Today we’re working up the classic GYN sick visit in vulvovaginal itching. We recommend The V Book by Elizabeth Stewart, MD, and though we haven’t read Dr. Jen Gunter’s The Vagina Bible yet, we’ve heard great things!
We start off the episode with a review of things that can cause itching, stratifying from benign to more worrisome. For benign causes, the primary culprit is vaginitis. Think yeast (Candida), bacterial vaginosis, or less commonly gonorrhea/chlamydia or trichomoniasis. Another benign cause is desquamative inflammatory vaginitis, that can be associated with large amounts of discharge. Genitourinary syndrome of menopause, or atrophic vagnitis, is another common cause in postmenopausal women.
Benign dermatoses of the vulva can include lichen planus, which manifests as a red or purplish raised rash, that can present as hypertrophic or ulcerative. It can further lead to lichen simplex chronicus, which is an area of thickened skin due to repeated excoriation. Lichen planus can also involve other areas of the body. Finally, benign dermatoses like eczema, contact dermatitis, or psoriasis can also affect the vulva.
More worrisome dermatoses can include lichen sclerosus. Generally benign, this is a chronic, progressive inflammatory mucocutaneous disease that peaks in prepubertal and in menopausal women. The skin becomes thin and parchment-paper or “cigarette paper”-like in consistency, whitening, and destruction of the architecture and narrowing of the vaginal introits. It can be worrisome, particularly in older women, because it can harbor vulvar intraepithelial neoplasia (VIN) or squamous vulvar cancer. Of course, both of those can also occur on their own, often in the context of HPV infection.
Another malignant dermatosis is extramammary Paget’s disease. In this case, the vulva have an eczematous appearance with slightly raised edges and a red background. This is rare, with the malignancy originating in the vulvar apocrine-gland-bearing skin cells.
Ok, so lots of things can cause this itching, but what should we do? Always start with a complete history and physical. Histories should have special focus on vulvar hygiene, as this is often the culprit. A physical exam should include all skin including the vulva, to rule out more significant dermatoses. With the vulva, we advise a “top down” systematic approach before proceeding with the speculum exam.
The gynecologists handy tool will be the wet mount. Vaginal pH should be < 4.5, and basic pHs may suggest infection or poor lactobacillus presence. Dropping 20% KOH solution on the slide will allow for better visualization of yeast, as well as allow for the performance of the whiff test. On microscopy, you should see plenty of squamous cells (large, squarish cells with small nucleus or no nucleus), compared to paranasal cells (small round cells with prominent nuclei). Sheets of squamous cells with paranasal cells suggests desquamative inflammatory vaginitis. Clue cells have stippled or fuzzy borders along squamous cells. Yeast often has the classic ‘budding pseudohyphae’ or ‘spaghetti and meatballs’ appearance.
Genital cultures may be helpful in identifying resistant or unusual organisms, such as Candida glabratta. If allergies are suspected, referral for patch testing may be worthwhile if avoidance isn’t feasible. Biopsy should be performed to rule out malignancy at ulcerating areas, with lichen sclerosus, or with other areas of concern.
With vulvar hygiene, go as simple as possible. As our mentor Dr. Crichton always says: if you wouldn’t put it in your eye, don’t put it on the vulva. Recommend cotton underwear during the day, no underwear at night; unscented detergents and soaps; only water on vulva; latex condoms and provide own lube with silicone lube; avoid panty liners every day, only during periods . Coconut oil makes for excellent personal moisturizer and lubricant.
If something is present, you should treat the condition. Infections should be treated with appropriate antimicrobials. Lichen planus should be given symptomatic treatment to stop itching. Lichen sclerosus often will need high potency steroids (i.e., clobetasol) to resolve. Malignancies will require excision with referral to oncology for true invasive cancers.
