Vulval itching and lesions

Vulval itching and lesions are common gynaecological complaints. Causes range from infections 🦠 to dermatological 🎨, neoplastic 🎗️, and inflammatory 🔥 conditions. Accurate diagnosis is vital to relieve symptoms and rule out serious pathology.

🔎 Common Causes of Vulval Itching

• 🦠 Infections:
  • 🍞 Candida (Thrush): Intense itching, redness, thick white "cottage cheese" discharge.
  • 🐟 Bacterial Vaginosis: Fishy odour, thin grey discharge, mild itch.
  • 💔 STIs (e.g., HSV): Painful ulcers, blisters, itching.
  • 🪳 Pubic Lice: Severe nocturnal itching due to lice infestation.
• 🎨 Dermatological Conditions:
  • 🧴 Contact Dermatitis: Allergic/irritant reaction to soaps, sanitary products → redness, vesicles, itching.
  • 🌀 Psoriasis: Red, scaly patches, sometimes mistaken for eczema.
  • ⚪ Lichen Sclerosus: White patches, thinning fragile skin, intense itch; associated with increased cancer risk. Long-term follow-up recommended.
• 🎗️ Neoplastic Causes:
  • ⚠️ Vulvar Intraepithelial Neoplasia (VIN): Pre-cancerous lesion, often with itching + visible plaque/lump.
  • 🎗️ Vulval Cancer: Rare but serious; lump, ulcer, or bleeding in older women.
• 🔥 Inflammatory Conditions:
  • 🌿 Lichen Planus: Painful erosions, itching, and sometimes discharge.
  • 🌙 Atrophic Vaginitis: Postmenopausal women; due to low oestrogen → dryness, thinning, itching.

🧾 Diagnosis

Diagnosis = history + exam + targeted tests. Always exclude malignancy 🎗️ if persistent or atypical.

📝 History & Examination

• 📅 Duration and onset of symptoms.
• 💧 Discharge, ulcers, or bleeding?
• 🔥 Associated symptoms → pain, burning, swelling.
• ❤️ Sexual history + STI risk factors.
• 🧴 Products used (soaps, perfumes, pads).
• 👀 Inspect vulva for redness, ulcers, lesions.
• ✋ Palpate vulva + inguinal nodes for tenderness or masses.

🔬 Investigations

• 🧪 Swabs: For bacterial, fungal, viral causes (NICE recommends confirmation before antibiotics).
• 🧬 Biopsy: If lesion persistent, atypical, or suspicious of VIN/cancer.
• 🔍 Colposcopy: For magnified inspection of suspicious vulval lesions.

💊 Management

• 🦠 Infections:
  • Topical antifungals (clotrimazole) for candida; oral fluconazole only if refractory or not in early pregnancy.
  • Antibiotics for BV or STIs following confirmation.
  • Antivirals (e.g., acyclovir) for herpes simplex infection.
  • Lice treatment with permethrin 1% cream rinse.
• 🎨 Dermatological:
  • Contact dermatitis → avoid triggers, emollients, mild topical steroids.
  • Lichen sclerosus → high-potency topical steroids; long-term follow-up, biopsy if symptoms change.
• 🎗️ Neoplastic:
  • VIN → excision, laser, or topical therapy.
  • Vulval cancer → surgery, radiotherapy, ± chemotherapy as indicated.
• 🔥 Inflammatory:
  • Lichen planus → topical/systemic steroids; immunosuppressants if severe.
  • Atrophic vaginitis → topical oestrogens + emollients.
• 🌸 General Measures: Good vulval hygiene, avoid irritants, cotton underwear, emollients for comfort.

📊 Vulval Itching – Causes & Management Table

📌 When to Refer

• 🎗️ Suspicion of VIN or vulval cancer → urgent referral (NICE NG12 / RCOG).
• Persistent itching despite appropriate treatment.
• Recurrent or resistant infections.

✅ Conclusion

Vulval itching can be benign (candida, dermatitis) 🌸 or serious (VIN, cancer) 🎗️. Always take a careful history, examine thoroughly, and use biopsy when in doubt. Early recognition, appropriate investigation, and treatment improve outcomes significantly.

📚 References

• RCOG – Gynaecological Guidance, Vulval Disorders
• Patient.info – Vulval Itch
• NICE NG12 – Suspected Cancer: Recognition & Referral
• OSCEstop – OSCE preparation resource