What are the treatment options for vulvovaginal pruritus (vaginal itchiness)?

From the Guidelines

For vaginal itchiness, start with over-the-counter antifungal creams like clotrimazole (1% cream for 7-14 days or 2% cream for 3 days) or miconazole (2% cream for 7 days, 4% cream for 3 days, 100 mg vaginal suppository for 7 days, 200 mg vaginal suppository for 3 days, or 1200 mg vaginal suppository for 1 day) if you suspect a yeast infection, as recommended by the 2021 Centers for Disease Control and Prevention guidelines 1. Avoid scented soaps, douches, and tight synthetic underwear which can worsen symptoms. Wear cotton underwear and loose-fitting clothes to reduce moisture and irritation. If symptoms persist beyond a week, if you have unusual discharge, strong odor, or pain, see a healthcare provider as the cause might be bacterial vaginosis, trichomoniasis, or another condition requiring prescription medication. For immediate relief, a cool compress or sitz bath with plain warm water can help soothe irritation. Vaginal itching commonly results from disruption of the normal vaginal pH and microbiome, which can happen due to antibiotics, hormonal changes, or irritants. Maintaining good hygiene without over-washing and avoiding potential irritants are key preventive measures. Some key points to consider when treating vaginal itchiness include:

• The diagnosis of vulvovaginal candidiasis can usually be made clinically when a woman presents with symptoms of pruritus, irritation, vaginal soreness, external dysuria, and dyspareunia, often accompanied by a change in vaginal discharge 1.
• Uncomplicated infection can be effectively treated with either single-dose fluconazole or short-course fluconazole for 3 days, both of which achieve >90% response 1.
• Treatment of vulvovaginal candidiasis should not differ on the basis of human immunodeficiency virus (HIV) infection status; identical response rates are anticipated for HIV-positive and HIV-negative women 1. It is essential to note that self-medication with OTC preparations should be advised only for women who have been diagnosed previously with VVC and who experience a recurrence of the same symptoms, and any woman whose symptoms persist after using an OTC preparation or who experiences a recurrence of symptoms within 2 months should seek medical care 1.

From the FDA Drug Label

If you have symptoms (such as itching and irritation) on the skin outside the vagina (vulva), apply the cream externally 2 times a day, up to a total of 7 days, as needed. Use the cream twice daily, for up to 7 days as needed. Apply the cream onto the skin outside the vagina (vulva) that itches and is irritated.

The treatment for vaginal itchiness is to apply the miconazole nitrate cream externally to the affected area, 2 times a day, for up to 7 days as needed.

• The cream should be applied to the skin outside the vagina (vulva) that itches and is irritated.
• If symptoms do not get better in 3 days, or if they last more than 7 days, you should stop use and ask your doctor 2.
• If you experience any severe side effects, such as abdominal pain, hives, skin rash, or severe vaginal burning, itching, or irritation, you should stop using the product and consult your doctor 2.

From the Research

Treatment Options for Vaginal Itchiness

• Vaginal itchiness can be caused by various factors, including vulvovaginal candidiasis, which can be treated with antifungal medications 3, 4, 5, 6, 7.
• A combined treatment approach using systemic antimicrobial drug therapy with oral fluconazole and topical drug therapy using metronidazole and clotrimazole has been proposed for the treatment of recurrent vulvovaginal candidiasis 3.
• Fluconazole and clotrimazole have been compared in several studies, with similar efficacy and safety profiles reported for the treatment of vulvovaginal candidiasis 4, 5, 7.
• Topical therapies, including clotrimazole, nystatin, and miconazole, have demonstrated similar efficacy with complete cure rates of 73%-100% for the treatment of cutaneous candidiasis 6.
• Oral fluconazole has been shown to be as effective as topical clotrimazole for the treatment of cutaneous candidiasis and is a commercially available option for systemic treatment 6.

Comparison of Fluconazole and Clotrimazole

• A study comparing fluconazole and clotrimazole for the treatment of vulvovaginal candidiasis found similar mycological cure rates of 79.2% and 80.0%, respectively 4.
• Another study found that fluconazole had a slightly better clinical cure rate than clotrimazole for the treatment of oral candidiasis, but similar mycological cure rates 7.
• The choice of therapy for vaginal candidiasis may depend on individual clinician preference, as there is no one therapy that is consistently better than others 5.