CKS Clinical solutions - Pruritus vulvae

THE CASE: A 50-year-old woman presents with a persistent vulvai itch over the past two months.

What causes pruritus vulvae?
Pruritus vulvae (PV) can be broadly classified into infective, dermatological and neoplastic causes. In a sample of 141 women with chronic symptoms referred to a dermatologist, dermatitis was found to be the commonest cause.1

It is rare not to find a cause of PV; therefore a diagnosis of idiopathic PV can only be made when all possible causes have been excluded.

What assessment should I make?
Confirm that the woman is complaining of vulval itch, not vulval pain.

Take a history about the duration of symptoms, hygiene practices, self-administered treatments (for example, antifungal creams), skin disorders, vaginal discharge, menopausal symptoms, and other systemic conditions, such as diabetes.

Examine the vulval area for signs of infection and dermatological problems (for example, dermatitis, lichen sclerosus).2

Assess the impact on the patient's quality of life, including psychosexual issues and sleep patterns. Consider blood tests and vaginal swabs to exclude infections.3-5

How do I treat pruritus vulvae?
Treat any underlying cause. If no cause is identified, offer an emollient to apply directly to the vulval area, and to use as a soap substitute.

Consider using a sedating antihistamine (for example. chlorphenamine) if nocturnal itching is a problem. If symptoms persist, consider the use of short-term (one to two weeks), mild potency corticosteroid cream (hydrocortisone 1%).

CKS recommends potent corticosteroids should only be used if a woman has been advised by a specialist or there is a strong suspicion of lichen sclerosus. A trial may be initiated in primary care while awaiting specialist review.

What lifestyle advice should I give?
Advise the woman to avoid irritants such as bubble bath, OTC preparations, wet wipes and perfumed sanitary towels around the vulval area.

Avoiding tight fitting garments and nylon underwear may help. Advise the patient not to use fabric conditioner when washing underwear or use spermicidally-lubricated condoms during sex.

Reassure that in the majority of cases a cause for PV is normally found and there is a very good chance the symptoms will improve if not disappear altogether with treatment, and general care of the vulva.4

When should I refer women with PV?
Refer to a dermatologist or gynaecologist if a cause is unclear; if symptoms persist despite treatment in primary care, or if a premalignant condition such as lichen sclerosus or lichen planus is suspected.3-5

Refer urgently all women with a suspected vulval carcinoma (for example, an unexplained vulval lump or ulcer).6

Evidence
Treatment recommendations are based on expert opinion. CKS found no trial evidence on how PV is best managed in primary care when there is no obvious underlying cause.

Referral recommendations are based on expert opinion and referral guidelines for suspected cancer published by NICE.

References
1. Fischer GO. The commonest causes of symptomatic vulvar disease: a dermatologist's perspective. Australas J Dermatol 1996; 37(1): 12-8.

2. Canavan TP, Cohen, D. Vulvar cancer. Am Fam Physician 2002; 66(7): 1269-74.

3. Doxanakis A, Bradshaw C, Fairley C, Pokorny CS. Vulval itch: all that itches is not thrush. Med Today 2004; 5(6): 54-63.

4. Edwards S, Handfield-Jones S, Gull S. National guideline on the management of vulval conditions. Int J STD AIDS 2002; 13(6): 411-5.

5. Nunns D. Pruritus vulvae. Curr Obstet & Gynaecol 2002; 12(4): 231-4.

6. NICE. Referral guidelines for suspected cancer: quick reference guide. CG27, London, NICE, 2005.

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP.

See www.cks.nhs.uk

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