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What self-care advice should I give to women with pruritus vulvae?
- Advise the woman:
- To shower rather than bath, and to clean the vulval area only once a day with a soap substitute (for example Epaderm® or Diprobase® cream) — over cleaning may aggravate vulval symptoms. Once the vulval area is clean, gently dab the vulval area dry with a soft towel or use a hairdryer on a cool setting held well away from the skin.
- Advise women with pruritus vulvae to avoid:
- Washing with water only or with soap as these cause dry skin and make itching worse.
- Contact of the vulval skin with:
- Shampoo.
- Bubble bath.
- Over-the-counter preparations used on the vulva, such as Vagasil® or vaginal washes.
- Wet wipes (feminine or baby).
- Perfumed sanitary towels and panty liners.
- Sponges or flannels — these may irritate the skin.
- Antiseptics such as Dettol®.
- Tight-fitting garments or synthetic clothes, for example nylon underwear, as these may irritate the vulval area.
- Fabric conditioner or biological washing powder when washing underwear.
- Use of spermicidally-lubricated condoms.
- Coloured toilet paper.
- Wearing nail varnish on fingernails if they are scratching.
- Wearing dark-coloured underwear — dark textile dyes (black, navy) may cause an allergy, however it is thought that if they are washed a few times before wearing, this is less likely to be a problem.
- Encourage all women with vulval symptoms to perform a self examination to monitor the skin condition and any suspicious areas.
- The following organizations provide patient information leaflets on how to perform a self examination:
Basis for recommendation
These recommendations are based on published expert opinion [BASHH, 2007; ACOG, 2008; Burrows et al, 2008; RCOG, 2010].
Self examination
- The recommendation regarding self examination is based on published expert opinion from the Royal College of Obstetricians and Gynaecologists [RCOG, 2010]. Although there is no trial evidence to support the use of self examination, many patient support groups and specialist societies recommend self examination to detect any suspicious areas.
What symptomatic treatment can I offer?
- For all women with pruritus vulvae, consider prescribing:
- An emollient — advise the woman to apply the emollient directly to the vulval area throughout the day (as well as using it as a soap substitute).
- When used every day (even when there are no symptoms), an emollient protects the skin and may help to prevent flare-ups.
- For more information on prescribing emollients, see the section on Emollients in the CKS topic on Eczema - atopic.
- A sedating antihistamine at night, such as hydroxyzine (which is licensed for pruritus) or chlorphenamine (off-label indication) to reduce nocturnal itch and scratching.
Basis for recommendation
Emollients
Sedating antihistamines
- The recommendation to use a sedating oral antihistamine at night is based on published expert opinion, as some women may be helped by oral antihistamines [Doxanakis et al, 2004; Bohl, 2005; DermNet NZ, 2010]. CKS identified no controlled trials that investigated the use of antihistamines for pruritus vulvae.
- If an antihistamine is considered appropriate, first-generation antihistamines (for example chlorphenamine and hydroxyzine) are more sedating than second-generation antihistamines, and may therefore be useful for night-time use [O'Donoghue and Tharp, 2005].
- Experts postulate that sedating oral antihistamines probably provide a reprieve from nocturnal scratching by inducing sedation, helping to break the itch-scratch-cycle [Weichert, 2004].
How should I manage pruritus vulvae with a known cause?
- A comprehensive discussion of the management of specific causes of pruritus vulvae is beyond the scope of this topic. A brief discussion follows, with links to other relevant CKS topics.
- Most women who present with pruritus vulvae have an identifiable cause which can be managed, including:
How should I manage dermatological conditions?
Dermatologists or gynaecologists with the necessary expertise will be able to give comprehensive advice for the treatment of individuals, but in general the following management is suitable.
- Manage the underlying dermatological cause.
- Contact dermatitis
- Identify and remove exposure to irritants (for example soaps and deodorants).
