Differential Diagnosis for Vaginal Itching in a 73-Year-Old Female

Single Most Likely Diagnosis

• Lichen sclerosis: This condition is characterized by thinning of the vulvar skin, leading to itching and discomfort. It's more common in postmenopausal women, and the lack of response to antifungal treatment suggests a non-infectious cause.

Other Likely Diagnoses

• Atrophic vaginitis: A common condition in postmenopausal women due to decreased estrogen levels, leading to vaginal dryness, itching, and discomfort. The negative vaginitis panel and lack of response to antifungal treatment make this a plausible diagnosis.
• Vulvar dermatitis: An inflammatory condition of the vulvar skin, which can cause itching, redness, and discomfort. It may be irritant or allergic in nature, and the patient's age and symptoms are consistent with this diagnosis.
• Psoriasis or eczema of the vulva: These skin conditions can cause itching, redness, and discomfort in the vulvar area, and may not respond to antifungal treatment.

Do Not Miss Diagnoses

• Vulvar cancer: Although rare, vulvar cancer can present with itching, discomfort, and a visible lesion. It's essential to rule out this diagnosis with a thorough examination and potentially a biopsy.
• Invasive fungal infections: Although the vaginitis panel was negative, and antifungal treatment was ineffective, it's crucial to consider the possibility of a resistant or unusual fungal infection, especially in an older adult.

Rare Diagnoses

• Vulvar vestibulitis: A condition characterized by chronic pain and itching in the vulvar vestibule, which may not respond to standard treatments.
• Neurological disorders: Certain conditions, such as neuropathy or nerve compression, can cause vulvar itching and discomfort. These diagnoses are less common but should be considered if other explanations are ruled out.