Chronic postmenopausal vulvar pruritus

Specialty: Nephrology and urology.

• senile vulvar itching
• persistent vulvar pruritus in menopause

Why it occurs

• Vulvar lichen sclerosus (idiopathic chronic inflammatory disease, highly prevalent in postmenopausal women, characterized by intense pruritus predominantly at night, whitish skin thinning and stenosis of the introitus)
• Severe vulvar atrophy due to hypoestrogenism (the thinned vulvar mucosa becomes extremely sensitive and prone to fissures and chronic irritation that is perceived as pruritus)
• Vulvar intraepithelial neoplasia - VIN or extramammary Paget's disease (premalignant or malignant lesion of the vulvar epidermis that may only present with persistent itching resistant to corticosteroids or antifungals)
• Vulvar psoriasis or chronic eczema (dermatological pathology located in skin folds)

Initial workup

Detailed inspection under a magnifying glass or colposcope (vulvoscopy) with application of 5% acetic acid to identify suspicious acetowhite areas; taking a microbiological smear to rule out opportunistic fungal superinfection; vulvar punch biopsy (of choice, essential in any persistent lesion or raised whitish plaques that do not respond to conventional treatment within 2 weeks to rule out neoplasia).

Standard management

• Clobetasol propionate 0.05% cream — apply a pea-sized amount locally every 24 hours for 4 weeks, gradually reducing frequency to 2-3 times per week as long-term maintenance therapy; It is the treatment of choice for vulvar lichen sclerosus; monitor skin atrophy
• Topical vaginal and vulvar estriol 0.1% — applied locally 2 times a week to treat associated vulvar atrophy
• Hydrocortisone cream 1% (for benign vulvar eczema for very short periods).