How should I manage acute genital pruritus?

Management of Acute Genital Pruritus

Begin by identifying the underlying cause through targeted examination and history, then treat accordingly with cause-specific therapy—most commonly addressing infectious etiologies (candidiasis, scabies, pubic lice), contact dermatitis, or lichen sclerosus.

Diagnostic Approach

Key History Elements

• Duration and pattern of symptoms: Acute vs. chronic, constant vs. intermittent 1
• Sexual partner symptoms: Similar itching in a partner strongly suggests scabies or pubic lice 2, 1
• Distribution of lesions: Scabies affects genitals, abdomen, and back; pubic lice remain confined to coarse hair areas 1
• Associated symptoms: Vaginal discharge suggests candidiasis; visible lice/nits indicate pediculosis 3, 2
• Recent product use: Soaps, douches, lubricants, or hygiene products can cause irritant contact dermatitis 4, 5

Physical Examination Findings

• Scabies: 1mm raised erythematous papules on genitals and abdomen with characteristic distribution 1
• Pubic lice: Visible lice or nits on pubic hair, pruritus in pubic area 2
• Candidiasis: Vulvovaginal erythema, white discharge, satellite lesions 3
• Lichen sclerosus (prepubertal girls): White patches, atrophy, "figure-eight" perianal pattern, fissures 6
• Contact dermatitis: Erythema, excoriations without specific lesion morphology 5

Treatment by Etiology

Scabies (Most Common Sexually Transmitted Cause)

First-line treatment: Permethrin 5% cream applied to all body areas from neck down, washed off after 8-14 hours 1

• Alternative: Lindane 1% lotion applied thinly from neck down, washed off after 8 hours (use with caution in certain populations) 1
• Partner management is mandatory: Treat all sexual partners within the last month simultaneously to prevent reinfection 1
• Environmental decontamination: Machine wash or dry-clean all bedding and clothing, or remove from body contact for at least 72 hours 1
• Important caveat: Pruritus may persist for several weeks after successful treatment due to ongoing immune response; re-treat after 1 week only if live mites are observed 1
• STI screening: Consider testing both partners since scabies among adults may be sexually transmitted 1

Pubic Lice (Pediculosis Pubis)

• Partner management: Treat sexual partners within the preceding month; use a 3-month look-back period for partner management 2
• Patients typically present with pruritus in the pubic area and visible lice or nits on pubic hair 2

Vulvovaginal Candidiasis

For uncomplicated VVC, choose from multiple effective options 3:

Topical Intravaginal Agents (Oil-based; may weaken latex condoms):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 3
• Clotrimazole 100mg vaginal tablet for 7 days 3
• Miconazole 2% cream 5g intravaginally for 7 days 3
• Terconazole 0.4% cream 5g intravaginally for 7 days 3

Oral Agent:

• Fluconazole 150mg oral tablet as a single dose 3

External Genital Itching:

• Apply clotrimazole cream to itchy, irritated skin outside the vagina twice daily for up to 7 days as needed 7

• Follow-up: Only if symptoms persist or recur within 2 months 3

• Partner treatment: Not routinely recommended unless male partner has symptomatic balanitis 3

• Recurrent VVC (≥4 episodes/year): Requires longer initial therapy (7-14 days topical or fluconazole 150mg repeated 3 days later) followed by maintenance regimen 3

Contact Dermatitis/Non-Specific Irritation

For external genital itching without infection 8:

• Hydrocortisone topical cream applied to affected area not more than 3-4 times daily (adults and children ≥2 years) 8
• For external anal and genital itching specifically: Clean area with mild soap and warm water, rinse thoroughly, gently dry before applying 8

General Hygiene Recommendations

Optimal Practices

• Daily washing: Once-daily (maximum twice-daily) washing of the vulva with pH-balanced, mild cleanser, ideally soon after bowel voiding 5
• Avoid harmful practices: No vaginal douching, which is associated with poor health outcomes 9, 5
• Product selection: Use products that are "body-similar" to vaginal secretions in terms of pH and osmolality; avoid products with potentially harmful ingredients 10, 5
• Lubricants/moisturizers: If needed for vaginal dryness, select products with physiological pH and osmolality 10

Common Pitfalls to Avoid

• Do not assume all genital itching is candidiasis: Many women self-treat with OTC antifungals inappropriately, delaying diagnosis of other etiologies 3
• Do not miss partner treatment: Failure to treat partners simultaneously in scabies or pubic lice leads to reinfection 2, 1
• Do not retreat scabies prematurely: Persistent itching after treatment is normal and does not indicate treatment failure unless live mites are present 1
• Do not overlook product-related causes: Many feminine hygiene products can cause irritation or allergic reactions 4, 5
• Do not forget STI screening: When scabies or pubic lice are diagnosed, screen for other sexually transmitted infections 1