What are the clinical features of desquamative inflammatory vaginitis?

Desquamative Inflammatory Vaginitis: Clinical Characteristics

Desquamative inflammatory vaginitis (DIV) is a rare chronic purulent vaginitis occurring predominantly in white perimenopausal women, characterized by profuse purulent discharge, severe vaginal inflammation with erythema and petechiae, elevated vaginal pH >4.5, and microscopic findings of increased inflammatory cells with parabasal epithelial cells. 1

Patient Demographics

• Occurs almost exclusively in white/Caucasian women (97-100% of cases) 1, 2, 3
• Peak incidence in perimenopause, with mean age approximately 48-51 years 1, 2, 4
• Approximately 50% of patients are postmenopausal 2

Clinical Symptoms

The primary presenting symptoms include:

• Profuse purulent vaginal discharge (often yellowish) 1, 5, 6, 7
• Vulvovaginal irritation and discomfort 1, 5, 7
• Dyspareunia (painful intercourse) 1, 5, 7
• Pain is a prominent feature 4

Physical Examination Findings

Vaginal examination reveals distinctive inflammatory changes:

• Diffuse erythema of vaginal walls (present in 36% as confluent erythema) 3, 6
• Ecchymotic findings and petechiae (classic finding in 54% of cases) 1, 3
• Vaginal walls show signs of exudative inflammation 6
• Vestibular involvement occurs in 72% of cases 2
• Heavy discharge is actually uncommon (only 2% in one series) 3
• Upper vagina involvement in 8% of cases 3

Laboratory and Microscopic Findings

DIV is defined by specific wet mount microscopy findings:

• Increased inflammatory cells (polymorphonuclear leukocytes) 1
• Parabasal epithelial cells (immature squamous cells indicating increased epithelial cell turnover) 1, 3
• Vaginal pH always elevated above 4.5 1
• Abnormal vaginal flora 1
• Notably, 54% have no significant abnormality on microbiological testing 3
• 20% may have pure growth of commensal organisms (including Group B streptococci in 13%) 3

Diagnostic Considerations

DIV is a diagnosis of exclusion - other causes of purulent vaginitis must be ruled out first 1, 5. The differential diagnosis includes:

• Infectious vaginitis (bacterial vaginosis, trichomoniasis, candidiasis)
• Contact irritant vaginitis
• Fixed drug eruptions
• Immunobullous diseases
• Estrogen hypersensitivity vulvovaginitis
• Graft-versus-host disease
• Vaginal lichen planus 3

Historical Triggers

More than half of cases (56%) have identifiable historical triggers, which is significantly higher than in vaginal lichen planus (15%, p<0.0001) 3. Common triggers include:

• Diarrhea
• Antibiotic treatment
• Other factors causing shifts in vaginal homeostasis 3

Pathophysiology

• Etiology remains unknown but the favorable response to anti-inflammatory agents suggests immune-mediated pathogenesis 1
• The condition represents increased epithelial cell turnover in response to inflammatory triggers 3
• May represent a spectrum with plasma cell vulvitis as hemorrhagic vestibulovaginitis with varying manifestations by location and severity 4

Clinical Course

DIV is a chronic condition with high relapse rates:

• 86% of patients experience dramatic symptom relief within 3 weeks (median) of appropriate treatment 2
• However, 32% relapse within 6 weeks after discontinuing treatment 2
• At 1 year: only 26% achieve cure, 58% remain asymptomatic but dependent on maintenance therapy, and 16% are only partially controlled 2
• Approximately 45% require long-term maintenance treatment 2, 3

Important Clinical Pitfalls

• Frequently misdiagnosed as candidiasis or bacterial vaginosis and repeatedly treated without resolution 7
• Often unrecognized even by experienced practitioners due to rarity and similarity to other inflammatory disorders 6
• Cervical ectropion may be an underrecognized cause or contributor to DIV symptoms 7
• The diagnosis should be reconsidered in patients with persistent vaginitis not responding to standard treatments 8