What is the initial management for a patient presenting with vulval pruritus?

Initial Management of Vulval Pruritus

Begin with regular emollients as the foundation of treatment, combined with a thorough assessment to identify the underlying cause, which is essential since vulvar pruritus is a symptom rather than a diagnosis. 1, 2

Immediate First-Line Measures

• Apply emollients regularly to maintain skin hydration and barrier function, with high lipid content moisturizers preferred for optimal results 1
• Keep fingernails short to minimize skin damage from scratching 1
• Eliminate potential irritants including scented soaps, bubble baths, douches, and tight synthetic clothing 2, 3

Essential Diagnostic Evaluation

Key History Elements to Obtain

• Assess the temporal pattern: cyclic pruritus before menses strongly suggests vulvovaginal candidiasis (VVC), occurring in 75% of women at least once 4
• Review all topical products used on the vulva, as contact dermatitis is a common cause 3, 5
• Document medication history, as certain drugs can trigger pruritus 1
• Inquire about systemic symptoms (weight loss, night sweats, fever) that may indicate underlying malignancy 6

Physical Examination Findings

• Check vaginal pH: pH ≤4.5 indicates VVC, while pH >4.5 suggests bacterial vaginosis or trichomoniasis 4
• Look for white cottage cheese-like discharge with vulvovaginal erythema (VVC) 4
• Examine for lichenification, excoriations, or atypical lesions that may indicate lichen sclerosus, eczema, or dysplasia 2, 7
• Assess for clue cells on wet mount (bacterial vaginosis) or yellow-green frothy discharge (trichomoniasis) 4

Treatment Algorithm Based on Diagnosis

For Suspected Vulvovaginal Candidiasis (Cyclic Pattern, pH ≤4.5)

• First-line: Topical azole antifungals achieve 80-90% cure rates 4
  • Clotrimazole 1% cream 5g intravaginally for 3 days for uncomplicated cases 4
  • Alternative: Fluconazole 150mg oral tablet, single dose 4
• For severe symptoms: Extend treatment to 7-14 days with clotrimazole 1% cream 4
• Critical pitfall: Do not treat asymptomatic colonization; only treat symptomatic patients 4
• Partner treatment is unnecessary as VVC is not primarily sexually transmitted 4

For Inflammatory Dermatoses (Eczema, Contact Dermatitis)

• Apply topical corticosteroids: Hydrocortisone for mild cases, applied to affected area 3-4 times daily 8
• For genital/anal itching specifically: Clean area with mild soap and warm water, rinse thoroughly, gently dry before applying hydrocortisone 8
• Continue emollients as maintenance therapy 1

For Suspected Lichen Sclerosus or Persistent Symptoms

• High-potency topical glucocorticoids are the mainstay of treatment 7
• Refer to dermatology or gynecology if diagnosis uncertain or symptoms persist beyond 2 weeks despite appropriate treatment 1

Pharmacologic Escalation for Refractory Cases

• Add a non-sedating antihistamine if initial measures insufficient: fexofenadine 180mg or loratadine 10mg daily 1
• Avoid sedating antihistamines due to risk of falls and cognitive impairment, especially in elderly patients 1
• Consider topical doxepin, menthol, or clobetasone butyrate for additional relief 1
• For persistent pruritus despite above measures, consider gabapentin, pregabalin, or SSRIs (paroxetine, mirtazapine) 1

Critical Differential Diagnoses Not to Miss

• Bacterial vaginosis: Malodorous discharge, pH >4.5, clue cells; treat with metronidazole 4
• Trichomoniasis: Yellow-green frothy discharge, pH >4.5; treat with metronidazole 2g single dose 4
• Vulvar intraepithelial neoplasia (VIN): Consider in refractory cases, especially with atypical lesions; requires biopsy 7
• Lichen sclerosus: Most common chronic dermatosis after candidiasis; presents with white plaques and architectural changes 7
• Bullous pemphigoid: Rare presenting feature in elderly patients; requires regular follow-up 1

When to Refer to Secondary Care

• Diagnostic uncertainty after initial evaluation 1
• Symptoms persist despite 2 weeks of appropriate primary care management 1
• Suspicion of dysplasia, lichen sclerosus, or other complex dermatoses 2, 7
• Atypical or suspicious lesions requiring biopsy 7

Common Pitfalls to Avoid

• Do not assume all vulvar pruritus is due to infection or dry skin; 20-30% of generalized pruritus cases have significant underlying causes 1
• Do not use single-dose antifungal regimens for severe symptoms; reserve for mild-to-moderate uncomplicated cases 4
• Do not perform routine test-of-cure for VVC; follow-up only if symptoms persist or recur within 2 months 4
• Do not delay biopsy in persistent cases, as invasive or preinvasive lesions must be excluded 7