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Recurrent Vulvar Itching. Greenjournal Obstetrics & Gynecology Vol.105. No6 June 2005 Page 1451-1455. Case Colleen M. Dennedy, MD Commentary Lori A Boardman, MD Fennifer Bott, MD. C a s e Age : 25-year-old Sex : female. Case Chief complaint.

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recurrent vulvar itching

Recurrent Vulvar Itching

Greenjournal Obstetrics & Gynecology

Vol.105. No6 June 2005

Page 1451-1455

Recurrent vulvar itching

slide2
Case Colleen M. Dennedy, MD
  • Commentary

Lori A Boardman, MD

Fennifer Bott, MD

Recurrent vulvar itching

slide3
C a s e
  • Age : 25-year-old
  • Sex : female

Recurrent vulvar itching

case chief complaint
Case Chief complaint

Recurrent vulvovaginal discharge and irritation

Recurrent vulvar itching

case present illness
CasePresent illness
  • A 25-year-old woman, has been severe intermittent vulvar burning, intermittent itching and constant mild-to-moderate vulvar pain over the past 18 months.
  • She has been treated with 7courses of antibiotics, with either a brief response or no improvement of her symptoms

Recurrent vulvar itching

case past history
CasePast History
  • Tx for vulvar itching (over the past half year)
    • metronidazole and clindamycin vaginal creams
    • clindamycin vaginal ovules
    • Burow’s solution (Bayer Consumer Care, Morris Towship, N) soaks
    • over-the-counter vaginal moisture solution
    • perineal cleansing pad
    • panty shields with baking soda
  • Medical Hx for migraines
  • Operation Hx Laparoscopic tubal ligation

Recurrent vulvar itching

case past history7
CasePast History
  • Using the following household products

- scented dryer sheets

- various laundry detergents

- deodorant soap

- scented liquid body wash

- topical lubricating jelly before intercouse

Recurrent vulvar itching

case family history further questioning by the specialist
CaseFamily History(furtherquestioning by the specialist)
  • atopic diseases, including asthma, hay fever and

dermatitis.

  • admits to occasional rubbing and scratching of the area

secondary to the intense pruritis that she often experiences.

Recurrent vulvar itching

case social history
CaseSocial History
  • Smoking : no
  • Alcohol : no
  • Using illicit drugs : no

Recurrent vulvar itching

case obstetrical history

CaseObstetrical History

Marriage yes

Recurrent vulvar itching

case review of system

CaseReview of system

Genitourinary system

Dysuria/Urinary frequency (+ / +)

Urinary or fecal incontinence (-)

Recurrent vulvar itching

case physical examination

CasePhysical Examination

Vulva

markedly erythematous

without lesions, ulcerations or excoriations

when the labia minora are separated, significant

erythema is noted

Vestibule : erythematous

Recurrent vulvar itching

case laboratory finding

CaseLaboratory finding

Microscopy : normal

- without yeast, clue cells, trichomonads or inflammatory

changes

- Maturation : normal

- Lactobacilli : present

Urine culture (-)

Recurrent vulvar itching

commentary
Commentary

Recurrent vulvar itching

commentary questions for the spicialist
CommentaryQuestions for the Spicialist
  • What is the differential diagnosis?
  • What is contact dermatitis?
  • Are there known risk factors for contact dermatitis of the vulva?

Why are some women more prone to this condition than other?

  • How is contact dermatitis distinguished from other vulvovaginal conditions?

Do any other tests need to be done to establish a diagnosis?

  • What happens if contact dermatitis is not treated?
  • How is contact dermatitis treated?
  • How Successful is treatment?

Recurrent vulvar itching

differential diagnosis

Differential Diagnosis

Recurrent vulvar itching

differential diagnosis17

Differential Diagnosis

Recurrent vulvar itching

differential diagnosis18

Differential Diagnosis

The greatest suspicion for this patient rests with

vulvovaginal candidiasis and/or contact

dermatitis

Recurrent vulvar itching

differential diagnosis candida albicans

Differential DiagnosisCandida albicans

Not confirmed on the basis of her normal microscopy and

negative fungal culture

→ the sensitivity of saline microscopy for diagnosing

candidiasis : 30~50% (10% potassium hydroxide improves this estimate)

As an aside a recent Cochrane review found no difference in relative effectiveness

(short term or long term) between oral and intravaginal fungal treatments in women

with vulvovaginal candidiasis but women preferred oral therapy.

