Makindo Medical Notes

Vulval itching and lesions are common gynaecological complaints encountered in clinical practice. They can be caused by various dermatological, infectious, neoplastic, and inflammatory conditions. Proper diagnosis and management are essential to provide relief and address underlying causes.

Common Causes of Vulval Itching

• Infections: Common infections that cause vulval itching include:
  • Candida (Thrush): Presents with intense itching, redness, and thick white discharge.
  • Bacterial Vaginosis: May cause mild itching with a fishy-smelling discharge.
  • Sexually Transmitted Infections (STIs): Such as herpes simplex virus (HSV), which can cause painful ulcers and itching.
  • Pubic Lice: Cause severe itching in the pubic region due to lice infestation.
• Dermatological Conditions:
  • Contact Dermatitis: Allergic or irritant reaction to soaps, perfumes, or sanitary products, causing itching, redness, and sometimes vesicles.
  • Psoriasis: Can affect the vulva, leading to red, scaly patches with itching.
  • Lichen Sclerosus: Chronic inflammatory condition presenting with white patches, thinning skin, and intense itching.
• Neoplastic Causes:
  • Vulvar Intraepithelial Neoplasia (VIN): Pre-cancerous changes in the vulva, often presenting with itching and visible lesions.
  • Vulval Cancer: Rare but important cause of itching, especially in older women, presenting with ulcers, lumps, or bleeding.
• Inflammatory Conditions:
  • Lichen Planus: Chronic inflammatory disorder that may cause vulval itching, pain, and erosions.
  • Atrophic Vaginitis: Seen in postmenopausal women due to decreased estrogen levels, causing thinning of the vaginal and vulval tissues, leading to itching and discomfort.

Diagnosis

Accurate diagnosis of vulval itching and lesions requires a thorough history, physical examination, and sometimes diagnostic tests such as swabs, biopsy, or colposcopy.

History and Exam

• Duration of symptoms
• Presence of any discharge, ulcers, or lesions
• Associated symptoms like pain, burning, or swelling
• Sexual history and use of contraceptives
• Personal hygiene products, clothing, or recent changes in products used
• Inspect the vulva for any redness, lesions, ulcers, or discharge.
• Palpate the vulva and inguinal lymph nodes for any lumps or tenderness.

Investigations

• Swabs: For bacterial, fungal, or viral infections.
• Biopsy: For suspicious lesions or chronic conditions like lichen sclerosis or suspected neoplastic changes.
• Colposcopy: For detailed examination of suspicious vulval lesions or ulcers.

Management

• Infections: Antifungal treatments for candidiasis, antibiotics for bacterial infections, and antiviral therapy for herpes infections.
• Dermatological Conditions:
  • Contact Dermatitis: Avoid triggers and use topical steroids or emollients to reduce inflammation.
  • Lichen Sclerosus: High-potency topical corticosteroids are the mainstay of treatment.
• Neoplastic Causes:
  • Vulvar Intraepithelial Neoplasia (VIN): Requires excision, laser therapy, or topical treatments based on severity.
  • Vulval Cancer: Treated with surgery, radiotherapy, or chemotherapy depending on the stage.
• Inflammatory Conditions:
  • Lichen Planus: Managed with topical or systemic corticosteroids and immunosuppressants for severe cases.
  • Atrophic Vaginitis: Treated with topical estrogen therapy to restore vaginal health.
• General Care: Good vulval hygiene, avoiding irritants, and using cotton underwear can help alleviate symptoms in many cases.

When to Refer

• Failure of first-line treatments to relieve symptoms.
• Suspicious lesions that may require biopsy or specialized care.
• Recurrent or severe infections that are resistant to standard treatment.

Conclusion

Vulval itching and lesions can be caused by a variety of underlying conditions, ranging from infections to dermatological and neoplastic causes. A thorough history, examination, and targeted management are essential for effective treatment. Referral to a specialist is recommended in cases of persistent or unclear diagnosis.