What is the treatment for pediatric vulvovaginitis?

Treatment of Pediatric Vulvovaginitis

The treatment of pediatric vulvovaginitis should focus on addressing the underlying cause, with topical antifungal agents like clotrimazole 1% cream applied to the external vaginal area for 7 days being the first-line treatment for fungal vulvovaginitis in young girls. 1

Diagnosis and Etiology

Vulvovaginitis is the most common gynecological complaint in pediatric and adolescent females 2. The causes differ between prepubertal and adolescent girls:

• Prepubertal girls: Non-specific causes are most common, with hygiene issues being predominant 2. Specific causes include:

  • Poor hygiene
  • Chemical irritants (soaps, bubble baths)
  • Foreign bodies
  • Infections (bacterial, fungal)
  • Pinworms
  • Labial adhesions
  • Lichen sclerosus

• Adolescent girls: Infections are more common, particularly:

  • Candida species (yeast)
  • Bacterial vaginosis
  • Sexually transmitted infections

Diagnosis should include:

• Clinical evaluation of symptoms
• Microscopic examination of vaginal secretions
• Vaginal pH measurement (normal pH ≤4.5 for yeast infections) 1

Treatment Algorithm

1. Non-specific Vulvovaginitis (Most common in prepubertal girls)

• First-line management:
  • Improved genital hygiene (cleaning from front to back)
  • Cotton underwear
  • Avoiding irritants (perfumed soaps, bubble baths)
  • Sitz baths with warm water

2. Fungal Vulvovaginitis (Candidiasis)

• For prepubertal girls:

  • Clotrimazole cream 1% applied to external vaginal area for 7 days 1
  • OR Nystatin 100,000 units applied topically to vaginal area once daily for 7-14 days 1

• For adolescents:

  • Topical antifungal agents (no one agent superior to another) 3:
    • Clotrimazole 1% cream 5g intravaginally for 7-14 days
    • Miconazole 2% cream 5g intravaginally for 7 days
    • Nystatin 100,000-unit vaginal tablet, one tablet for 14 days
  • OR single 150-mg oral dose of fluconazole 3
  • For severe cases: fluconazole 150 mg every 72 hours for 2-3 doses 3

3. Bacterial Vulvovaginitis

• For specific bacterial pathogens:
  • Topical antibiotics may be preferable to systemic treatment, showing fewer recurrences (2.22% vs 13.33%) and fewer side effects 4
  • For beta-hemolytic Streptococci or Enterococci: appropriate antibiotic based on culture results

4. For C. glabrata infections (resistant to standard treatments)

• Topical intravaginal boric acid, 600 mg daily for 14 days 3
• OR Nystatin intravaginal suppositories, 100,000 units daily for 14 days 3

Special Considerations

Application Technique

• For prepubertal girls: Apply medication gently to the external vaginal area only, avoiding deep insertion into the vagina 1
• For adolescents: Intravaginal application may be appropriate

Follow-up

• No routine follow-up needed if symptoms resolve completely
• Reevaluation necessary if symptoms persist after completing treatment 1
• Persistent symptoms may indicate:
  • Non-albicans Candida species
  • Alternative diagnoses (bacterial infections, irritative dermatitis)
  • Possible foreign body (especially in prepubertal girls with persistent discharge)

Recurrent Vulvovaginal Candidiasis

For recurring vulvovaginal candidiasis in adolescents, use 10-14 days of induction therapy with a topical agent or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months 3

Prevention

• Maintain good genital hygiene
• Use cotton underwear
• Avoid tight-fitting clothing
• Avoid irritants like perfumed soaps and bubble baths
• Weight control if necessary
• Address any voiding dysfunction 5

Common Pitfalls

1. Treating without proper diagnosis - always confirm the cause before initiating specific treatment
2. Using oral azoles in young children with uncomplicated vulvovaginitis 1
3. Failing to consider foreign bodies in cases of persistent discharge, especially with blood-tinged discharge
4. Not addressing underlying hygiene issues, which can lead to recurrence
5. Overlooking the possibility of sexual abuse when sexually transmitted organisms are isolated

By following this structured approach to pediatric vulvovaginitis, clinicians can effectively manage this common condition while minimizing unnecessary antibiotic use and improving patient outcomes.