What is the treatment for pruritus over the labia majora?

Treatment for Itching Over Labia Majora

For pruritus over the labia majora, first-line treatment should be topical corticosteroids such as hydrocortisone 1% cream applied to the affected area no more than 3-4 times daily. 1, 2

Diagnostic Approach

Before initiating treatment, consider potential causes:

• Primary skin conditions (contact dermatitis, vulvar Fordyce adenitis)
• Infections (fungal, bacterial)
• Systemic causes (if generalized pruritus is present)
• Irritants (soaps, detergents containing sodium lauryl sulfate)

Treatment Algorithm

First-line Treatments:

1. Topical Corticosteroids

   • Hydrocortisone 1% cream applied to affected area 3-4 times daily 2
   • Avoid prolonged use to prevent skin thinning
   • Suitable for inflammatory causes of pruritus

2. Proper Hygiene Measures

   • Clean affected area with mild soap and warm water
   • Gently pat dry rather than rubbing 2
   • Avoid irritating soaps and detergents 3
   • Wear loose, cotton underwear

Second-line Treatments (based on suspected cause):

1. If fungal infection is suspected:

   • Clotrimazole cream applied to affected external area twice daily for up to 7 days 4

2. For persistent pruritus:

   • Non-sedating antihistamines (fexofenadine 180mg, loratadine 10mg, or cetirizine 10mg daily) 1
   • Note: Cetirizine is not effective for uremic pruritus 5

3. For neuropathic pruritus:

   • Consider gabapentin (900-3600mg daily) or pregabalin (25-150mg daily) 1
   • Particularly beneficial in elderly patients 1

Special Considerations

• For elderly patients: Emollients with high lipid content are recommended; avoid sedating antihistamines due to risk of falls and cognitive impairment 1

• For severe cases: Systemic corticosteroids (0.5-2 mg/kg daily) may provide temporary relief 1

• For vulvar Fordyce adenitis: Consider tetracyclines, oral zinc, or isotretinoin for recurrent painful papules/nodules on labia 6

When to Refer

Consider referral to gynecology or dermatology if:

• Symptoms persist despite appropriate treatment
• Suspicion of vulvar cancer (presence of mass or ulcer) 5
• Diagnostic uncertainty exists
• Symptoms significantly impact quality of life

Common Pitfalls to Avoid

1. Overuse of topical steroids - Can lead to skin atrophy and thinning
2. Inadequate hygiene - Too little or excessive cleaning can worsen symptoms
3. Ignoring underlying causes - Treating symptoms without addressing the cause leads to recurrence
4. Using irritating products - Scented soaps, detergents with sodium lauryl sulfate can exacerbate symptoms 3
5. Long-term use of sedating antihistamines - May predispose to dementia except in palliative care 5

Remember that pruritus is a symptom, not a diagnosis. Identifying and treating the underlying cause is essential for long-term relief and preventing recurrence.