The vulva comprises the external genital organ in women, with the surface covered by skin. Itching, which is an unpleasant sensation, of the vulval skin is a very common symptom in women. The sensation of itch leads to a desire to scratch the area, however, prolonged scratching will damage the skin and lead to a vicious ‘itch-scratch-itch’ cycle which further increases the itching.
Itching, which may vary in intensity, can be intermittent or constant. If present for more than 6 weeks it is termed chronic and can sometimes become very severe and difficult to treat. Environmental factors such as heat, dryness and stress contribute to the intensity and persistence of itch. Complications of chronic itch include ; difficulty in sleeping, difficulty in concentrating, decreased sexual desire and sexual function, agitation, depression and secondary infection.
What causes vulval itch?
There are numerous causes of vulval itch which include a wide range of pathologies and conditions. Sometimes there is more than one cause present.
Thrush (a fungal infection) is a very common cause of itch. Other infections include genital warts (a viral infection) and scabies (a mite infection).
Skin dermatoses (inflammations) are amongst the most common causes of vulval itch. Conditions include eczema, lichen simplex, lichen sclerosus and psoriasis. Vulval skin is most susceptible to irritants and allergens which can trigger an immune response causing a contact dermatitis. Frequent offenders consist of body fluids, hygiene products and topical medications.
Vulval intraepithelial neoplasia (VIN)
Vulval intraepithelial neoplasia is a skin condition where the cells become overactive, and increase in size and become larger. It is a precancerous condition and in a proportion (about 15%) of women will progress to cancer.
This is an increasingly common problem, particularly among women in their 40s. VIN is commonly associated with certain types of human papillomavirus, cigarette smoking and conditions where the immune system may be low. In some women it is associated with a pre-existing dermatosis such as lichen sclerosus. The commonest symptom is itching but about 1/3 of women will have no symptoms. The diagnosis can be difficult as the appearance of VIN varies but most women have visible lesions that are elevated. Biopsy is essential to get an accurate early diagnosis. Treatment is indicated for all cases of VIN and afterwards, women should be closely monitored.
Infrequently, vulval itch may occur because of a disease elsewhere in the body. These include; thyroid problems, liver and kidney disease, postmenopausal atrophy and Sjorgen’s disease.
Skin lesions such as fissures and skin tags may be found occasionally and very occasionally a reaction to a drug may be responsible. Other rare causes include nerve damage and psychological problems.
How can the cause of my itch be identified?
The most important thing is to take a proper history including a full allergy and drug history. A detailed, careful examination is vital. Investigations for patients with itch on the skin with a rash include a skin biopsy and laboratory investigation. Patients with itch normal, non-inflamed skin may need laboratory and radiological tests adapted to the patient’s history and pre-existing diseases.
How can my itch be treated?
First of all an accurate diagnosis is crucial as treating itch depends on identifying and removing the cause. The aims of treatment are to control or stop the symptom of itch, disease activity and reduce inflammation. It should be noted that many conditions are chronic and expectation of cure should be realistic.
Minimising the symptoms
Whatever the cause, these general guidelines should be followed to minimise/prevent the symptoms:
- Avoid irritants and aggravating factors — many topical agents can be irritating
- Avoid over washing and pay attention to hygiene
- Restrict time in the shower or bath
- Apply moisturisers immediately after bathing
- Avoid wearing wool or tight clothing
- Avoid cleansers containing alcohol
- Use a barrier cream or ointments e.g. zinc if there is incontinence or sweating, they help the skin to retain water
- Avoid rapid changes in environmental humidity
- Avoid hot or spicy foods
- Avoid alcohol
The sensation of itching is heightened if the skin is warm. Patients should therefore take measures to cool the skin, including having tepid showers, wearing light clothes that absorb sweat and avoiding over heated rooms where appropriate.
Treatment with Emollients and Moisturisers
Specific treatment will be determined according to the cause. However, Emollients and Moisturisers are a must. These act on the top layers of skin to soften, soothe, smooth and hydrate it. Dryness is an important remediable cause. Most common ones consist of soft paraffin or a combination of soft, liquid and hard paraffin. They should be used both as a soap substitute and to moisturise the skin to help restore and preserve the barrier function of skin. The effects are short lived so use frequently and liberally on a maintenance basis; 15-25gm a week with x 2 daily application to groins and vulva. You may try different ones but try and avoid those with dyes and fragrances even if the skin is clear. Smooth on, don’t rub in, and always apply in the direction of hair growth. Ointments are particularly suitable for dry, chronic lesions but may exacerbate acne and folliculitis.
If itching continues to be a problem despite treatment, there are a number of drugs available to use – however, these should always be discussed with a doctor before using.
If the root cause is an infection, it can usually be treated accordingly. Common infections include:
- Bacterial Vaginosis
- Cytolytic Vaginosis
- Atrophic Vaginitis
- Desquamative Inflammatory Vaginitis
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Treating Vulval Dermatoses
Generalized skin disease can affect the vulva as part of the process but there are a number of conditions which are more specifically localized to vulval skin. These are grouped together under the term vulval dermatoses.