What is the treatment for desquamative inflammatory vaginitis?

Treatment of Desquamative Inflammatory Vaginitis

Topical 2% clindamycin or topical 10% hydrocortisone are the first-line treatments for desquamative inflammatory vaginitis (DIV), with dramatic symptom relief typically occurring within 3 weeks. 1

Understanding DIV

• DIV is an uncommon form of chronic purulent vaginitis that occurs mainly in Caucasian women with peak occurrence during perimenopause 2
• Characterized by vaginal inflammation, purulent discharge, vestibulo-vaginal irritation, and dyspareunia 2
• Diagnosis involves finding increased inflammatory cells and parabasal epithelial cells on microscopy, abnormal vaginal flora, and elevated pH (>4.5) 2
• DIV is a diagnosis of exclusion after ruling out other causes of purulent vaginitis 2

First-Line Treatment Options

Topical Clindamycin

• 2% clindamycin cream or suppositories are highly effective with >95% of patients showing clinical improvement 3
• Typically administered intravaginally for 4-6 weeks initially 4
• Most commonly used treatment (54% of patients in large case series) 1

Topical Corticosteroids

• 10% hydrocortisone is an effective alternative treatment (used in 46% of patients) 1
• Addresses the inflammatory component of DIV 2
• The favorable response to anti-inflammatory agents suggests an immune-mediated etiology 2

Treatment Course and Outcomes

• Median time to symptom relief is approximately 3 weeks 1
• Initial treatment typically continues for a median of 8 weeks 1
• After initial treatment:
  • 26% of patients achieve complete cure 1
  • 58% remain asymptomatic but require maintenance treatment 1
  • 16% achieve only partial control of symptoms 1
• Relapse occurs in approximately 30-32% of patients within 6 weeks after discontinuing treatment 1, 3

Maintenance Therapy

• Long-term maintenance therapy is frequently required (approximately 35-45% of patients) 1, 4
• Favorable initial response to therapy is associated with better clinical prognosis by 20 weeks of follow-up 1
• Postmenopausal patients may require supplementary estrogen therapy to maintain remission 3

Special Considerations

• Identifying and addressing potential triggers (e.g., antibiotics, diarrhea) may help reduce the need for long-term maintenance therapy 4
• In rare cases where cervical ectropion is identified as a potential cause of DIV, cryotherapy of the cervix may provide complete resolution of symptoms 5
• DIV is a chronic inflammatory process involving both vagina and vestibule, requiring careful monitoring and adjustment of treatment regimens 1

Treatment Algorithm

1. Confirm diagnosis through clinical examination and laboratory findings
2. Initiate first-line therapy with either:
   • Topical 2% clindamycin intravaginally daily for 4-6 weeks 4, OR
   • Topical 10% hydrocortisone intravaginally daily for 4-6 weeks 1
3. Assess response after 3 weeks (median time to symptom relief) 1
4. Continue initial treatment for approximately 8 weeks total 1
5. If symptoms resolve, attempt to discontinue treatment
6. If relapse occurs, reinitiate treatment and consider long-term maintenance therapy 1
7. For postmenopausal women with persistent symptoms, consider supplementary estrogen therapy 3
8. Monitor for potential triggers and address them to potentially reduce need for maintenance therapy 4