What is the treatment for vulvitis?

Treatment of Vulvitis

The first-line treatment for vulvitis depends on the specific cause, with topical azole creams or suppositories for 1-7 days being recommended for vulvovaginal candidiasis, which is a common cause of vulvitis. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential to identify the specific cause of vulvitis:

• Clinical assessment: Evaluate for characteristic symptoms such as pruritus, burning, discharge, and vulvar erythema
• Laboratory tests:
  • Microscopic examination with saline solution and KOH preparation
  • Measurement of vaginal pH
  • Whiff test
  • Vaginal cultures or nucleic acid amplification tests when necessary 1

Treatment Based on Etiology

1. Infectious Causes

Vulvovaginal Candidiasis (VVC)

• First-line treatment options:
  • Topical azole creams or suppositories for 1-7 days
  • Fluconazole 150 mg as a single oral dose 1, 2
  • Options include:
    • Butoconazole 2% cream for 3 days
    • Clotrimazole 1% cream for 7-14 days
    • Clotrimazole 100 mg vaginal tablet for 7 days
    • Miconazole 2% cream for 7 days
    • Terconazole 0.4% cream for 7 days 2

Bacterial Vaginosis

• Metronidazole treatment (oral or topical) 1

Trichomoniasis

• Metronidazole 2g orally in a single dose 1
• Sexual partners should also be treated 1

2. Non-Infectious Causes

Contact or Allergic Dermatitis

• Identify and remove irritants (soaps, detergents, feminine hygiene products) 1
• Topical corticosteroids for inflammation 3
  • High-potency topical steroids like clobetasol propionate 0.05% have shown success in treating specific types of vulvitis such as Zoon's vulvitis 3

SGLT2 Inhibitor-Induced Vulvitis

• Treat underlying candidiasis with fluconazole
• Topical agents may allow continuation of diabetes medication
• In resistant cases, discontinuation of the SGLT2 inhibitor may be necessary 4

Special Populations

Pregnant Women

• Use only topical azole therapies for 7 days
• Avoid oral fluconazole due to potential risk of spontaneous abortion 1

Immunocompromised or Diabetic Patients

• Longer duration of therapy (7-14 days)
• Closer monitoring 1

Elderly Patients

• Require longer treatment duration (7-14 days) due to reduced immune function and slower healing time 1

Recurrent Vulvovaginal Candidiasis

For women experiencing ≥4 episodes per year:

• Initial intensive treatment followed by maintenance therapy
• Long-term prophylactic therapy may be warranted
• Oral antifungal therapy may improve compliance but carries greater potential for systemic toxicity 5

Prevention Strategies

• Use condoms correctly
• Avoid irritants such as perfumed soaps and feminine hygiene products
• Use appropriate lubricants during intercourse
• Wear cotton underwear 1

Common Pitfalls

1. Self-diagnosis and treatment: Patients often incorrectly self-diagnose and treat with over-the-counter antifungals, potentially missing other causes or concurrent infections 6, 5

2. Inadequate evaluation: Telephone triage or brief office visits may lead to misdiagnosis; comprehensive evaluation is necessary to distinguish between various causes of vulvovaginal symptoms 6

3. Overlooking non-infectious causes: Not all vulvitis is infectious; consider allergic contact dermatitis, systemic dermatoses, autoimmune diseases, and neuropathic pain syndromes 6, 7

4. Failure to treat partners: In cases of sexually transmitted infections like trichomoniasis, failure to treat partners can lead to reinfection 1

5. Inappropriate treatment duration: Different populations (pregnant, elderly, immunocompromised) may require longer treatment durations 1