Desquamative Inflammatory Vaginitis: Definition and Treatment
What is DIV?
Desquamative inflammatory vaginitis (DIV) is a rare, chronic inflammatory condition of the vagina and vestibule that occurs almost exclusively in white women, with peak incidence in the perimenopausal period (mean age 48.6 years) 1. DIV is characterized by profuse purulent vaginal discharge, severe vulvovaginal irritation, dyspareunia, and diffuse vaginal erythema with petechiae 2, 1.
Key Diagnostic Features
DIV is a diagnosis of exclusion requiring specific findings 2:
- Wet mount microscopy showing: Increased inflammatory cells (predominantly neutrophils) and parabasal epithelial cells (immature squamous cells)
- Vaginal pH: Always elevated above 4.5
- Vaginal flora: Abnormal, often with commensal organisms (20% show pure growth of organisms like Group B streptococci) 3
- Physical examination: Vaginal erythema with petechiae (54% of cases show classic ecchymotic findings), though 36% present with only confluent erythema 3
Critical caveat: 54% of DIV patients have no significant abnormality on routine microbiological testing 3, making this easily missed if relying solely on cultures.
Differential Diagnosis to Exclude
Before diagnosing DIV, you must exclude 2, 3:
- Vulvovaginal candidiasis
- Bacterial vaginosis
- Trichomoniasis
- Contact irritant vaginitis
- Lichen planus
- Immunobullous diseases
- Genitourinary syndrome of menopause
Treatment Approach
First-line treatment is topical vaginal clindamycin 2% cream OR topical vaginal hydrocortisone 10%, both of which provide dramatic symptom relief within 3 weeks (median) in 86% of patients 1.
Initial Treatment Protocol
Choose one of the following:
- Clindamycin 2% vaginal cream (used in 54% of successfully treated cases) 1
- Hydrocortisone 10% vaginal cream (used in 46% of successfully treated cases) 1
Treatment duration: 4-6 weeks initially 3
Expected Response and Long-term Management
- 95% of patients show symptomatic and objective improvement at initial review 3
- However, DIV is a chronic condition requiring maintenance therapy in the majority of cases
At 1-year follow-up 1:
- 26% achieve complete cure (treatment discontinued)
- 58% remain asymptomatic but require ongoing maintenance therapy
- 16% achieve only partial control
Maintenance Therapy Strategy
Of patients who initially respond, 32% relapse within 6 weeks of stopping treatment 1. Therefore:
- If symptoms recur after initial treatment discontinuation: Resume topical clindamycin or hydrocortisone as maintenance therapy
- Maintenance frequency: Typically requires ongoing intermittent or continuous application (specific frequency should be titrated to symptom control)
- Long-term maintenance is required in approximately 35-45% of cases 1, 3
Important Clinical Considerations
Historical triggers are present in 56% of cases 3, most commonly:
- Recent antibiotic use
- Diarrheal illness
- Other disruptions to vaginal homeostasis
If triggers are ongoing and controllable, addressing them may lead to cure - 10 patients with persistent triggers achieved cure once triggers were eliminated 3.
Alternative Treatment Option
Dequalinium chloride (DQC), a local antiseptic with broad antimicrobial spectrum, has shown efficacy for DIV in recent studies and offers a safe, well-tolerated alternative 4, though it is not yet widely recommended as first-line therapy.
Prognosis Indicator
A favorable initial response to therapy within the first 3 weeks is associated with positive long-term clinical prognosis by 20 weeks of follow-up (P=.01) 1.
Clinical Pitfalls to Avoid
- Don't rely solely on culture results - over half of DIV cases show no significant microbiological abnormalities 3
- Don't mistake DIV for recurrent candidiasis or bacterial vaginosis - these patients are frequently misdiagnosed and repeatedly treated unsuccessfully 5
- Don't discontinue treatment too early - median treatment duration before attempting discontinuation is 8 weeks, and relapse is common 1
- Consider cervical ectropion as a potential contributing factor in refractory cases 5
- Remember this occurs almost exclusively in white women - 97-100% of cases in published series 1, 3