The itchy vulva
What is the vulva?
The vulva, or external genitalia of the female, includes the mons pubis, labia majora (outer lips), labia minora (inner lips), clitoris, perineum (tissue between vagina and anus) and the external openings of the urethra and vagina.
Itching often affects the vulva. The sensation of itch in this site is also referred to as pruritus vulvae. Pruritus vulvae should be distinguished from vulval pain and from vulvodynia, which refers to chronic burning symptoms in the absence of clinical signs. Vulval itch, pain and/or burning can co-exist.
Who gets an itchy vulva?
Girls and women of any age and race can experience mild, moderate or severe vulval itch, which can be intermittent or continuous. They may or may not have an associated skin condition.
What causes an itchy vulva?
One or more specific conditions may be the cause of vulval itch.
Itch due to infections
Candida albicans infection (vulvovaginal thrush) is the most important microorganism to consider in a postpubertal woman with vulval itch. Candida can be a cause of napkin dermatitis in babies. Postmenopausal women are unlikely to have Candida albicans infection, unless they are diabetic, they are treated with oestrogen or antibiotics, or candida is secondary to an underlying skin disease.
There are several less common infections that may cause vulval itch.
- Bacterial vaginosis causes a frothy, malodorous discharge, and uncommonly causes vulval itch, possibly as a result of contact dermatitis.
- Genital viral warts are often itchy.
- Pinworms can reside in the vagina or anus and cause itch when they exit at night.
- Infections that rarely cause vulval itch include cytolytic vaginosis (associated with vaginal lactobacilli) and trichomoniasis.
Itch due to an inflammatory skin condition
Irritant contact dermatitis is the most common cause of an itchy vulva at all ages. It can be acute, relapsing or chronic. It may be due to diverse causes, including:
- Age-related prepubertal or postmenopausal lack of oestrogen
- Underlying tendency to atopic dermatitis
- Scratching for another reason
- Friction from skin folds, clothing, activity, or sexual intercourse
- Moisture due to occlusive underwear
- Urine and/or faeces
- Soap or harsh cleanser
- Frequent washing
- Inappropriate or unnecessary chemical applications, including over-the-counter or prescribed medications
- Fissuring of the posterior fourchette
- Normal, excessive or infected vaginal secretions
Severe vulval itch may be due to:
Other common skin disorders that may cause vulval itch include:
- Seborrhoeic dermatitis
- Allergic contact dermatitis*
- Irritant or allergic contact urticaria
*Potential vulval allergens include:
- Methylisothiazolinone, a preservative in moist wipes
- Various textile dyes in underwear
- Fragrance in a douche or antiperspirant
- Rubber accelerants in condom, menstrual cup or underwear
Itch due to neoplasia
Benign and malignant neoplastic disorders of the vulva are often asymptomatic in their early stages, but they can cause itch. The most common cancerous lesions are:
- Squamous intraepithelial lesions (SIL, also known as vulval intraepithelial neoplasia or VIN)
- Extramammary Paget disease
- Invasive vulval cancer (squamous cell carcinoma)
Itch due to neuropathy
Neuropathy should be considered as a cause of vulval itch if there are no signs of infection or skin disease apart from lichen simplex — which can be secondary to a pruritic neuropathy — especially if vulvodynia is present. The neuropathy may be caused by injury, surgery or disease locally (pudendal entrapment), within the pelvis or in the spine.
What are the clinical features of an itchy vulva?
The clinical features depend on the underlying cause of the vulval itch. There may be an obvious or subtle rash, or no signs of disease at all.
When assessing the cause, it’s important to determine the precise location of the symptoms. Itch often only affects one anatomic part of the vulva:
- Convex areas and thighs: irritant contact dermatitis due to urinary incontinence (symmetrical) or rarely, allergic contact dermatitis (asymmetrical)
- Flexures: seborrhoeic dermatitis, nonspecific or candida intertrigo
- Mons pubis: seborrhoeic dermatitis, folliculitis
- Labia majora: genital psoriasis, atopic dermatitis, lichen simplex (unilateral or bilateral)
- Labia minora: lichen sclerosus, lichen planus
- Vaginal introitus: erosive lichen planus, atrophic vulvovaginitis, vaginal discharge or infection
- Perineum: dermatitis, lichen sclerosus
- Any site: neoplasia
The itch can also involve other adjacent skin of the abdomen, thighs and perianal area.
