalized itching. Uraemic symptoms are nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, mental status changes, visual disturbances and increased thirst. Generalized oedema, malaise, reduced urine output or a history of renal failure
Renal failure causes uraemia . This is another systemic illness and this also leads to generalized itching. Uraemic symptoms are nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, mental status changes, visual disturbances and increased thirst.
Drug history Some drugs may induce pruritus , as a side effect. This pruritus may be either acute in drugs such as morphine, sufentanil, fentanyl, butorphanol or chronic in drugs such as hydroxyethyl starch. Drug history
Some drugs may induce pruritus , as a side effect. This pruritus may be either acute in drugs such as morphine, sufentanil, fentanyl, butorphanol or chronic in drugs such as hydroxyethyl starch.
Allergy history Allergies may mimic this symptom. it can be due to systemic allergy or local allergic reaction to any externally applied chemicals such as cream soaps, perfumes, deodorants or allergy to condoms or sanitary ware. Allergy history
Allergies may mimic this symptom. it can be due to systemic allergy or local allergic reaction to any externally applied chemicals such as cream soaps, perfumes, deodorants or allergy to condoms or sanitary ware.
Obstetric history Vulval engorgement and increased risk of vaginal discharge and thrush during pregnancy cause itch in vulva. Lower oestrogen levels during breast feeding period may also cause an itch in vulva. Obstetric history
Vulval engorgement and increased risk of vaginal discharge and thrush during pregnancy cause itch in vulva. Lower oestrogen levels during breast feeding period may also cause an itch in vulva.
Menstrual history After reaching menopause , due to the lower oestrogen levels, vulval skin become thin and dry. Menstrual history
After reaching menopause , due to the lower oestrogen levels, vulval skin become thin and dry.
Past history of any psychiatric illness Some psychiatric illnesses like dementia, schizophrenia, primary depressive disorders, personality disorders and behavioral disorders may present with recurrent vulval pruritus. Past history of any psychiatric illness
Some psychiatric illnesses like dementia, schizophrenia, primary depressive disorders, personality disorders and behavioral disorders may present with recurrent vulval pruritus.
Social history Use of illicit drugs/ alcohol is important as recreational use of illicit drugs, such as opiates, amphetamines, and cocaine may induce generalized pruritus. Social history
Use of illicit drugs/ alcohol is important as recreational use of illicit drugs, such as opiates, amphetamines, and cocaine may induce generalized pruritus.
Family history Family history of thyroid disease, haematological malignancy will be helpful in arriving at a diagnosis. Family history
Family history of thyroid disease, haematological malignancy will be helpful in arriving at a diagnosis.