- For mild itching, consider prescribing a mild potency topical corticosteroid ointment, such as hydrocortisone 1% for 2–4 weeks, and then review.
- Seek specialist advice if stronger corticosteroids are being considered. Stronger potency corticosteroids (such as betamethasone or clobetasol) may be considered if, symptoms are severe, if the skin is lichenified, or to break the itch-scratch-cycle.
- Consider referral to dermatology for skin patch testing if avoidance of irritants has not helped.
- For more information, see the CKS topic on Dermatitis - contact.
- Seborrhoeic dermatitis
- Ketoconazole shampoo can be used as body wash for seborrhoeic dermatitis.
- For more information, see the CKS topic on Seborrhoeic dermatitis.
- Psoriasis
- Lichen simplex
- Consider prescribing a potent topical corticosteroid ointment (such as betamethasone), for 1–2 weeks to break the itch-scratch cycle and bring the condition under control.
- Lichen sclerosus and lichen planus
- Refer to secondary care for confirmation the diagnosis.
- Once the diagnosis is confirmed in secondary care, very potent corticosteroids are usually initiated by a specialist, repeated intermittent courses of topical steroids may be required for longer term management.
- For more information on prescribing:
Basis for recommendation
CKS identified no trial evidence to support these recommendations. They are based on guidelines published by the British Association for Sexual Health and HIV [BASHH, 2007] and published expert opinion [Salim and Wojnarowska, 2005; RCOG, 2010].
Lichen simplex
- The recommendation to use potent topical corticosteroids in women with lichen simplex (for a short period) to bring the condition under control in the early stages is based on published expert opinion [Salim and Wojnarowska, 2005]. It is thought that weaker-potency topical corticosteroids are not effective for breaking the itch-scratch-cycle in women with lichen simplex.
Lichen sclerosus and lichen planus
- Referral is recommended to confirm the diagnosis because women with lichen sclerosus and lichen planus have a small risk (3–5%) of developing cancer.
Skin patch testing
- The recommendation to refer a woman with dermatitis to dermatology for skin patch testing is based on published expert opinion from the Royal College of Obstetricians and Gynaecologists (RCOG) [RCOG, 2010].
- The RCOG state that specific allergic reactions are often identified in women with pruritus vulvae and that most studies suggest that 26–80% of women referred with vulval symptoms have at least one positive result on patch testing. The most common allergens identified have been cosmetics, medicaments. and preservatives. Other allergens identified include fragrances, preservatives in topical treatments, rubber, and textile dyes.
How should I manage infections or infestations?
- For information on the manage the underlying infection or infestation, see the CKS topics on:
Basis for recommendation
The evidence to support the management of infections and infestations is discussed within the relevant CKS topic.
How should I manage pruritus vulvae caused by a possible neoplasm?
- Refer urgently (within 2 weeks) all women with an unexplained vulval lump or ulcer.
- If the woman presents with vulval pruritus or pain, but no other specific features, it is reasonable to use a period of 'treat, watch, and wait' as initial management. The woman should be followed up until symptoms resolve or a diagnosis is confirmed. If symptoms persist, refer with urgency depending on the symptoms and degree of concern about cancer.
- Vulval intraepithelial neoplasia — a skin biopsy is required to confirm the diagnosis and pick up any early cancers. As 50% of women have associated abnormalities including cervical intraepithelial neoplasia or cancer, it is very important to have annual cervical smears.
- Usually all vulval intraepithelial neoplasia lesions are treated to reduce the risk of cancer (in secondary care). Treatments which may be offered include removal of affected tissue, topical imiquimod, or 5-fluorouracil.
Basis for recommendation
These recommendation to refer urgently all women with an unexplained vulval lump or ulcer are based on guidance issued by the National Institute for Health and Clinical Excellence; Referral guidelines for suspected cancer [NICE, 2005].
Vulval intraepithelial neoplasia
How should I manage hormonal changes which cause pruritus vulvae?