Examination may reveal apparently normal skin, scratch marks (excoriations) and the specific features associated with the underlying cause of the itch.
Morphology may be modified according to the site, with minimal scale evident.
- Candida albicans vaginitis causes thick white vaginal discharge, erythema, oedema and candida vulvitis causes satellite red superficial papules, pustules, desquamation and erosions.
- Candida can also cause subtle fissuring and subclinical dermatitis.
- Viral warts are clustered as soft condylomata.
- Acute irritant contact dermatitis may be shiny or waxy or scald-like.
- Genital or flexural psoriasis has symmetrical circumscribed erythematous plaques, but they are rarely scaly.
- Seborrhoeic dermatitis presents with salmon pink, poorly defined patches, sometimes with mild exfoliation.
- Allergic contact dermatitis can have varied morphology, but tends to be asymmetrical, intermittent.
- Lichen simplex presents as confluent thickened papules with broken off hairs.
- Lichen sclerosus typically has white plaques, ecchymoses and erosions.
- Lichen planus may present as violaceous or hyperpigmented papules with reticulated white network (thighs), appear similar to lichen sclerosus; erosive lichen planus causes tender well-defined red patches and erosions (introitus/vagina).
- An intraepithelial or invasive squamous lesion should be considered if there is a solitary plaque with irregular shape, structure, surface and colour. Firm or hard consistency and/or ulceration and bleeding are particularly concerning.
Complications of an itchy vulva
Erosive lichen planus in particular can also cause significant pain/soreness as well as itch.
How is the cause of an itchy vulva diagnosed?
The cause or causes of an itchy vulva may be diagnosed through careful history (include genitourinary and musculoskeletal systems) and examination of the vulva.
A full skin examination may reveal a skin condition or disease in another site that gives a clue to why the vulva is itchy.
- Bacterial and viral swabs of the affected area and of the vagina may be taken for microbiological examination.
- Skin biopsy of the area affected by itch or visible skin condition may be necessary to determine its exact nature. Sometimes several biopsies may be taken.
- Patch tests are sometimes performed to see whether any contact allergy is present.
What is the treatment for an itchy vulva?
The conditions causing an itchy vulva often require specific treatment. For example:
- Topical and oral antifungal, antibiotic or antiviral medications (aciclovir) for infection
- Topical steroids or calcineurin inhibitors for inflammatory disease
- Oral antihistamines for contact urticaria
- Surgery for neoplasia
- Tricyclic antidepressants, serotonin reuptake agents, and anticonvulsants for neuropathic symptoms
- Minimise scratching or rubbing the affected area.
- Wear loose fitting absorbent underwear and outer clothing.
- Avoid occlusive nylon such as pantihose.
- Select modern absorbent underwear.
- Keep cool, especially at night-time.
- Apply emollients (eg sorbolene) and barrier preparations (eg petroleum jelly).
- Hydrocortisone cream can be used safely and purchased without prescription.
Contact dermatitis occurs quite readily when inflamed skin affects the genital area.
- Wash once or twice daily with lukewarm water alone or use a soap-free cleanser.
- Do not use leave-on moist wipes, antiperspirants or other cosmetics in the vulva.
- Insert tampons with care or use reusable silicone menstrual cups.
- Change sanitary pads, pantiliners and/or incontinence products frequently.
- Avoid riding bicycles or horses.
Tricyclic antidepressants may be prescribed to control intractable itch, even in the absence of a defined neuropathy.
How can vulval itch be prevented?
Vulval itch cannot always be prevented, depending on its cause. However, vulval health is optimised by the nonspecific measures described above.
What is the outlook for vulval itch?
Vulval itch is usually a minor, short-lived nuisance. However, some women may suffer from vulval itch for years, and may only receive temporary relief from treatment.
On DermNet NZ:
- Genital skin problems
- Vulval/vaginal problems in prepubertal females
- Skin problems related to menopause
- Bacterial vaginosis
- Vulval Skin Care – British Association of Dermatologists