Clinicals - Examination

Fact Explanation
Excoriation marks Scratching due to pruritus can damage the skin. Depending on the reason, the area of excoriation can differ: limited to vulva in vulval carcinoma, can extend to the anus in fecal incontinence, is generalized in liver failure. Excoriation marks
Scratching due to pruritus can damage the skin. Depending on the reason, the area of excoriation can differ: limited to vulva in vulval carcinoma, can extend to the anus in fecal incontinence, is generalized in liver failure.
Curd like whitish vaginal discharge In vulvovaginal candidiasis there will be a curd like whitish vaginal discharge that is visible on speculum examination. Curd like whitish vaginal discharge
In vulvovaginal candidiasis there will be a curd like whitish vaginal discharge that is visible on speculum examination.
Infestation with genital lice or scabies mite Various developmental stages of pubic lice can be seen in the pubic hair while scabies affects the skin. Infestation with genital lice or scabies mite
Various developmental stages of pubic lice can be seen in the pubic hair while scabies affects the skin.
Skin dermatoses , Lichen sclerosus, commonly affects vulvogenital and perianal areas causing white thickening of the skin. It can lead to permanent scarring .
Vulval dermatitis is a rash causing red, swollen, and hot skin, excessive dryness of the skin, fluid-filled/ oozing blisters leaving crusts and scales.
Lichen planus is a shiny, firm, reddish purple bumps. These bumps may have tiny white lines (Wickham’s striae) running through them.
Vulval psoriasis causes a raised, reddish, scaly plaque.
Skin dermatoses ,
Lichen sclerosus, commonly affects vulvogenital and perianal areas causing white thickening of the skin. It can lead to permanent scarring .
Vulval dermatitis is a rash causing red, swollen, and hot skin, excessive dryness of the skin, fluid-filled/ oozing blisters leaving crusts and scales.
Lichen planus is a shiny, firm, reddish purple bumps. These bumps may have tiny white lines (Wickham’s striae) running through them.
Vulval psoriasis causes a raised, reddish, scaly plaque.
Ulcers, growths or bleeding over the vulval area In vulval carcinoma, patients commonly present with pruritus vulvae (70%), a mass or an ulcer (57%) and bleeding (25%). These patients are also likely to have palpable inguinal lymph nodes. Ulcers, growths or bleeding over the vulval area
In vulval carcinoma, patients commonly present with pruritus vulvae (70%), a mass or an ulcer (57%) and bleeding (25%). These patients are also likely to have palpable inguinal lymph nodes.
Evidence of chronic liver failure Jaundice, generalized oedema, ascites, Features of hepatic encephalopathy such as drowsiness, confusion. In these patients polished nails can be seen due to recurrent scratching all over the body. Evidence of chronic liver failure
Jaundice, generalized oedema, ascites, Features of hepatic encephalopathy such as drowsiness, confusion. In these patients polished nails can be seen due to recurrent scratching all over the body.
Evidence of uraemia Uraemic features like recurrent vomiting, mental status changes and generalized oedema, wasting, anaemia can be identified during physical examination. Evidence of uraemia
Uraemic features like recurrent vomiting, mental status changes and generalized oedema, wasting, anaemia can be identified during physical examination.
Evidence of thyroid disease Look for a thyroid goitre. According to several studies generalized pruritus can be associated with, thyroiditis( in the presence of antithyroid antibodies), hyperthyroidism( with warm, sweaty skin) and hypothyroidism( due to xerosis). Evidence of thyroid disease
Look for a thyroid goitre. According to several studies generalized pruritus can be associated with, thyroiditis( in the presence of antithyroid antibodies), hyperthyroidism( with warm, sweaty skin) and hypothyroidism( due to xerosis).
Evidence of haematological malignancy Anemia, bleeding manifestations, lymphadenopathy may give a clue towards the diagnosis of a hematological malignancy.
Haematological malignancies such as Hodgkin’s disease is often preceded by an intense, burning itch. Polycythemia vera in majority of cases pruritus was triggered by water. In leukemia pruritus can be the presentation of the disease.
Evidence of haematological malignancy
Anemia, bleeding manifestations, lymphadenopathy may give a clue towards the diagnosis of a hematological malignancy.
Haematological malignancies such as Hodgkin’s disease is often preceded by an intense, burning itch. Polycythemia vera in majority of cases pruritus was triggered by water. In leukemia pruritus can be the presentation of the disease.
Mental state examination This will help to identify any associated psychiatric illness. Mental state examination
This will help to identify any associated psychiatric illness.
Evidence of complications During the examination evidence of secondary bacterial infection such as tender,red, swollen skin with pus formation or bleeding are helpful in identifying secondary bacterial infection. Evidence of complications
During the examination evidence of secondary bacterial infection such as tender,red, swollen skin with pus formation or bleeding are helpful in identifying secondary bacterial infection.
Temperature measurement This is also helpful especially in the presence of secondary bacterial infection. Temperature measurement
This is also helpful especially in the presence of secondary bacterial infection.

