What is the treatment for vulval excoriation?

Treatment of Vulval Excoriation

The first-line treatment for vulval excoriation is topical hydrocortisone applied to the affected area no more than 3-4 times daily to reduce inflammation and relieve itching. 1

Diagnostic Considerations

• Vulval excoriation is often secondary to an underlying condition that causes itching, leading to scratching and subsequent skin damage 2
• Common underlying causes include:
  • Vulvovaginal candidiasis (especially recurrent cases) 3
  • Dermatological conditions (eczema, psoriasis, lichen simplex chronicus) 2, 4
  • Contact dermatitis from irritants or allergens 2
• Biopsy should be considered for non-responding or atypical lesions to rule out conditions like extramammary Paget's disease or vulvar intraepithelial neoplasia 5

Treatment Algorithm

Step 1: Address the Underlying Cause

• Perform vaginal cultures to identify infectious causes, particularly Candida species 3, 6
• For confirmed vulvovaginal candidiasis:
  • Uncomplicated cases: Single 150-mg dose of fluconazole 3
  • Severe cases: 150 mg of fluconazole in two sequential doses (second dose 72 hours after initial dose) 3
  • Non-albicans Candida: Longer duration therapy (7-14 days) with a non-fluconazole azole drug 3

Step 2: Treat the Excoriation

• Apply topical hydrocortisone to affected areas 3-4 times daily 1
• For adults and children over 2 years of age, apply directly to the affected area 1
• For more severe cases, consider a moderate-potency topical corticosteroid ointment (not cream) for a limited period 4

Step 3: Break the Itch-Scratch Cycle

• Avoid potential irritants (soaps, detergents, jewelry, cosmetics) 1
• Wear loose-fitting cotton underwear to reduce friction and moisture 2
• Apply cool compresses to relieve itching 6

Special Considerations

• For recurrent vulvovaginal candidiasis (≥4 episodes per year):
  • Initial therapy: 7-14 days of topical therapy or 150-mg oral fluconazole repeated after 3 days 3
  • Maintenance therapy: Fluconazole 150 mg once weekly for 6 months 3
• For posterior fourchette fissures that don't respond to medical therapy, perineoplasty may be considered 4
• For skin fold fissures, prolonged use of topical corticosteroid ointment may be necessary after eliminating any underlying infection 4

Treatment Pitfalls to Avoid

• Self-diagnosis and inappropriate use of over-the-counter antifungal preparations can worsen irritation 6
• Using estrogen cream alone for bacterial infections may delay appropriate treatment 7
• Failing to identify and treat the underlying cause will lead to recurrence of excoriation 2, 6
• Overlooking the possibility of malignancy in non-healing lesions 5

Follow-up Recommendations

• Patients should be reassessed after 2-4 weeks of treatment to evaluate response 2
• For recurrent or persistent symptoms, consider referral to a multidisciplinary vulval service with dermatologists and gynecologists 2
• All patients should undergo surveillance following treatment for recurrent disease 3