What are the treatment options for feminine itching?

Treatment of Feminine Itching

For feminine (vulvovaginal) itching, start with topical clotrimazole 1% cream 5g intravaginally for 7-14 days if vulvovaginal candidiasis is suspected, or topical hydrocortisone 2.5% for inflammatory causes, after confirming the diagnosis with vaginal pH testing and wet mount microscopy. 1, 2

Initial Diagnostic Approach

Before treating, establish the underlying cause through simple office-based testing:

• Check vaginal pH first: pH ≤4.5 suggests vulvovaginal candidiasis (VVC), while pH >4.5 indicates bacterial vaginosis or atrophic vaginitis 1
• Perform wet mount microscopy using both saline and 10% KOH preparations to identify yeasts, pseudohyphae (VVC), clue cells (bacterial vaginosis), or absence of lactobacilli (atrophy) 1
• Yeast culture remains the gold standard when diagnosis is uncertain or symptoms persist despite treatment 3

Treatment Algorithm Based on Etiology

If Vulvovaginal Candidiasis is Confirmed

First-line topical azole therapy:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
• Alternative: Miconazole 2% cream 5g intravaginally for 7 days 1
• Alternative: Terconazole 0.4% cream 5g intravaginally for 7 days 1
• Topical azoles achieve 80-90% symptom relief and negative cultures after completion 1

Oral alternative if topical therapy not preferred:

• Fluconazole 150mg single oral dose 1

For external vulvar itching accompanying VVC:

• Apply the same antifungal cream to external irritated skin twice daily for up to 7 days 2

If Atrophic Vaginitis (Genitourinary Syndrome of Menopause) is the Cause

In postmenopausal women:

• Vaginal estrogen replacement is strongly recommended to prevent recurrent symptoms and address the underlying atrophy 1
• This is particularly important as atrophic changes create a predisposing environment for recurrent infections 4

If Inflammatory Dermatologic Cause (Lichen Sclerosus, Eczema, Contact Dermatitis)

For inflammatory vulvar pruritus:

• Hydrocortisone 2.5% or triamcinolone 0.1% applied to affected area 3-4 times daily 5, 6
• For lichen sclerosus specifically, potent topical corticosteroids are the mainstay of treatment 3

If Pruritus of Unknown Origin After Negative Workup

Stepwise approach:

• Start with emollients and self-care advice as first-line 3
• Consider topical doxepin (limited to 8 days, 10% body surface area, 12g daily maximum) 3
• Topical clobetasone butyrate or menthol may provide benefit 3
• Avoid crotamiton cream, topical capsaicin, or calamine lotion as these are not effective 3

Oral antihistamines if topical measures fail:

• Non-sedating H1 antagonists: fexofenadine 180mg or loratadine 10mg 3
• Mildly sedative option: cetirizine 10mg 3
• Consider combining H1 and H2 antagonists (e.g., fexofenadine plus cimetidine) 3

Neuropathic agents for persistent symptoms:

• Gabapentin, pregabalin, or antidepressants (paroxetine, fluvoxamine, mirtazapine) 3, 6

Special Considerations and Common Pitfalls

When multiple etiologies coexist:

• Treat the acute infection first (VVC with topical azoles), then initiate vaginal estrogen therapy to address underlying atrophy and prevent recurrence 1

Self-medication caution:

• Over-the-counter antifungal preparations should only be used if the patient was previously diagnosed with VVC and experiences identical recurrent symptoms 1
• Irrational use of combination products containing topical steroids can result in skin atrophy, striae, and other complications 7

Pregnancy considerations:

• Topical steroids can be safely continued during pregnancy if needed 3
• Avoid fluconazole during pregnancy as it may be associated with spontaneous abortion and craniofacial/heart defects 3

Referral indications:

• Refer to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 3
• Refer to dermatology if symptoms persist despite topical therapies (approximately 10% of patients) 6

Follow-Up Requirements

• Return for follow-up only if symptoms persist or recur within 2 months after treating VVC 1
• For chronic pruritus lasting less than 1 year with few primary skin changes, consider laboratory evaluation including complete blood count, comprehensive metabolic panel, and thyroid function testing to rule out systemic causes 6