Investigations - Diagnosis

Fact Explanation
vaginal pH test Microscopy examination- low vaginal swab Fungal culturing The most common species causing Vulvovaginal candidiasis is C.albicans. Demonstration of a species of Candida with a wet-mount test/potassium hydroxide (KOH) preparation in a clinically suspected patient will helpful to confirm the diagnosis.
Vaginal pH usually normal in vulvovaginal candidiasis.
Fungal cultures is not use in initial stage but useful in asymptomatic patients but at risk of colonizing.
vaginal pH test Microscopy examination- low vaginal swab Fungal culturing
The most common species causing Vulvovaginal candidiasis is C.albicans. Demonstration of a species of Candida with a wet-mount test/potassium hydroxide (KOH) preparation in a clinically suspected patient will helpful to confirm the diagnosis.
Vaginal pH usually normal in vulvovaginal candidiasis.
Fungal cultures is not use in initial stage but useful in asymptomatic patients but at risk of colonizing.
Biopsy from lesion Histological examination will help in differentiating vulval dermatitis and help to diagnose vulval carcinoma.
Biopsy appearance in Vulval Intraepithelial Neoplasia(VIN):
VIN 1-loss of differentiation in lower 1/3 of the epidermis
VIN 2- loss of differentiation in lower 2/3 of the epidermis
VIN 3- loss of differentiation in the entire epidermis, but the basement membrane is intact.
Biopsy from lesion
Histological examination will help in differentiating vulval dermatitis and help to diagnose vulval carcinoma.
Biopsy appearance in Vulval Intraepithelial Neoplasia(VIN):
VIN 1-loss of differentiation in lower 1/3 of the epidermis
VIN 2- loss of differentiation in lower 2/3 of the epidermis
VIN 3- loss of differentiation in the entire epidermis, but the basement membrane is intact.
AST, ALT, Serum protein, Direct/ indirect billirubin levels These tests are useful for medical management if the primary cause is liver failure. AST, ALT, Serum protein, Direct/ indirect billirubin levels
These tests are useful for medical management if the primary cause is liver failure.
Serum creatinine, Serum electrolytes, Blood urea These tests are useful for medical management if the primary cause is kidney failure. Serum creatinine, Serum electrolytes, Blood urea
These tests are useful for medical management if the primary cause is kidney failure.
Urodynamic studies and voiding diaries This helpful in identifying associated urinary incontinence Urodynamic studies and voiding diaries
This helpful in identifying associated urinary incontinence
TSH, free T4 These tests are useful for medical management if the primary cause is thyroid disease. TSH, free T4
These tests are useful for medical management if the primary cause is thyroid disease.
Full Blood Count, Bone marrow biopsy These tests useful in a haematological malignancy. Full Blood Count, Bone marrow biopsy
These tests useful in a haematological malignancy.

Investigations - Management

Fact Explanation
Low vaginal/ vulval swab for culture and ABST secondary infection screening Low vaginal/ vulval swab for culture and ABST
secondary infection screening
Urine full report (UFR), Urine culture and ABST Scratching of the vulvae damage to local skin and may lead to dysuria. these tests can be used to exclude any urinary tract infection in this condition. Urine full report (UFR), Urine culture and ABST
Scratching of the vulvae damage to local skin and may lead to dysuria. these tests can be used to exclude any urinary tract infection in this condition.
Full blood count (FBC) Can get an idea about patient's improvement. Full blood count (FBC)
Can get an idea about patient's improvement.
Low vaginal/ vulval Swab for culture and Anti biotic sensitivity test If there is any evidence of secondary bacterial infection this test will be useful in further treatment. Low vaginal/ vulval Swab for culture and Anti biotic sensitivity test
If there is any evidence of secondary bacterial infection this test will be useful in further treatment.
Full blood count High neutrophil count- bacterial infection
Increased eosinophil count-an allergic reaction/ presence of a parasitic infection
High lymphocyte count- viral infection Abnormal WBC counts-a neoplastic process
Low haemoglobin level- Chronic renal failure
Full blood count
High neutrophil count- bacterial infection
Increased eosinophil count-an allergic reaction/ presence of a parasitic infection
High lymphocyte count- viral infection Abnormal WBC counts-a neoplastic process
Low haemoglobin level- Chronic renal failure
Erythrocyte sedimentation rate (ESR) This is a nonspecific investigation but increased in infectious diseases and may be extremely high in neoplastic disease Erythrocyte sedimentation rate (ESR)
This is a nonspecific investigation but increased in infectious diseases and may be extremely high in neoplastic disease
Fungal culturing Fungal cultures is not use in initial stage but useful in asymptomatic patients who are at risk of colonizing. When a primary cause can not be found, this will be helpful to exclude any fungal infection. Fungal culturing
Fungal cultures is not use in initial stage but useful in asymptomatic patients who are at risk of colonizing. When a primary cause can not be found, this will be helpful to exclude any fungal infection.
Biopsy from lesion If the primary cause is vulval carcinoma, this will be helpful in staging. Biopsy from lesion
If the primary cause is vulval carcinoma, this will be helpful in staging.

