What are the treatments for vaginal irritation?

Treatment of Vaginal Irritation

The most effective treatment for vaginal irritation depends on identifying the specific cause, with topical antifungal agents being the first-line treatment for vulvovaginal candidiasis, metronidazole for bacterial vaginosis and trichomoniasis, and addressing underlying causes for non-infectious irritation. 1, 2

Diagnostic Approach

Before initiating treatment, determine the cause of vaginal irritation:

• Symptoms assessment:

  • Pruritus (itching) and white discharge suggest candidiasis
  • Fishy odor suggests bacterial vaginosis
  • Burning, soreness, dyspareunia (painful intercourse), and discharge suggest various causes

• Physical examination findings:

  • Vaginal pH: Normal (≤4.5) in candidiasis; elevated (>4.5) in bacterial vaginosis and trichomoniasis
  • Microscopic examination: KOH preparation for yeast/pseudohyphae; saline wet mount for clue cells or trichomonads
  • "Whiff test": Positive (fishy odor) with KOH in bacterial vaginosis

Treatment by Specific Cause

1. Vulvovaginal Candidiasis (VVC)

First-line treatments:

• Topical azoles (available OTC):

  • Clotrimazole 1% cream 5g intravaginally for 7-14 days
  • Clotrimazole 100mg vaginal tablet for 7 days
  • Clotrimazole 500mg vaginal tablet, single application
  • Miconazole 2% cream 5g intravaginally for 7 days
  • Miconazole 200mg vaginal suppository for 3 days
  • Terconazole 0.4% cream 5g intravaginally for 7 days
  • Terconazole 0.8% cream 5g intravaginally for 3 days 1

• Oral option:

  • Fluconazole 150mg oral tablet, single dose 3

For complicated/recurrent VVC:

• Extended duration therapy with first-line agents
• For C. glabrata infection: Topical intravaginal boric acid, 600mg daily for 14 days 4, 5

2. Bacterial Vaginosis

First-line treatments:

• Metronidazole 500mg orally twice daily for 7 days
• Metronidazole gel 0.75% intravaginally once daily for 5 days
• Clindamycin cream 2% intravaginally at bedtime for 7 days 6, 2

For recurrent bacterial vaginosis:

• Extended treatment duration
• Consider vaginal products containing Lactobacillus crispatus 5

3. Trichomoniasis

Recommended regimen:

• Metronidazole 2g orally in a single dose, OR
• Metronidazole 500mg orally twice daily for 7 days (preferred for recurrent cases)
• Treatment of sexual partners is essential 1, 6, 5

4. Non-infectious Causes

• Atrophic vaginitis:

  • Vaginal moisturizers and lubricants
  • Topical estrogen therapy if not contraindicated

• Irritant/allergic vaginitis:

  • Identify and remove irritants (soaps, detergents, douches)
  • Avoid tight-fitting clothing and synthetic underwear
  • Use cotton underwear and breathable fabrics

• Inflammatory vaginitis:

  • Topical clindamycin
  • Topical steroids may be beneficial 2, 5

Special Considerations

• Pregnancy: Metronidazole 2g single dose for trichomoniasis; only topical azoles (not oral fluconazole) for candidiasis 1, 3

• HIV infection: Same treatment regimens as HIV-negative patients 1

• Recurrent symptoms: Reassess diagnosis, consider extended treatment duration, or alternative diagnoses like desquamative inflammatory vaginitis or vulvodynia 5

Prevention Strategies

• Maintain good genital hygiene
• Avoid irritants (perfumed products, douches)
• Wear cotton underwear
• Wipe from front to back after using the toilet
• Control underlying conditions like diabetes 4, 7

Follow-up

Reassessment within 1-2 weeks is recommended if symptoms persist. Consider alternative diagnosis if no improvement after 72 hours of appropriate therapy 4.