What are the recommended evaluation and treatment options for labial pain, itching, swelling, discharge, lesions, or changes in size or shape?

Evaluation and Management of Labial Conditions

Initial Assessment

For labial symptoms (pain, itching, swelling, discharge, lesions, or changes in size/shape), perform a focused examination looking for specific diagnostic features: porcelain-white plaques with ecchymosis (lichen sclerosus), grouped vesicles on an erythematous base (herpes), homogenous discharge with fishy odor (bacterial vaginosis), or thick white "curdled" discharge (candidiasis). 1, 2

Key Diagnostic Features to Identify

Lichen Sclerosus:

• Porcelain-white papules and plaques, often with areas of ecchymosis 1
• Characteristic sites: interlabial sulci, labia minora, clitoral hood, clitoris, perineal body 1
• Follicular delling and occasional hyperkeratosis 1
• Perianal involvement in 30% of cases 1
• Main symptom is itch (worse at night), but may be asymptomatic 1
• Scarring may cause loss of labia minora, sealing of clitoral hood, burying of clitoris 1

Herpes Labialis (Cold Sores):

• Grouped vesicles progressing through erythema, papule, vesicle, pustulation, ulceration, and scabbing 3, 4
• Prodromal symptoms: tingling, burning, itching 3
• Peak viral titers occur in first 24 hours after lesion onset 3

Vaginitis (if discharge present):

• Bacterial vaginosis: homogenous noninflammatory discharge, pH >4.5, clue cells, positive whiff test 2
• Candidiasis: thick "curdled" white discharge, vulvar pruritus, hyperemic vagina, pH 3.8-4.2 2
• Trichomoniasis: foul frothy discharge, pH >4.5, punctate cervical microhemorrhages 2

When to Perform Biopsy

Obtain a biopsy if: 1

• Atypical features or diagnostic uncertainty
• Suspicion of neoplastic change (persistent hyperkeratosis, erosion, erythema, new warty/papular lesions)
• Disease fails to respond to adequate treatment
• Pigmented areas present

Biopsy is not always essential when clinical features are typical, particularly in children. 1

Treatment Algorithms by Condition

Lichen Sclerosus

First-line treatment: Potent topical corticosteroids 1, 5

• Apply clobetasol propionate 0.05% ointment once daily to affected areas 1, 5
• Continue until symptoms resolve and skin appearance normalizes 1
• For maintenance, reduce frequency as tolerated 1

Supportive measures:

• Apply white soft paraffin ointment every 2-4 hours to protect affected skin 1, 5
• Use Mepitel dressings to eroded areas to reduce pain and prevent adhesions 1

Common pitfall: Discontinuing treatment too early leads to recurrence; lichen sclerosus requires long-term management 1

Herpes Labialis (Cold Sores)

For acute episodes - initiate within 24 hours of symptom onset (ideally during prodrome): 3, 4

First-line (immunocompetent adults):

• Valacyclovir 2g twice daily for 1 day (12 hours apart) 3, 4
• Alternative: Famciclovir 1500mg single dose 3, 5
• Alternative: Acyclovir 400mg five times daily for 5 days 3, 5

For frequent recurrences (≥6 episodes per year): 3, 4

• Valacyclovir 500mg once daily (increase to 1000mg once daily for very frequent recurrences) 3
• Alternative: Acyclovir 400mg twice daily 3, 4
• Daily suppressive therapy reduces recurrence frequency by ≥75% 3
• After 1 year of continuous therapy, consider discontinuation to reassess recurrence rate 3

For widespread HSV with crusted lesions:

• Valacyclovir 1000mg orally twice daily for 7-10 days, continuing until all lesions fully crusted 3
• Alternative: Famciclovir 500mg twice daily for 7-10 days 3
• For immunocompromised patients: Consider IV acyclovir 5-10mg/kg every 8 hours 3

Critical timing: Treatment started after 24 hours has markedly diminished efficacy 3

Preventive measures:

• Apply sunscreen or zinc oxide to prevent UV-triggered recurrences 3, 4, 5
• Identify and avoid personal triggers (fever, stress, menstruation) 3, 4

Common pitfalls:

• Relying on topical antivirals (ineffective compared to oral therapy) 3, 4
• Starting treatment too late (after lesions fully developed) 3
• Using topical antivirals for suppressive therapy (cannot reach site of viral reactivation) 3, 4

Herpetic Gingivostomatitis

Antiviral therapy:

