Pruritus vulvae
Exam Tips
- In OSCEs, first distinguish itch from pain and ask about irritants, discharge, nocturnal symptoms, sexual risk, menopause/breastfeeding, diabetes, and impact on sleep/sex/mood.
- Classic pattern recognition: lichen sclerosus often has white fragile figure-of-eight vulval/perianal plaques with vaginal sparing; this is a high-yield exam clue.
- Always mention chaperone, consent, dignity, and full anogenital plus targeted extragenital skin/oral examination.
- If discharge/infection signs are present, send swabs; if lesions are persistent/atypical/scarring/suspicious, arrange urgent specialist assessment and biopsy.
- Safety point frequently tested: avoid oral fluconazole in pregnancy; use topical azole regimens instead.
Definition
Pruritus vulvae is persistent or recurrent itching localised to the vulva (mons pubis, labia, clitoris, perineum, and external urethral/vaginal openings), and it is a symptom rather than a single diagnosis. In UK practice, an underlying cause is usually found on focused history and examination, and more than one cause may coexist (for example, irritant dermatitis with candidiasis). It should be distinguished from vulval pain syndromes such as vulvodynia, although overlap can occur.
Pathophysiology
Vulval itch arises from activation of cutaneous and mucosal itch pathways by inflammation, infection, barrier disruption, or neoplastic change. Common mechanisms include irritant/allergic contact dermatitis (epidermal barrier injury with cytokine-mediated inflammation), candidal overgrowth in a warm moist environment, and chronic inflammatory dermatoses (for example lichen sclerosus/lichen planus) causing epithelial damage and altered local immunity. Repeated scratching drives an itch-scratch cycle, leading to lichenification (lichen simplex), excoriation, secondary bacterial infection, and peripheral neural sensitisation that perpetuates symptoms even after the original trigger improves.
Risk Factors
- Irritant exposure: soaps, perfumes, wet wipes, detergents, sanitary products, over-washing
- Allergen exposure: topical antibiotics (for example neomycin), local anaesthetic creams, latex/spermicides, fragranced products
- Diabetes mellitus (higher risk of vulvovaginal candidiasis)
- Urinary or faecal incontinence causing chronic skin irritation
- Menopause or breastfeeding-related hypoestrogenism (atrophic vulvovaginal change)
- Personal/family atopy (eczema, asthma, hay fever) and history of chronic skin disease
- Sexual risk factors for STI-related vulvovaginitis
- Friction, heat, sweating, tight occlusive clothing, exercise
Clinical Features
Symptoms
- Vulval itch (often worse with heat, moisture, friction, menses, or after irritants)
- Soreness/burning with scratching; may coexist with dyspareunia
- Nocturnal itch with perianal itch (suggests threadworm, especially in younger patients)
- Vaginal discharge or malodour if infectious cause is present
- Sleep disturbance, sexual dysfunction, low mood/anxiety in chronic disease
Signs
- Excoriations, fissures, erythema, oedema, erosions or ulceration
- Lichenification/thickened plaques and pigment change (lichen simplex pattern)
- Atrophic or scarring change with architectural loss in chronic inflammatory dermatoses
- Lichen sclerosus pattern: white fragile plaques, purpura/ecchymosis, often figure-of-eight vulval-perianal distribution with vaginal sparing
- Features of candidiasis: vulval erythema/oedema with adherent curdy discharge
- Associated extragenital signs (psoriasis at elbows/knees/scalp, oral lesions in lichen planus, eczema elsewhere)
Investigations
Management
Lifestyle Modifications
- Stop potential irritants/allergens: avoid perfumed soaps, bubble baths, wipes, deodorants, topical OTC combinations; use bland emollient as soap substitute
- Reduce friction/moisture: loose cotton underwear, avoid tight synthetic clothing, change out of sweaty clothes promptly
- Gentle vulval care: lukewarm water only or emollient wash, pat dry, avoid over-washing/scrubbing
- Break itch-scratch cycle: keep nails short, consider night-time behavioural strategies, treat sleep disturbance
- Address contributory factors: optimise diabetes control, manage incontinence, review medicines and barrier products
Pharmacological Treatment
Topical corticosteroids for inflammatory vulval dermatoses
- Clobetasol propionate 0.05% ointment: thin layer once nightly for 4 weeks, then alternate nights for 4 weeks, then twice weekly for 4 weeks (typical induction for vulval lichen sclerosus)
Use ointment rather than cream on vulval skin where possible. Review response and diagnosis if poor improvement. Safety: prolonged unsupervised potent steroid use can cause skin atrophy; however, undertreatment of lichen sclerosus increases scarring and malignant risk.
Antifungal therapy for vulvovaginal candidiasis
- Clotrimazole 500 mg pessary intravaginally as a single dose
- Clotrimazole 10% vaginal cream 5 g intravaginally as a single dose
- Fluconazole 150 mg orally as a single dose (if not pregnant)
Treat only when candidiasis is likely/confirmed. Safety: avoid oral fluconazole in pregnancy; use topical azoles in pregnancy. Check interactions with azoles and consider recurrent disease work-up if frequent episodes.
Management of dermatitis/eczema with itch
- Hydrocortisone 1% ointment thinly once or twice daily for short courses in mild disease
- Emollient barrier ointment applied frequently
Primary treatment is trigger avoidance plus skin barrier restoration. Escalate potency only with clear indication and follow-up. Avoid sensitising combination products containing local anaesthetics or topical antibiotics unless specifically indicated.
Symptomatic antipruritic support
- Chlorphenamine 4 mg at night as needed for short-term nocturnal itch
Sedating antihistamines do not treat the cause but may help sleep. Safety: counsel about drowsiness, impaired driving, and anticholinergic effects.
Surgical / Interventional
- Punch/incisional biopsy of persistent, atypical, or suspicious vulval lesions
- Definitive excision/oncological management if vulval intraepithelial neoplasia or invasive squamous cell carcinoma is diagnosed
Complications
- Chronic itch-scratch cycle causing lichen simplex chronicus and irreversible architectural change
- Secondary bacterial infection of excoriated skin
- Sexual dysfunction, dyspareunia, sleep disturbance, anxiety/depression, reduced quality of life
- Scarring complications in lichen sclerosus (labial resorption, introital stenosis, clitoral burying/pseudocyst, urinary/sexual dysfunction)
- Malignant transformation risk in chronic inflammatory/neoplastic precursor disease (for example SCC risk in lichen sclerosus/lichen planus/VIN)
Prognosis
Outcome depends on the underlying diagnosis and how early targeted treatment starts. Many acute causes (for example candidiasis or irritant dermatitis) improve quickly with trigger removal and specific therapy, but chronic inflammatory disorders may relapse over years and require long-term follow-up to prevent scarring and detect premalignant or malignant change early.
Sources & References
✅NICE Guidelines(1)
- Pruritus vulvae[overview]
📖Textbook References(1)
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 311, 312)[context]