Management - Supportive

Fact Explanation
Stopping/ reducing the itchiness using moisturisers Emollients such as aqueous cream, emulsifying ointment will help to get rid of itchiness for a certain extend despite of the cause. Stopping/ reducing the itchiness using moisturisers
Emollients such as aqueous cream, emulsifying ointment will help to get rid of itchiness for a certain extend despite of the cause.
Prevent further damaging to skin by avoiding the itch-scratch cycle Scratching causes itching and it causes more scratching which again causes more itching. This goes as a cycle because excessive scratching cause thickening of the skin and then it becomes even itchier. Better thing is describe the patient about this cycles and advice try not to scratch if at all possible.

It is important to keep nails cut short to minimize the damage causing to skin during scratching.
Prevent further damaging to skin by avoiding the itch-scratch cycle
Scratching causes itching and it causes more scratching which again causes more itching. This goes as a cycle because excessive scratching cause thickening of the skin and then it becomes even itchier. Better thing is describe the patient about this cycles and advice try not to scratch if at all possible.

It is important to keep nails cut short to minimize the damage causing to skin during scratching.
Modifications in under wears - Important to use cotton under wears which quickly absorb wetness around genital areas and avoid nylon/ synthetic underwear material which tends to block fresh air, and causes more sweating.
- Wear loose, light color under wears which reduce heat and sweating.
- Change underwear daily.
- Wash and dry under wears in sunlight which helps to reduce fungal infections
- Consider wearing no underwear when possible(at home, at night)
Modifications in under wears
- Important to use cotton under wears which quickly absorb wetness around genital areas and avoid nylon/ synthetic underwear material which tends to block fresh air, and causes more sweating.
- Wear loose, light color under wears which reduce heat and sweating.
- Change underwear daily.
- Wash and dry under wears in sunlight which helps to reduce fungal infections
- Consider wearing no underwear when possible(at home, at night)
Maintain vulval hygiene - Wash vulva gently as scrub/wash vigorously can further damage the skin.
- Repeated cleaning of the area with soap may cause dryness, so wash with water, dry the area properly with a soft towel and apply some moisturiser.
-Avoid hot water baths
- Prevent shaving the pubic hair, but cutting them in to short will help.
Maintain vulval hygiene
- Wash vulva gently as scrub/wash vigorously can further damage the skin.
- Repeated cleaning of the area with soap may cause dryness, so wash with water, dry the area properly with a soft towel and apply some moisturiser.
-Avoid hot water baths
- Prevent shaving the pubic hair, but cutting them in to short will help.
Help with sleep Pruritic vulva often worse at night and will disturb the sleep. sedative antihistamine will be helpful in this condition(
eg; Chlorphenamine)
Help with sleep
Pruritic vulva often worse at night and will disturb the sleep. sedative antihistamine will be helpful in this condition(
eg; Chlorphenamine)

Management - Specific

Fact Explanation
Anti fungal cream If the primary reason is due to a fungal infection, local application of anti fungal cream and anti fungal vagina pessary is the specific treatment option. Anti fungal cream
If the primary reason is due to a fungal infection, local application of anti fungal cream and anti fungal vagina pessary is the specific treatment option.
Anthelmintic treatment If the primary reason is due to a worm infestation this is the treatment of choice (eg: Mebendazole - in threadworm infestation) Anthelmintic treatment
If the primary reason is due to a worm infestation this is the treatment of choice (eg: Mebendazole - in threadworm infestation)
Parasiticidal treatment Scabies- Permethrin is an effective parasiticide. Application of crotamine can be used to control itchiness after treatment. Topical corticosteroids will also reduce itch and inflammation after successful treatment.

