What is the treatment for vaginal eczema?

Treatment of Vaginal Eczema

For vaginal/vulvar eczema, use the least potent topical corticosteroid that controls symptoms, combined with consistent emollient therapy and avoidance of irritants, reserving moderate-to-potent steroids for more severe cases. 1

First-Line Treatment Approach

Emollients and Skin Barrier Protection

• Apply emollients liberally and frequently to provide a surface lipid film that retards water loss from the epidermis, most effective when applied after bathing 1
• Use a dispersible cream as a soap substitute instead of regular soaps and detergents, which remove natural skin lipids and worsen dryness 1
• Avoid extremes of temperature and irritant materials like wool directly against the skin; cotton clothing is preferred 1

Topical Corticosteroids

• Topical corticosteroids are the mainstay of treatment for eczema and should be applied no more than twice daily 1
• Start with the least potent preparation required to control the eczema, and when possible, stop corticosteroids for short periods 1
• For mild-to-moderate vulvar eczema, mild-potency steroids like 1% hydrocortisone are appropriate 2
• For more severe cases, moderate-potency topical corticosteroids probably result in more participants achieving treatment success (52% vs 34% with mild potency) 3
• Potent topical corticosteroids probably result in large increases in treatment success (70% vs 39% with mild potency) for moderate-to-severe eczema 3
• Once-daily application of potent topical corticosteroids is probably as effective as twice-daily application 3

Alternative Topical Agents

• Ichthammol (1% in zinc ointment) is less irritant than coal tar and can be useful for lichenified eczema 1
• Coal tar solution at 1% strength in hydrocortisone ointment is adequate and does not cause systemic side effects unless used extravagantly 1

Adjunctive Treatments

Antihistamines

• Sedating antihistamines are useful as short-term adjuvants during relapses with severe pruritus, primarily for their sedative properties 1
• Non-sedating antihistamines have little to no value in atopic eczema 1
• Large doses may be required in children, and should be used at night to avoid daytime sedation 1

Treatment of Secondary Infection

• Look for signs of bacterial infection including crusting or weeping 1
• Flucloxacillin is the most appropriate antibiotic for treating S. aureus, the commonest pathogen 1
• Phenoxymethylpenicillin should be given if β-hemolytic streptococci are isolated 1
• Erythromycin may be used for flucloxacillin resistance or penicillin allergy 1
• Grouped, punched-out erosions or vesiculation indicate herpes simplex infection, which responds to oral acyclovir given early 1

Long-Term Management Strategy

Proactive Therapy for Relapse Prevention

• For recurrent eczema, consider proactive (weekend) therapy with topical corticosteroids applied twice weekly to previously affected areas, which probably results in large decreases in relapse likelihood (from 58% to 25%) 3
• Continue emollient treatment to unaffected skin alongside intermittent anti-inflammatory therapy 4

Safety Considerations

Local Adverse Events

• Abnormal skin thinning is rare with short-term use (1% across trials), but increases with higher-potency steroids 3
• Very potent and potent topical corticosteroids should be used with caution for limited periods only, particularly in the genital area 1
• Long-term intermittent use (up to 5 years) of mild-to-moderate potency steroids probably results in little to no difference in skin thinning risk 5
• The main risk with potent steroids is suppression of the pituitary-adrenal axis with possible interference of growth in children 1

Critical Differential Diagnosis

Important caveat: Ensure the diagnosis is truly eczema and not vulvovaginal candidiasis, which presents similarly but requires antifungal treatment 1, 6, 7

• Vulvovaginal candidiasis is characterized by pruritus, erythema, and sometimes white discharge with normal vaginal pH (<4.5) 1, 7
• If yeast infection is suspected, diagnose with wet preparation showing yeasts/pseudohyphae or positive culture 1, 7
• Treat confirmed candidiasis with topical azoles (clotrimazole 1% cream for 7-14 days) or single-dose oral fluconazole 150 mg 1, 6, 7
• In refractory cases, consider squamous epithelial dysplasia (VIN), lichen sclerosus, or other chronic dermatoses 8

When to Refer

• Failure to respond to first-line treatment is an indication for referral to a dermatology specialist 1
• Deterioration in previously stable eczema may indicate secondary infection or development of contact dermatitis requiring further evaluation 1