What is the treatment for desquamative vaginitis?

Treatment of Desquamative Inflammatory Vaginitis

Desquamative inflammatory vaginitis (DIV) is most effectively treated with either topical 2% clindamycin or topical 10% hydrocortisone for initial therapy, with treatment typically required for 4-6 weeks followed by maintenance therapy in many cases. 1

Diagnosis and Clinical Characteristics

DIV is a chronic inflammatory condition characterized by:

• Vaginal inflammation and rash
• Purulent vaginal discharge
• Diffuse exudative vaginitis
• Epithelial cell exfoliation
• Vaginal pain and discomfort

Laboratory findings typically include:

• Elevated vaginal pH
• Increased parabasal cells on microscopy
• Absence of normal lactobacilli
• Presence of inflammatory cells
• Often gram-positive cocci on Gram stain 2

DIV occurs almost exclusively in white women, with a mean age of approximately 48-49 years, and affects both pre- and postmenopausal women. 1

Treatment Algorithm

First-Line Treatment Options:

1. Topical 2% clindamycin cream or suppositories

   • Apply intravaginally once or twice daily for 4-6 weeks 1, 2
   • Shown to be effective in >95% of patients 2

2. Topical 10% hydrocortisone

   • Apply intravaginally once daily for 4-6 weeks 1
   • Particularly useful when inflammatory component is prominent

Treatment Response and Duration:

• Most patients (86%) experience significant symptom relief within approximately 3 weeks 1
• Initial treatment should continue for a median of 8 weeks 1
• A favorable initial response to therapy is associated with better long-term prognosis 1

Maintenance Therapy:

• Approximately 58% of patients remain asymptomatic but dependent on maintenance therapy at 1 year 1
• Maintenance regimens typically involve less frequent application (2-3 times weekly) of the effective initial treatment

For Postmenopausal Women:

• Consider supplementary estrogen therapy to maintain remission 2
• This may help address potential estrogen deficiency that could play a role in pathogenesis

Treatment Outcomes and Prognosis

Based on follow-up data at 1 year 1:

• 26% of patients achieve complete cure
• 58% remain asymptomatic but require maintenance therapy
• 16% achieve only partial control of symptoms

Relapse is common, occurring in approximately 32% of patients within 6 weeks after treatment discontinuation 1

Differential Diagnosis

DIV must be distinguished from other conditions that may present similarly:

• Erosive lichen planus 3
• Candida vulvovaginitis
• Bacterial vaginosis
• Contact irritant vaginitis
• Fixed drug eruptions
• Immunobullous diseases
• Estrogen hypersensitivity vulvovaginitis 4

Special Considerations

• DIV appears to have triggers in approximately 56% of cases, most commonly diarrhea or antibiotic treatment 4
• When ongoing triggers are identified and controlled, some patients can achieve complete cure without maintenance therapy 4
• The condition may represent a disruption in vaginal homeostasis leading to an inflammatory response with increased epithelial cell turnover 4
• No consistent microbiologic pathogen has been identified, though there is often an absence of lactobacilli and increased prevalence of group B streptococci 2

Pitfalls and Caveats

• DIV is often misdiagnosed due to its rarity and similarity to other inflammatory vulvovaginal disorders 5
• Standard treatments for common vaginal infections like bacterial vaginosis or yeast infections will be ineffective
• Long-term maintenance therapy is frequently required, so patients should be counseled about the chronic nature of this condition
• Treatment discontinuation should be attempted gradually with careful monitoring for relapse
• If symptoms persist despite appropriate therapy, reconsider the diagnosis and evaluate for other conditions in the differential diagnosis