How to manage persistent vulval skin changes in a child treated with Pimafucin (natamycin) cream?

Management of Persistent Vulval Skin Changes in a 7-Year-Old on Pimafucin

Continue the Pimafucin cream as prescribed and proceed with the planned pediatric dermatology referral for definitive diagnosis and management of the persistent hyperpigmentation and chronic inflammation, as these skin changes are not typical of simple vulvovaginal candidiasis and require specialist evaluation to exclude other dermatological conditions.

Key Clinical Context

This case presents two distinct issues requiring separate management approaches:

• Vaginal discharge: Improving on current antifungal therapy 1
• Persistent vulval skin changes: Chronic inflammation and hyperpigmentation of labia minora that have not resolved despite treatment 1

Management of the Vaginal Discharge

Current Treatment Assessment

• The genital swab showed no yeast isolated, only mixed bacterial flora with gram-positive cocci and gram-negative bacilli 1
• Despite absence of yeast on culture, the discharge has improved on Pimafucin (natamycin) cream, suggesting either:
  • Initial candidal infection that has resolved
  • Non-specific vulvovaginitis responding to the cream's antimicrobial properties 2, 3

Recommended Actions for Discharge

• Complete the current 2-week course of Pimafucin cream three times daily as prescribed 2
• Perform urine dipstick today to exclude urinary tract infection as a contributing factor 1
• Emphasize proper hygiene and use of emollients to prevent recurrence 1
• If discharge recurs after completing treatment, consider that this may represent non-candidal vulvovaginitis requiring different management 1

Management of Persistent Skin Changes

Why Specialist Referral is Essential

The persistent hyperpigmentation and chronic inflammation are not typical features of vulvovaginal candidiasis and warrant investigation for alternative diagnoses 1. Key considerations include:

• Lichen sclerosus: A chronic inflammatory dermatosis that can present with hypopigmentation (though hyperpigmentation can occur), requires long-term topical corticosteroid therapy, and needs monitoring for complications 1
• Other vulval dermatoses: Including eczema, psoriasis, or other chronic inflammatory conditions 4, 5
• Post-inflammatory changes: From chronic irritation or previous infection 1

Appropriate Follow-up Timeline for Children

According to guidelines for pediatric vulval conditions, girls should be reviewed at 3 months after initial consultation, then 6 months later 1. Your planned follow-up appointment aligns with this recommendation.

Addressing the Recent Trauma

• The perineal trauma from falling onto a pot handle has resolved without ongoing complications 1
• No acute laceration, bleeding, or bruising was noted on emergency department examination 1
• No further intervention needed for the trauma itself

Critical Next Steps

1. Complete Pimafucin course (currently on day 14 of planned 14-day treatment) 2
2. Urine dipstick today to exclude UTI 1
3. Continue emollients for vulval skin care 1
4. Await pediatric dermatology assessment for the persistent skin changes - this is the most important step 1
5. Return if symptoms worsen or new concerns arise before scheduled follow-up 1

Important Caveats

• Do not assume skin changes are fungal simply because antifungal cream was prescribed - the negative yeast culture and persistent skin changes despite treatment suggest an alternative diagnosis 1
• Biopsy may be necessary if the pediatric specialist cannot make a clinical diagnosis, though this is typically reserved for atypical or concerning lesions in children 1, 5
• Long-term follow-up may be required depending on the final diagnosis - conditions like lichen sclerosus require monitoring through puberty 1
• Avoid multiple courses of antifungals without documented yeast infection, as this can lead to resistance and does not address the underlying skin pathology 1