Dr Amy FitzGerald, Gynaecologist, Subiaco
The vulva comprises mostly of skin but is subject to a unique set of influences including reproductive hormones and its specific microbiome.
It is also affected by what can be a harsh physical environment, impacted by heat, friction and moisture. This can make managing vulval conditions and infections challenging.
The impact of vulval conditions on patients should not be underestimated. Wellbeing, sexual function, mood, self-esteem and body image, can all be affected.
Vulval conditions can be debilitating. The stigma associated with them often leads to late presentations contributing to delays in diagnosis and management.
Mainstays of vulval care include avoiding drying soaps by using a soap free wash, with a paraffin-based ointment and reducing exposure to irritants including heat, moisture, soaps, bleaches, dyes, urine and faeces.
This can be done by wearing lose cotton underwear, increasing underwear free time at night, using ‘leak proof’ or period underwear instead of pads or liners, limiting time in tight clothing, especially post workout or wet bathers, and treating and managing urinary and faecal incontinence.
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Benign vulval dermatosis
Lichen Simplex (Chronicus) is characterised by localised well circumscribed thickened plaques typically affecting the labia majora and is the result of the itch-scratch cycle.
It can occur due to multiple dermatoses, for example allergic, contact or irritant dermatitis, systemic disease, and psychiatric conditions. Management centres around removing irritants, breaking the itch-scratch cycle, treating underlying conditions and re-establishing the normal skin barrier.
Topical corticosteroid ointment and vulval care as described above are mainstays of treatment. Steroid ointments is preferred. Tricyclic antidepressants may be used in severe refractory cases when simple measures fail.
Image available here.
Lichen Sclerosus
Lichen Sclerosus is a lifelong autoimmune condition, which can occur at any age and has a bimodal distribution affecting premenarchal girls and more commonly peri and post-menopausal women.
Itch is the most common feature; however, some women are asymptomatic. The disease is characterised by periods of control with recurrent flares. Ultrapotent topical steroids, such as 0.05% betamethasone dipropionate ointment in optimised vehicle, or compounded clobetasol propionate 0.05% ointment, are mainstays of treatment.
Apply daily or twice daily for two-to-four-weeks to induce remission before gradually weaning down to twice per week maintenance. A less potent steroid can be used for mild cases. Ideally use the least potent steroid that achieves control two to three times per week for lifelong maintenance.
Long term sequelae of LS include permanent changes in vulval architecture, narrowing of vaginal aperture, dyspareunia and approximately a 2-5% lifetime risk of progression to vulval intraepithelial neoplasia (VIN) and squamous cell carcinoma of the vulva.
Image available here.
Suppressive steroid treatment appears to reduce the risks. Unilateral lesions or ulcers should prompt suspicion of malignancy and early review for biopsy. LS requires lifelong steroid therapy and follow up, typically yearly with a gynaecologist or dermatologist.
Vulval infections
Symptoms of recurrent, chronic and difficult to treat vulvovaginal candidiasis include pruritus and burning, with resultant dysuria and dyspareunia. Vaginal discharge can be present but is often not the white cottage cheese like discharge of acute VVC.
Symptoms often worsen in the premenstrual phase of the cycle. Chronic VVC pathogenesis is thought to be a hypersensitivity reaction to candida.
It requires a well oestrogneised vagina and is rare in post-menopausal women without risk factors like diabetes and recent antibiotics.
Recurrent VVC is commonly defined as over four infections per year. Treatment regimens vary but commonly require induction with po fluconazole 150mg daily every three days for three doses, then 150mg weekly for six months.
Speciation and sensitivities can be requested from vaginal swabs. Candida glabrata should be managed with boric acid pessaries 600mg PV nocte for 14 days.
If symptoms are not improving on usual management, consider:
- Swapping combined oral contraceptive pill to a low or non-oestrogen contraceptive
- Ceasing SGLT2 inhibitors (flozin) which cause glycosuria leading to contact irritant dermatitis and contribute to candidiasis
- 1% hydrocortisone ointment for co-existing dermatitis from topical antifungal cream bases which can be irritating
- Treating asymptomatic partners. Candida diets and probiotics lack evidence and are not recommended.
Bacterial vaginosis
Bacterial vaginosis is the most common cause of vaginal discharge in women of reproductive age, commonly presenting with a thin grey, white, malodorous discharge.
It is due to vaginal microbiome dysbiosis with vaginal microbiota changing from lactobacilli dominating to increased anerobic bacteria numbers and diversity. BV is associated with increased risk of miscarriage, premature labour, chorioamnionitis, endometritis and pelvic inflammatory disease (PID) and is worth treating.
Options are Metronidazole 400mg PO bd for seven days, Clindamycin 2% intravaginal cream 5g nightly for seven nights, or Metronidazole gel 0.75% one applicator intravaginally nightly for five nights. These are considered safe in pregnancy.
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Male partner treatment requires seven days of po Metronidazole and bd topical Clindamycin cream and can reduce BV recurrence. Treat male-female couples synchronously and advise avoiding sexual contact during treatment.
Condoms should be used if engaging in sexual contact during treatment, but Clindamycin cream can weaken latex condoms for 72 hours post the last dose.
Key messages
- Lichen Sclerosus is a lifelong condition requiring steroid ointment suppression and follow up to prevent loss of vulvar architecture, dyspareunia and malignancy.
- Not all itching is thrush, consider alternative diagnosis particularly in post-menopausal women
- Concurrently treating male and female partners to prevent BV recurrence is recommended.
Author competing interests – nil
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