Recurrent vulvar itching

differential diagnosis candida albicans20

Differential DiagnosisCandida albicans

Atypical candidiasis (eg. C. glabratea, C. parapsilosis)

Sx

- may cause itching as well as the more typical burning

antifungals(oral and topical) are largely ineffective

result in little physical evidence of inflammation

microscopy can be difficult in this diagnosis

- blastospores of several species do not form hyphae or pseudohyphae

- vaginal cultures obtained on at least 2 occasions preferably while

symptomatic

☞ if 2 consecutively obtained cultures are negative for Candida

species, the diagnosis of recurrent disease can be confidently

excluded

Recurrent vulvar itching

differential diagnosis chronic dermatologic conditions

Differential Diagnosischronic dermatologic conditions

vulvar manifestations develop in approimately 20% of women with

psoriasis and this can be localized to the vulva

Lesions on the vulva typically lack the scale classically associated

with this disease and do not involve the vagina.

Psoriasis (compared with dermatitis)

- more symmetrical, erythematous and better defined

Seborrheic dermatitis can also be considered but in the present case

the characteristic greasy scales overlying erythematous patches or

plaques are lacking

Given the patient’s history of repetitive exposure to a variety of

potentially irritating and/or allergenic substances and physical

finding, contact dermaitis seems the most likely diagnosis

Recurrent vulvar itching

contact dermatitis

Contact Dermatitis

Dermaitis (or eczema)

: poorly demarcated, erythematous and usually itchy rash.

Subtypes: numerous

classified as exogenous (irritant of allergic contact dermatitis)

endogeous (atopic of seborrheic dermatitis)

> 20~60% of patients seen with chronic vulvar symptoms

Common to see a mixed picture, in which endogenous dermatitis or

another epithelial disorder has been worsened by use of ointments or

creams to which the patient has adversely reacted.

Recurrent vulvar itching

contact dermatitis23

Contact Dermatitis

Contact Dermatitis

: an inflammation of the skin caused by exposure to an external

agent that as either as and irritant or as an allergen.

Recurrent vulvar itching

risk factors

Risk factors

Any process that alters or damages any component of the

epidermis compromises its function

Loss of estrogen

: epithelial thinning of the vagina and introitus

– a less effective barrier results

With existing dermatoses (eg. Lichen sclerosus)

Family of persomal history of atopy

(eg. Asthma , rhinitis, conjunctivitis or hives)

Recurrent vulvar itching

diagnosis

Diagnosis

Clinical sign

mild erythema, swelling and scaling to marked erythema,

fissures, erosions and ulcers

Routine bacterial cultures of vaginal flora

limited value

Fungal cultures

Biopsy

if the patient dose not respond to treatment.

Patch testing

Recurrent vulvar itching

treatment what happens if contact dermatitis is not treated lichen simplex chronicus

TreatmentWhat happens if contact dermatitis is not treated? ☞ Lichen simplex chronicus

Lichen simplex chronicus

- a chronic eczematous disease characterized by intense and

unrelenting itching and scratching

- 10~35% of patients evaluated

- 65~75% of patients will report a history of atopic disease.

(may be a localized variant of atopic dermatitis)

- All patients : pruritus admit to vigorous scratching or rubbing

- Clinically appears as one or more erythematous, scaling,

lichenified plaques

- In long standing disease

: skin appears thickened and leathery

areas of hyperpigmentation and hypopigmentation may be

present

Recurrent vulvar itching

treatment what happens if contact dermatitis is not treated lichen simplex chronicus27

TreatmentWhat happens if contact dermatitis is not treated? ☞Lichen simplex chronicus

Lichen simplex chronicus

- represent an end-stage response to a wide variety of possible

initiating processes including

enviromental factors

eg. heat, excessive sweating and irritation from clothing or

topically applied products

dermatologic deseases

eg. Candidiasis, lichen sclerosus

Recurrent vulvar itching

treatment

Treatment

Recurrent vulvar itching

treatment29

Treatment

Medication

- antihistamine & sedative properities (doxepin or hydroxyzine)

can be added to control nocturnal itching while cetirizine or a

SSRI can used during the day

- anti-inflammatory therapy

: begin with a mid to high-potency topical corticosteroid for

2~3weeks

- a weaker corticosteroid (1%hydrocortisone) can then be

continued as needed

Recurrent vulvar itching

slide30

Case

Impression

Contact dermatitis

Lichen simplex chronicus

Plan

Recurrent vulvar itching