What is the appropriate management for vulvar skin breakdown?

Management of Vulvar Skin Breakdown

For vulvar skin breakdown, immediately apply white soft paraffin ointment every 4 hours to protect eroded areas, use non-adherent silicone dressings (Mepitel) to prevent adhesions and reduce pain, and apply potent topical corticosteroids once daily to non-eroded inflamed surfaces. 1

Immediate Protective Measures

The cornerstone of acute management is barrier protection and moisture control:

• Apply white soft paraffin ointment to all affected vulvar skin and mucosa immediately, then reapply every 4 hours throughout the acute phase 1
• Use Mepitel (non-adherent silicone) dressings directly on eroded areas to minimize pain and prevent formation of adhesions 1
• These measures address the primary pathophysiology of skin breakdown by creating a protective barrier while allowing healing

Anti-Inflammatory Therapy

Topical corticosteroids are essential for reducing inflammation in non-eroded tissue:

• Apply a potent topical corticosteroid ointment (such as clobetasol propionate 0.05%) once daily to involved, non-eroded vulvar surfaces 1
• For oral/labial involvement that may extend to the vulva, consider betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse, or clobetasol propionate 0.05% mixed with Orabase applied directly to affected areas 1
• Critical pitfall: Never apply corticosteroids to actively eroded/denuded areas, as this impairs healing; reserve them for inflamed but intact skin 1

Infection Prevention and Treatment

Secondary infection is a frequent complication requiring vigilant monitoring:

• Examine the vulvar area daily and document findings during the acute illness 1
• Take swabs regularly if bacterial or candidal infection is suspected 1
• For confirmed candidal infection, treat with topical azole therapy for 7-14 days (clotrimazole 1% cream 5g intravaginally daily, miconazole 2% cream 5g intravaginally daily, or terconazole 0.4% cream 5g intravaginally daily) 2, 3
• Consider mupirocin ointment applied three times daily if bacterial superinfection is present 4
• Important distinction: Treat only confirmed infections with positive cultures or microscopy; do not treat asymptomatic colonization 2

Urinary Catheterization

Preventing urethral strictures is a critical but often overlooked intervention:

• Catheterize all patients with significant vulvar skin breakdown to prevent stricture formation in the urethra 1
• This is particularly important when erosions involve the periurethral area
• Dysuria in vulvar breakdown typically represents external dysuria (urine contacting inflamed skin) rather than true urinary tract pathology 2

Pain Management

Adequate analgesia improves quality of life and treatment adherence:

• Offer topical lidocaine 5% ointment for persistent vulvar pain, which can be applied before activities that provoke discomfort 5
• Systemic analgesics may be required for severe cases
• Pain is a prominent feature during the acute phase and should be aggressively managed 1

Underlying Cause Investigation

Vulvar skin breakdown has multiple potential etiologies that require different long-term management:

• If infectious: Confirm vulvovaginal candidiasis with wet-mount microscopy showing yeast/pseudohyphae and vaginal pH ≤4.5 2, 3
• If inflammatory dermatosis: Consider lichen sclerosus, lichen planus, contact dermatitis, lichen simplex chronicus, or psoriasis—these require biopsy for definitive diagnosis 6, 7
• If Stevens-Johnson syndrome/TEN: The management outlined above is specifically validated for this severe mucocutaneous condition 1
• Biopsy will often be needed to establish the correct diagnosis, particularly in chronic or recurrent cases 8

Special Considerations for Vaginal Involvement

When breakdown extends to the vagina:

• Early assessment by a vulval specialist is recommended to consider use of dilators to prevent vaginal synechiae 1
• Perform speculum examination with plastic speculums to fully assess all vaginal walls 1
• Insert a dilator or tampon wrapped in Mepitel into the vagina to prevent formation of synechiae 1
• In uncircumcised males with genital involvement, check for preputial retractability 1

Common Pitfalls to Avoid

• Do not delay barrier protection: White soft paraffin should be applied immediately upon recognition of skin breakdown, not after other measures fail 1
• Do not apply corticosteroids to eroded areas: This is a critical error that delays healing; corticosteroids are for inflamed intact skin only 1
• Do not treat empirically for candidiasis: Confirm infection with microscopy or culture before initiating antifungal therapy, as empirical treatment may delay appropriate management 2, 5
• Do not overlook urinary catheterization: Failure to catheterize can result in permanent urethral strictures 1
• Do not assume single etiology: Vulvar conditions are often multifactorial and require systematic evaluation of all components 8