How should persistent vulvar pruritus be treated in a woman after genital herpes, assuming the lesions are resolving?

Treatment of Persistent Vulvar Pruritus After Genital Herpes

For persistent vulvar itching after resolving genital herpes lesions, the most likely cause is secondary vulvovaginal candidiasis (VVC), which should be treated with topical azole antifungals for 7-14 days or a single dose of oral fluconazole 150 mg. 1

Diagnostic Approach

The key clinical question is whether the pruritus represents:

• Secondary vulvovaginal candidiasis (most common after antiviral therapy) 1
• Residual inflammation from healing herpes lesions 2
• Contact dermatitis from topical treatments 3
• Lichen simplex chronicus from chronic scratching 3

Critical Clinical Distinctions

• If vaginal discharge is present with vulvar itching, VVC is the most likely diagnosis and requires antifungal treatment 1
• If only external vulvar pruritus without discharge, consider contact dermatitis or lichen simplex chronicus 3
• Approximately 10-20% of women harbor Candida species asymptomatically, and VVC frequently follows antibacterial or antiviral therapy 1

First-Line Treatment for Vulvovaginal Candidiasis

Topical Azole Regimens (Preferred for Uncomplicated VVC)

Topical azoles are more effective than nystatin and achieve 80-90% cure rates: 1

• Clotrimazole 1% cream 5g intravaginally for 7-14 days (available OTC) 1
• Miconazole 2% cream 5g intravaginally for 7 days (available OTC) 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1

Oral Therapy Alternative

• Fluconazole 150 mg oral tablet as a single dose is equally effective and offers superior convenience 1

Important Caveat About Oil-Based Preparations

These creams and suppositories are oil-based and may weaken latex condoms and diaphragms, requiring alternative contraception during treatment 1

Treatment Algorithm

Step 1: Assess for VVC Features

• Increased vaginal discharge (thick, white, "cottage cheese" appearance)
• Vulvar erythema and edema
• Absence of malodor (distinguishes from bacterial vaginosis)

Step 2: Initiate Empiric Antifungal Therapy

• For mild-to-moderate symptoms: Single-dose fluconazole 150 mg OR 7-day topical azole 1
• For severe symptoms or immunocompromised patients: 10-14 day topical azole course 1

Step 3: Reassess at 2 Weeks

• If symptoms persist after OTC preparation or recur within 2 months, the patient must seek medical evaluation for culture and alternative diagnoses 1
• Consider complicated VVC requiring extended therapy if diabetes, immunosuppression, or non-albicans Candida species are present 1

Alternative Diagnoses to Consider

If Antifungal Treatment Fails

Perform the following assessments: 3

• Vulval dermatitis/eczema: Requires topical corticosteroids (low-to-moderate potency for vulvar skin) 3
• Lichen simplex chronicus: Requires breaking the itch-scratch cycle with topical corticosteroids and antihistamines 3
• Contact dermatitis: Identify and eliminate irritants (soaps, detergents, topical medications) 3
• Residual HSV symptoms: Rare but may require extended antiviral therapy 4, 2

When to Obtain Cultures

Obtain vaginal cultures if: 1

• Symptoms persist despite appropriate antifungal therapy
• Recurrent VVC (≥4 episodes annually)
• Suspicion of non-albicans Candida species (particularly C. glabrata, which requires 10-14 day therapy) 1

Critical Pitfalls to Avoid

Do Not Use Topical Antivirals for Pruritus

Topical acyclovir is substantially less effective than oral therapy and should never be used for genital herpes, and it provides no benefit for post-herpetic pruritus 4, 5, 2

Do Not Prescribe Corticosteroids for Active HSV

Topical or systemic corticosteroids are absolutely contraindicated in HSV infections, as they potentiate viral replication and worsen disease 4

Avoid Unnecessary OTC Self-Treatment

Self-medication with OTC antifungals should only occur in women previously diagnosed with VVC who recognize recurrent symptoms 1

Inappropriate use of OTC preparations delays diagnosis of other vulvovaginal conditions and can lead to adverse outcomes 1

Screen for Sexually Transmitted Infections

Depending on risk factors, screening for other STIs should be considered, as VVC can occur concomitantly with STDs 1, 3

Follow-Up Recommendations

• Patients should return only if symptoms persist or recur within 2 months 1
• For recurrent VVC (≥4 episodes/year), consider maintenance suppressive therapy after initial treatment 1
• Sexual partners do not require routine treatment unless male partner has symptomatic balanitis (erythema and pruritus of glans) 1