What are the treatment options for vulva irritation?

Treatment of Vulvar Irritation

The treatment of vulvar irritation depends critically on identifying the underlying cause through systematic evaluation of vaginal pH, discharge characteristics, and microscopy, with most cases falling into three categories: vulvovaginal candidiasis (treated with topical or oral azoles), trichomoniasis (treated with metronidazole), or bacterial vaginosis (treated with metronidazole or clindamycin), while non-infectious irritant dermatitis requires avoidance of irritants and barrier protection. 1

Diagnostic Algorithm for Vulvar Irritation

The first step is measuring vaginal pH to narrow the differential:

• pH 3.8-4.5 (normal): Suggests vulvovaginal candidiasis or non-infectious causes 2
• pH >4.5 (elevated): Suggests bacterial vaginosis or trichomoniasis 2

Next, perform wet mount microscopy and assess discharge characteristics:

• Thick white curdy discharge + yeast/pseudohyphae: Vulvovaginal candidiasis 2
• Thin white homogeneous discharge + clue cells + fishy odor with KOH: Bacterial vaginosis 2
• Frothy yellow-green discharge + motile trichomonads + vulvar inflammation: Trichomoniasis 2, 3
• Minimal discharge + vulvar inflammation + no pathogens: Irritant or contact dermatitis 2, 4

Treatment by Etiology

Uncomplicated Vulvovaginal Candidiasis

For uncomplicated candidiasis, a single 150 mg oral dose of fluconazole is the recommended first-line treatment, achieving >90% cure rates. 1

Alternative topical regimens (all equally effective):

• Clotrimazole 100 mg vaginal tablet daily for 7 days 1
• Clotrimazole 500 mg vaginal tablet as single dose 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1

Important caveat: Oil-based creams and suppositories may weaken latex condoms and diaphragms 1

Complicated Vulvovaginal Candidiasis

For severe acute candidiasis, use fluconazole 150 mg every 72 hours for 2-3 doses 1

For recurrent vulvovaginal candidiasis (≥4 episodes per year):

• Induction: 10-14 days of topical azole or oral fluconazole 1
• Maintenance: Fluconazole 150 mg weekly for 6 months 1

Non-albicans Candida (especially C. glabrata)

When azole therapy fails for C. glabrata:

• First-line: Boric acid 600 mg in gelatin capsule intravaginally daily for 14 days 1
• Alternative: Nystatin 100,000 unit suppositories daily for 14 days 1
• Third option: 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days 1

Trichomoniasis

Oral metronidazole is the treatment of choice, with cure rates of 90-95%. 1

Critical requirement: Sexual partners MUST be treated simultaneously to prevent reinfection 3

Patients should avoid sexual intercourse until both partners complete treatment 1

Bacterial Vaginosis

Standard treatment: Metronidazole 500 mg orally twice daily for 7 days, with 80-90% cure rates 5

Important note: BV has a 50-80% recurrence rate within one year 5

The absence of significant vulvar inflammation distinguishes BV from other causes of vaginitis 2

Irritant/Contact Dermatitis

When objective signs of vulvar inflammation exist with minimal discharge and no identifiable pathogens, suspect mechanical or chemical irritation 2

Treatment approach:

• Eliminate all potential irritants: soaps, douches, perfumed products, tight clothing 6
• Improve hygiene practices: gentle cleansing with water only, pat dry thoroughly 6
• Barrier protection: petroleum jelly or zinc oxide to protect inflamed skin 4

Common pitfall: Poor hygiene and irritants such as soap are major contributors to vulvar pruritus, especially in prepubertal girls, but also affect adult women 6

Special Populations

Pregnancy

Only 7-day topical azole therapies are recommended for pregnant women with vulvovaginal candidiasis; oral fluconazole should be avoided. 1

For trichomoniasis in pregnancy, symptomatic women may be treated with oral metronidazole to relieve symptoms 1

HIV-Positive Women

Treatment for vulvovaginal candidiasis should not differ based on HIV status; identical response rates are expected 1

When to Refer or Reassess

Patients should return for follow-up only if:

• Symptoms persist after treatment 1
• Symptoms recur within 2 months of initial treatment 1
• Self-treatment with OTC preparations fails 1

Critical warning: Self-diagnosis of yeast vaginitis is unreliable; incorrect diagnosis results in overuse of topical antifungal agents with subsequent risk of contact and irritant vulvar dermatitis 1

If standard testing is negative but symptoms persist, consider:

• Retesting for bacterial vaginosis using Gram stain or DNA probe (90% sensitivity) 5
• Lichen sclerosus, lichen planus, or lichen simplex chronicus 7
• Vulvodynia (chronic vulvar pain without obvious etiology) 8