CHAPTER 89
Contact Vulvovaginitis
Presentation
Patients complain of severe vulvar itching that may be accompanied by edematous swelling. Occasionally, there will be tenderness, pain, burning, and dysuria severe enough to cause urinary retention. The vulvovaginal area is variably inflamed, erythematous, and edematous. In more severe cases, there may be vesiculation and ulceration; in cases in which there is chronic contact dermatitis, there may be lichenification, scaling, and skin thickening.
What To Do:
Try to determine if condition is exogenous (from contact) or endogenous (atopic). If an offending agent can be identified, have the patient stop using it. Most reactions are caused by agents that the patient unknowingly applies or uses for hygienic or therapeutic purposes. Chemically scented douches, soaps, bubble baths, deodorants, perfumes, dyed or scented toilet paper, dyed underwear, scented tampons or pads, and additional feminine hygiene products are the most common causative agents. Neomycin-containing topical medication is another frequent source. Less commonly, plant allergens, such as poison oak or poison ivy, may trigger the reaction. Use of latex condoms and proteins in seminal plasma may also be an inapparent source of contact dermatitis.
If the diagnosis is unclear, rule out an alternative cause of vulvar pruritus, such as pinworms (see Chapter 69) or Trichomonas organisms (see Chapter 95). Candida albicans may also be the cause of pruritus, but it may present as an overgrowth when contact vulvovaginitis is the primary problem. Atypical herpes simplex virus should also be considered. Atopic or eczematous changes can be causative as well; therefore look at buttock and labial folds.
When the findings are typical for contact vulvovaginitis, instruct the patient in the use of warm to cool baths twice a day for 5 minutes, and then apply topical steroids as a treatment and to seal in moisture. Trying cool, wet compresses soaked with boric acid or Burow solution (Domeboro) has also been recommended.
Prescribe liberal amounts of topical corticosteroids, such as fluocinolone (Synalar cream 0.025%) or triamcinolone (Aristocort A 0.025% cream) bid to qid (dispense 15-g tube). For mild symptoms, hydrocortisone 1% or 2.5% or triamcinolone 0.1% can be used daily for 2 to 4 weeks, then twice per week. For moderate to severe symptoms, clobetasol propionate or betamethasone dipropionate ointment 0.05% can be used nightly for 30 days. One can also try tapering starting with applications twice daily for 2 weeks, then daily for 2 weeks, then on Monday, Wednesday, and Friday for 2 weeks. Finally, the patient should be reevaluated. In the past, there has been concern about atrophy with steroid use. These potent steroids have been used up to 12 weeks on the vulva without adverse effects.
In more severe cases, or if topical is increasing the irritation, use triamcinolone intramuscular (IM) 60 mg. This may be used every 6 weeks for up to 3 doses. Alternatively, a steroid taper dose pack, such as prednisone (Sterapred DS or Sterapred DS 12 day) or methylprednisolone (Medrol Dosepack 4-mg tablets) for systemic therapy could be prescribed.
Some suggest a sedating antipruritic agent helps with nighttime itching and scratching. The antidepressant Doxepin (Sinequan), 10 to 25 mg or the sedating antihistamine hydroxyzine (Atarax, Vistaril), 25 to 50 mg at 7 pm, may help with sleep.
What Not To Do:
Do not have the patient use hot baths or compresses. This will usually exacerbate the burning and pruritus.
Do not prescribe nonsedating antihistamines. They are relatively ineffective in treating contact vulvitis and may increase discomfort by drying the vaginal mucosa.
Discussion
The major problem with managing contact vulvovaginitis is identifying the primary irritant or allergen. In many cases, more than one substance is involved, or potentially involved, and may be totally unsuspected by the patient (such as the use of scented toilet paper). For this reason, a thorough investigative history is important. Include questions about hygiene practices, clothing, and fabrics.
An allergic reaction can take 12 to 72 hours to develop, is usually very pruritic, and can often last for weeks.
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