What is the treatment for vulval itching?

Treatment for Vulval Itching

The first-line treatment for vulval itching is topical azole antifungals, as vulvovaginal candidiasis (VVC) is the most common cause, with options including clotrimazole cream or fluconazole oral tablet for uncomplicated cases. 1

Diagnostic Approach

Before initiating treatment, determine the underlying cause:

• Vulvovaginal candidiasis (VVC) - characterized by pruritus, erythema in the vulvovaginal area, and possibly white discharge; pH is typically normal (≤4.5) 1
• Trichomoniasis - presents with diffuse, malodorous, yellow-green discharge with vulvar irritation 1
• Bacterial vaginosis - characterized by vaginal discharge with fishy odor, particularly after applying KOH 1
• Non-infectious causes - including lichen simplex chronicus, contact dermatitis, or other dermatological conditions 2, 3

Treatment Algorithm

1. For Uncomplicated VVC (most common cause)

First-line options:

• Topical treatments:

  • Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 4
  • Clotrimazole 2% cream 5g intravaginally for 3 days 1, 4
  • Miconazole 2% cream 5g intravaginally for 7 days 1
  • Tioconazole 6.5% ointment 5g intravaginally in a single application 1

• Oral treatment:

  • Fluconazole 150mg oral tablet, single dose 1

2. For Trichomoniasis

• Oral metronidazole (recommended regimen results in 90-95% cure rates) 1
• Treatment of sex partners is recommended to prevent reinfection 1

3. For Bacterial Vaginosis

• Oral metronidazole or clindamycin 1
• Follow-up evaluation one month after treatment completion 1

4. For Complicated VVC

For recurrent VVC (four or more episodes per year), severe cases, or non-albicans infections:

• Longer initial therapy followed by maintenance antifungal regimen for six months 1
• For non-albicans infections, boric acid appears useful 1

Special Considerations

Pregnancy

• Only seven-day topical azole therapies are recommended for pregnant women with VVC 1
• Fluconazole during pregnancy may be associated with spontaneous abortion and birth defects 1

HIV Infection

• Treatment for VVC in women with HIV should not differ from those without HIV 1
• Lower CD4+ T-cell counts are associated with increased rates of VVC 1

External Vulvar Itching

• For external vulvar itching associated with VVC, apply a small amount of topical azole cream to the affected area 2 times daily for up to 7 days 4

Important Caveats

• Self-medication with over-the-counter preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 1
• Any woman whose symptoms persist after using OTC preparations or who experiences recurrence within 2 months should seek medical care 1, 5
• Unnecessary or inappropriate use of OTC preparations is common and can lead to delayed treatment of other causes of vulvovaginitis 1, 5
• Topical azole creams and suppositories are oil-based and may weaken latex condoms and diaphragms 1
• For persistent or recurrent symptoms, consider obtaining vaginal cultures to identify unusual species, particularly non-albicans Candida 1

Follow-Up

• Patients should return for follow-up only if symptoms persist or recur within 2 months 1
• For complicated VVC, follow-up evaluation is recommended to ensure treatment effectiveness 1