Recurrent Vulvar Itching

1. Recurrent Vulvar Itching Greenjournal Obstetrics & Gynecology Vol.105. No6 June 2005 Page 1451-1455 Recurrent vulvar itching

2. Case Colleen M. Dennedy, MD • Commentary Lori A Boardman, MD Fennifer Bott, MD Recurrent vulvar itching

3. C a s e • Age : 25-year-old • Sex : female Recurrent vulvar itching

4. Case Chief complaint Recurrent vulvovaginal discharge and irritation Recurrent vulvar itching

5. CasePresent illness • A 25-year-old woman, has been severe intermittent vulvar burning, intermittent itching and constant mild-to-moderate vulvar pain over the past 18 months. • She has been treated with 7courses of antibiotics, with either a brief response or no improvement of her symptoms Recurrent vulvar itching

6. CasePast History • Tx for vulvar itching (over the past half year) • metronidazole and clindamycin vaginal creams • clindamycin vaginal ovules • Burow’s solution (Bayer Consumer Care, Morris Towship, N) soaks • over-the-counter vaginal moisture solution • perineal cleansing pad • panty shields with baking soda • Medical Hx for migraines • Operation Hx Laparoscopic tubal ligation Recurrent vulvar itching

7. CasePast History • Using the following household products - scented dryer sheets - various laundry detergents - deodorant soap - scented liquid body wash - topical lubricating jelly before intercouse Recurrent vulvar itching

8. CaseFamily History(furtherquestioning by the specialist) • atopic diseases, including asthma, hay fever and dermatitis. • admits to occasional rubbing and scratching of the area secondary to the intense pruritis that she often experiences. Recurrent vulvar itching

9. CaseSocial History • Smoking : no • Alcohol : no • Using illicit drugs : no Recurrent vulvar itching

10. CaseObstetrical History Marriage yes Recurrent vulvar itching

11. CaseReview of system Genitourinary system Dysuria/Urinary frequency (+ / +) Urinary or fecal incontinence (-) Recurrent vulvar itching

12. CasePhysical Examination Vulva markedly erythematous without lesions, ulcerations or excoriations when the labia minora are separated, significant erythema is noted Vestibule : erythematous Recurrent vulvar itching

13. CaseLaboratory finding Microscopy : normal - without yeast, clue cells, trichomonads or inflammatory changes - Maturation : normal - Lactobacilli : present Urine culture (-) Recurrent vulvar itching

14. Commentary Recurrent vulvar itching

15. CommentaryQuestions for the Spicialist • What is the differential diagnosis? • What is contact dermatitis? • Are there known risk factors for contact dermatitis of the vulva? Why are some women more prone to this condition than other? • How is contact dermatitis distinguished from other vulvovaginal conditions? Do any other tests need to be done to establish a diagnosis? • What happens if contact dermatitis is not treated? • How is contact dermatitis treated? • How Successful is treatment? Recurrent vulvar itching

16. Differential Diagnosis Recurrent vulvar itching

17. Differential Diagnosis Recurrent vulvar itching

18. Differential Diagnosis The greatest suspicion for this patient rests with vulvovaginal candidiasis and/or contact dermatitis Recurrent vulvar itching

19. Differential DiagnosisCandida albicans Not confirmed on the basis of her normal microscopy and negative fungal culture → the sensitivity of saline microscopy for diagnosing candidiasis : 30~50% (10% potassium hydroxide improves this estimate) As an aside a recent Cochrane review found no difference in relative effectiveness (short term or long term) between oral and intravaginal fungal treatments in women with vulvovaginal candidiasis but women preferred oral therapy. Recurrent vulvar itching

20. Differential DiagnosisCandida albicans Atypical candidiasis (eg. C. glabratea, C. parapsilosis) Sx - may cause itching as well as the more typical burning antifungals(oral and topical) are largely ineffective result in little physical evidence of inflammation microscopy can be difficult in this diagnosis - blastospores of several species do not form hyphae or pseudohyphae - vaginal cultures obtained on at least 2 occasions preferably while symptomatic ☞ if 2 consecutively obtained cultures are negative for Candida species, the diagnosis of recurrent disease can be confidently excluded Recurrent vulvar itching

21. Differential Diagnosischronic dermatologic conditions vulvar manifestations develop in approimately 20% of women with psoriasis and this can be localized to the vulva Lesions on the vulva typically lack the scale classically associated with this disease and do not involve the vagina. Psoriasis (compared with dermatitis) - more symmetrical, erythematous and better defined Seborrheic dermatitis can also be considered but in the present case the characteristic greasy scales overlying erythematous patches or plaques are lacking Given the patient’s history of repetitive exposure to a variety of potentially irritating and/or allergenic substances and physical finding, contact dermaitis seems the most likely diagnosis Recurrent vulvar itching

22. Contact Dermatitis Dermaitis (or eczema) : poorly demarcated, erythematous and usually itchy rash. Subtypes: numerous classified as exogenous (irritant of allergic contact dermatitis) endogeous (atopic of seborrheic dermatitis) > 20~60% of patients seen with chronic vulvar symptoms Common to see a mixed picture, in which endogenous dermatitis or another epithelial disorder has been worsened by use of ointments or creams to which the patient has adversely reacted. Recurrent vulvar itching

23. Contact Dermatitis Contact Dermatitis : an inflammation of the skin caused by exposure to an external agent that as either as and irritant or as an allergen. Recurrent vulvar itching

24. Risk factors Any process that alters or damages any component of the epidermis compromises its function Loss of estrogen : epithelial thinning of the vagina and introitus – a less effective barrier results With existing dermatoses (eg. Lichen sclerosus) Family of persomal history of atopy (eg. Asthma , rhinitis, conjunctivitis or hives) Recurrent vulvar itching

25. Diagnosis Clinical sign mild erythema, swelling and scaling to marked erythema, fissures, erosions and ulcers Routine bacterial cultures of vaginal flora limited value Fungal cultures Biopsy if the patient dose not respond to treatment. Patch testing Recurrent vulvar itching

26. TreatmentWhat happens if contact dermatitis is not treated? ☞ Lichen simplex chronicus Lichen simplex chronicus - a chronic eczematous disease characterized by intense and unrelenting itching and scratching - 10~35% of patients evaluated - 65~75% of patients will report a history of atopic disease. (may be a localized variant of atopic dermatitis) - All patients : pruritus admit to vigorous scratching or rubbing - Clinically appears as one or more erythematous, scaling, lichenified plaques - In long standing disease : skin appears thickened and leathery areas of hyperpigmentation and hypopigmentation may be present Recurrent vulvar itching

27. TreatmentWhat happens if contact dermatitis is not treated? ☞Lichen simplex chronicus Lichen simplex chronicus - represent an end-stage response to a wide variety of possible initiating processes including enviromental factors eg. heat, excessive sweating and irritation from clothing or topically applied products dermatologic deseases eg. Candidiasis, lichen sclerosus Recurrent vulvar itching

28. Treatment Recurrent vulvar itching

29. Treatment Medication - antihistamine & sedative properities (doxepin or hydroxyzine) can be added to control nocturnal itching while cetirizine or a SSRI can used during the day - anti-inflammatory therapy : begin with a mid to high-potency topical corticosteroid for 2~3weeks - a weaker corticosteroid (1%hydrocortisone) can then be continued as needed Recurrent vulvar itching

30. Case Impression Contact dermatitis Lichen simplex chronicus Plan Recurrent vulvar itching