Pruritus vulvae

Management Strategy

Pruritus vulvae describes a symptom that may be psychologically distressing, socially embarrassing, and detrimental to sexual health and function. Identifying all etiologies is critical to management. Secondary pruritus vulvae may be caused by anatomic alteration, infection/infestation, inflammatory dermatosis, neoplasm, systemic disease, or neurologic dysfunction ( Table 207.1 ). The role of radiculopathies or pudendal nerve entrapment as a cause of vulvar pruritus is increasingly recognized. Furthermore, vulvar pain (vulvodynia) may be difficult to distinguish from vulvar pruritus and is often comorbid. It should be noted that diabetes mellitus, an increasingly common diagnosis worldwide, may contribute to vulvar pruritus through various pathogeneses, including frequent/persistent candidiasis, neuropathic pain, autonomic dysfunction, and primary pruritus. In the absence of any secondary cause of pruritus, the condition is considered primary until proven otherwise.

A thorough history is the first step in understanding all possible etiologies of pruritus vulvae in a given patient. A personal or family history of any inflammatory dermatosis may direct the differential diagnosis. Any history of self-directed treatment should be elicited. In addition, a complete mucocutaneous examination should be performed with attention to primary and secondary findings. This should entail visual and manual inspection of the vulva, vagina, and perianal skin and the complete mucocutaneous integument (i.e., the oral cavity, conjunctivae, and nasal mucosa, as well as a total body skin, scalp, and nails examination). In conducting the genital exam, it is vital to distinguish normal vulvar anatomy (which varies widely) from any pruritus-associated pathology. Special care should be given to distinguish physiologic pigmentation from associated erythema, inflammation, or infiltrative process in vulvar skin, regardless of skin tone. In skin of color, clinical findings can vary from pink to tan to violaceous or hyperpigmented lesions. The clinician should also preform palpation of inguinal lymph nodes and sensory testing for light touch of the vulva and vaginal vestibule. Utilizing current International Society for the Study of Vulvovaginal Disease (ISSVD) terminology to classify dermatologic findings is useful in forming a differential. A number of specific investigations may further aid in diagnosis.

Upon identification of any primary or secondary etiologies, appropriate treatment should be instituted. If no etiology is identified (primary pruritus vulvae), then symptomatic relief is the goal of therapy. The tenets of treatment are to interrupt the itch–scratch cycle, restore the skin barrier, and minimize impact on quality of life. The critical first step is to identify and remove all suspected local irritants and allergens . The patient should be counseled to institute a number of lifestyle modifications ( Table 207.2 ). The patient may resist some measures, particularly the avoidance of fragranced or ‘cleansing’ products, due to desire for a ‘clean’ vulva and vagina; they may believe natural secretions and odors are offensive or even the cause of their symptoms. To the contrary, elaborate hygiene regimens contribute to local irritation and contact sensitivity and may confound or be the primary cause of persistent pruritus. Talc in particular is highly irritating, and investigation of its role in ovarian cancer remains inconclusive. Whenever possible, systemic rather than local preparations should be used in the treatment of pruritus to limit concurrent secondary irritation. However, it has also been reported that ingested food and drug metabolites excreted in urine and stool can serve as allergens and/or irritants, contributing to anogenital pruritus.

Maintenance of barrier function facilitates healing and limits irritant contact. The use of petrolatum- and zinc-based ointments helps to seal in moisture and protect the affected skin from external chemical and physical insults. Ointments generally contain fewer inactive ingredients, thus limiting potential irritants or allergens. In low-estrogen states, the use of topical or systemic estrogen helps restore vaginal and vulvar mucosal barrier function.

Corticosteroids are used to reduce inflammation. Corticosteroid ointment should be used sparingly once or twice a day. Close clinical supervision is necessary to identify and mitigate adverse effects (e.g., striae, folliculitis, atrophy). Intralesional (injected) and systemic corticosteroids may be effective for recalcitrant pruritus. Non-inflammatory idiopathic disease does not benefit from topical corticosteroids. When topical steroid does not alleviate symptoms, other etiologies must be considered.

Corticosteroids reduce pruritus but are often insufficient to interrupt the itch–scratch cycle. Antihistamines such as hydroxyzine or topical doxepin are recommended for night-time therapy. For daytime pruritus, a low-dose selective serotonin reuptake inhibitor is advised. Amitriptyline , pregabalin , or gabapentin may be effective in pruritus characterized by pain, burning, or stinging sensations. Local anesthetics such as lidocaine 2% jelly may be used to facilitate intercourse or otherwise provide temporary relief.

Numerous investigative treatments for specific genital conditions have shown relief of pruritus and may be indicated off-label. The systemic immunotherapy ixekizumab (an interleukin-17A inhibitor) has been shown to significantly improve itch in patients with genital psoriasis. Dupilumab (an interleukin-4 receptor α-blocker) was effective in a case of recalcitrant anogenital pruritus in a male. Innovative therapies, including phototherapy, platelet-rich plasma, and adipose-derived stem cells, have shown promise in specific pruritic conditions (such as lichen sclerosus) and may be considered in the future for primary pruritus vulvae.

Ultimately, management of pruritus vulvae requires that providers display utmost empathy and compassion. Difficulties in diagnosis and treatment can be exhausting and frustrating for affected patients. It is important to assess subjective impact of the condition on the patient’s mental health and functional status and refer for supportive therapy as needed. Lifestyle changes and specific therapies should be adopted through shared decision-making.