• Acyclovir 400mg orally five times daily for 5-10 days (mild cases) 3
• For severe cases requiring hospitalization: Acyclovir 5-10mg/kg IV every 8 hours until lesions regress, then switch to oral 3

Supportive oral care: 1, 3

• Apply white soft paraffin ointment to lips immediately and every 2 hours 1
• Use mucoprotectant mouthwash (e.g., Gelclair) three times daily 1
• Clean mouth daily with warm saline or oral sponge 1

Pain management: 1

• Benzydamine hydrochloride oral rinse/spray every 3 hours, especially before meals 1
• If inadequate: Viscous lidocaine 2% (15mL per application) 1
• For severe discomfort: Cocaine mouthwash 2-5% three times daily 1

Antiseptic therapy (twice daily): 1

• Hydrogen peroxide 1.5% mouthwash (10mL) OR
• Chlorhexidine digluconate 0.2% (10mL, may dilute 50% to reduce soreness) 1

Topical corticosteroids: 1

• Betamethasone sodium phosphate 0.5mg in 10mL water as 3-minute rinse-and-spit, four times daily 1
• For severe inflammation: Clobetasol propionate 0.05% mixed equally with Orabase, applied directly to affected mucosa once daily 1

Secondary infection management: 1

• Candidal infection: Nystatin oral suspension 100,000 units four times daily for 1 week OR Miconazole oral gel 5-10mL four times daily for 1 week 1, 5

Vaginitis with Labial Involvement

Bacterial vaginosis (if symptomatic): 2, 6

• Intravaginal preparations preferred (fewer systemic effects) 2
• Partner therapy not required 6

Vulvovaginal candidiasis (if symptomatic): 2, 6, 7

• First-line: Topical azole antifungals 2
• For recurrent infections: Fluconazole 150mg weekly for up to 12 consecutive weeks 2
• Partner therapy not required 6
• Consider vaginal boric acid for treatment-resistant cases 7

Trichomoniasis: 2, 6, 7

• Metronidazole 2g single oral dose 2
• Alternative: Metronidazole for 1 week 7
• Partner therapy mandatory 6
• Treatment failure usually due to untreated partner 2

Contact Dermatitis/Irritative Dermatitis

First-line approach: 8

• Eliminate harmful habits (excessive soap use, inappropriate cosmetic products) 8
• Apply topical corticosteroids for inflammation 8
• Hydrocortisone (for mild cases): Apply to affected area 3-4 times daily 9
• For more severe cases: Use potent topical corticosteroids 5, 8

If contact dermatitis suspected: Perform specific allergy testing 8

Special Populations

Children with lichen sclerosus:

• Ecchymosis may be striking and mistaken for sexual abuse 1
• Confirmation of lichen sclerosus does not exclude coincident abuse 1
• Perianal involvement frequent; may present with constipation due to painful fissuring 1

Immunocompromised patients with herpes:

• Higher acyclovir resistance rates (7% vs <0.5% in immunocompetent) 3
• Episodes typically longer and more severe 3
• May require higher doses or longer treatment duration 3
• For confirmed acyclovir-resistant HSV: Foscarnet 40mg/kg IV three times daily 3

Elderly patients requiring antivirals:

• Assess renal function (creatinine clearance) before initiating valacyclovir, acyclovir, or famciclovir 3
• Adjust doses based on renal function to avoid drug accumulation and neurotoxicity 3

Contagiousness and Transmission Counseling

For herpes labialis: 3

• Patients remain contagious until all lesions are fully crusted 3
• Avoid direct contact (kissing) and sharing items that contact the mouth during active lesions 3
• Asymptomatic viral shedding can occur even on suppressive therapy 3
• Suppressive therapy reduces but does not eliminate transmission risk 3
• Partners should be informed that zero transmission risk does not exist 3

Follow-Up and Monitoring

Lichen sclerosus: 1

• Routine follow-up required
• Biopsy needed if: suspicion of neoplastic change, failure to respond to treatment, extragenital features suggesting morphoea overlap, pigmented areas

Herpes on suppressive therapy: 3

• Regular assessment of therapy effectiveness and tolerability 3
• Consider trial off therapy after 1 year to reassess recurrence frequency 3

Vaginitis: 7

• If no response to initial treatment, reconsider diagnosis 7
• Consider alternative diagnoses: desquamative inflammatory vaginitis, genitourinary syndrome of menopause, vulvodynia 7