Vulvovaginal pruritus

Specialty: Nephrology and urology.

• vaginal itching
• vulvar itching
• female genital itching

Why it occurs

• Vulvovaginal candidiasis (opportunistic infection by Candida albicans or other species that generates severe inflammation and intense itching sensation)
• Bacterial vaginosis (vaginal dysbiosis with loss of lactobacilli and overgrowth of Gardnerella vaginalis and anaerobes, causing mild itching and malodorous discharge)
• Vaginitis due to Trichomonas vaginalis (sexually transmitted parasitic infection with diffuse erythema of the vaginal and vulvar mucosa)
• Vulvar lichen sclerosus (idiopathic chronic inflammatory disease of the vulvar skin that produces white plaques, epidermal atrophy and intractable pruritus)
• Irritant or allergic contact dermatitis (due to the use of intimate soaps with perfumes, fabric softeners, latex condoms or lubricants)

Initial workup

Careful vulvovaginal physical examination with good lighting; measurement of pH of vaginal secretion (typically acidic <4.5 in candidiasis, but typically >4.5 in bacterial vaginosis and trichomoniasis); fresh microscopic examination of vaginal secretion with 0.9% saline solution to visualize yeasts/hyphae, motile trichomonads or clue cells after addition of 10% potassium hydroxide (positive Whiff test for amine odor); specific vaginal culture for fungi and bacteria; Vulvar biopsy with Key punch if lichen sclerosus or malignancy is suspected.

Standard management

• Fluconazole — 150 mg orally as a single dose for uncomplicated vulvovaginal candidiasis; In recurrent cases, a weekly maintenance regimen may be indicated.
• Clotrimazole — 100 mg vaginal suppositories daily for 6 days, or 2% vaginal cream for 3 days for alternative local treatment
• Metronidazole — 500 mg every 12 hours orally for 7 days for the effective treatment of bacterial vaginosis or trichomoniasis; warn avoid alcohol consumption due to disulfiram effect
• Clobetasol propionate 0.05% cream (daily topical application in a decreasing manner, very high potency corticosteroid indicated only in confirmed vulvar lichen sclerosus).