Genital lice- Permethrin and malathion will use to eliminate. Here second treatment is needed after 7 days to kill lice come out of the surviving eggs.
Parasiticidal treatment
Scabies- Permethrin is an effective parasiticide. Application of crotamine can be used to control itchiness after treatment. Topical corticosteroids will also reduce itch and inflammation after successful treatment.

Genital lice- Permethrin and malathion will use to eliminate. Here second treatment is needed after 7 days to kill lice come out of the surviving eggs.
Valval dermatitis lichen sclerosus- Strong topical steroid creams/ ointments (eg; clobetasol propionate) should be applied as a thin layer for a few weeks or months .

vulval dermatitis- If there is any identifiablr irritant is present, remove the irritant to avoid future contact. Application of topical steroid creams/ ointments is the medical treatment.

Lichen planus- Antihistamines Pills will be helpful for itchiness. Topical corticosteroid cream/ointment, corticosteroid pills (eg; prednisone), PUVA therapy, retinoic acid use to treat this condition.

vulval psoriasis- Tar creams, calcipotriol (Vitamin D), salacylic acid should apply in the morning and cortisone should be applied at night .
Valval dermatitis
lichen sclerosus- Strong topical steroid creams/ ointments (eg; clobetasol propionate) should be applied as a thin layer for a few weeks or months .

vulval dermatitis- If there is any identifiablr irritant is present, remove the irritant to avoid future contact. Application of topical steroid creams/ ointments is the medical treatment.

Lichen planus- Antihistamines Pills will be helpful for itchiness. Topical corticosteroid cream/ointment, corticosteroid pills (eg; prednisone), PUVA therapy, retinoic acid use to treat this condition.

vulval psoriasis- Tar creams, calcipotriol (Vitamin D), salacylic acid should apply in the morning and cortisone should be applied at night .
Chronic liver failure, thyroid disease, haematological malignancy Symptomatic management of pruritus will be useful and specific managment of the medical condition should be consider. Chronic liver failure, thyroid disease, haematological malignancy
Symptomatic management of pruritus will be useful and specific managment of the medical condition should be consider.
Renal failure with uraemia Haemodialysis will helpful in uraemia. Renal failure with uraemia
Haemodialysis will helpful in uraemia.
Vulval carcinoma Surgery is the main way of treatment both in curative and palliative intentions. Surgery will depend on the stage at presentation . Radiotherapy and chemotherapy also play a role in reducing morbidity. Vulval carcinoma
Surgery is the main way of treatment both in curative and palliative intentions. Surgery will depend on the stage at presentation . Radiotherapy and chemotherapy also play a role in reducing morbidity.
Idiopathic vulval itching After excluding other causes this condition should be consider. General vulval skin care, Topical local anaesthetic gel, amitriptyline ( start with low dose at night and increase as required, then gradually reduce dose over 3 months) and antiepileptics like gabapentin( rarely use with specialist referral for chronic pain) can be used. Idiopathic vulval itching
After excluding other causes this condition should be consider. General vulval skin care, Topical local anaesthetic gel, amitriptyline ( start with low dose at night and increase as required, then gradually reduce dose over 3 months) and antiepileptics like gabapentin( rarely use with specialist referral for chronic pain) can be used.
Psychotherapy Aromatherapy, autogenic training, brief dynamic psychotherapy, cognitive–behavioral therapy, habit-reversal behavioral therapy, stress management and structured education are identified as effective in this condition. Psychotherapy
Aromatherapy, autogenic training, brief dynamic psychotherapy, cognitive–behavioral therapy, habit-reversal behavioral therapy, stress management and structured education are identified as effective in this condition.
Urinary incontinence Pelvic floor exercises and anticholinergic drug (eg; oxybutynin) are helpful. Urinary incontinence
Pelvic floor exercises and anticholinergic drug (eg; oxybutynin) are helpful.

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