- Manage the underlying cause:
Basis for recommendation
The evidence to support the management of hormonal changes is discussed within the relevant CKS topic.
How should I manage gastrointestinal disease or urinary incontinence which is causing pruritus vulvae?
- Manage the underlying cause:
- Faecal incontinence or poor peri-anal hygiene — advise on appropriate hygiene and manage faecal incontinence (for example regular toileting, use of barrier creams).
- Urinary incontinence — manage appropriately. See guidance from the National Institute for Health and Clinical Excellence (NICE) (pdf) on the management of urinary incontinence in women.
Basis for recommendation
The advice regarding faecal incontinence and good personal hygiene is based on what CKS considers to be good practice.
How should I manage a systemic cause of pruritus vulvae?
- Manage the underlying cause:
Basis for recommendation
The evidence to support the management of systemic causes is discussed within the relevant CKS topic.
How do I manage pruritus vulvae with an unknown cause?
The aim of treatment is to reduce irritation of the vulval area, relieve itch, reduce scratching, and break the itch-scratch-cycle.
- Offer symptomatic treatment with an emollient and a sedating antihistamine.
- Consider prescribing a short trial (1-2 weeks) of low potency topical corticosteroids (hydrocortisone 1% ointment).
- If symptoms persist despite treatment with an emollient, a sedating oral antihistamine, and a trial of low potency topical corticosteroids, refer for further investigation to a dermatologist, gynaecologist, or vulval clinic.
- While the woman is waiting to be seen by a specialist advise her to continue using an emollient and a sedating antihistamine.
Basis for recommendation
These recommendations are based on expert opinion, because CKS found no trial evidence on how pruritus vulvae is best managed in primary care when there is no obvious underlying cause [Doxanakis et al, 2004; Bohl, 2005; Wray, 2009].
- Low potency topical corticosteroids
- CKS identified evidence from one small trial which showed that moderately potent topical corticosteroids are no more effective than placebo for treating pruritus vulvae with an unknown cause [Lagro-Janssen and Sluis, 2009].
- Opinion from CKS expert reviewers was divided regarding the use of low potency topical corticosteroids in women who have pruritus vulvae that has an unknown cause. However, CKS recommends that treatment may be considered on the basis that some women may benefit, and a short trial of low potency corticosteroids is unlikely to cause harm.
When should I refer a woman with pruritus vulvae?
- Referral to a dermatologist or gynaecologist with expertise in managing vulval disease is indicated if:
- The cause of the pruritus vulvae is unclear and symptoms persist:
- In most women an identifiable cause can be found.
- The urgency of the referral will depend on the nature of the symptoms and degree of concern (if any) about cancer.
- The cause is known, but symptoms persist despite primary care management:
- For example, some women with contact dermatitis may require referral to try and identify the irritant or allergen. If allergic contact dermatitis is suspected, then patch test investigations may be initiated.
- A premalignant condition, such as vulval intraepithelial neoplasia, lichen sclerosus, or lichen planus, is suspected:
- Accurate diagnosis is important because the woman may require long-term follow up. Women who require long-term follow up include those with troublesome ongoing symptoms, localized skin thickening, previous cancer, or vulval intraepithelial neoplasia.
- Specialist advice on management is often necessary.
- Urgent referral (within 2 weeks) is indicated if:
- Vulval carcinoma is suspected (for example if the woman has an unexplained vulval lump or ulcer).
Basis for recommendation
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Non-drug management
Age from 16 years onwards
Advice only: avoidance of vulval irritants
Bland emollients
Age from 16 years onwards
Advice only: over-the-counter purchase
Aqueous cream: Apply to vulva 3 to 4 times a day
Aqueous cream
Apply to the vulva liberally as a moisturiser 3 to 4 times a day, and after bathing. If the condition is inflammatory, also use as a soap substitute.
Supply 100 grams.
Aqueous cream: Apply to the vulva 3 to 4 times a day
Aqueous cream
Apply to the vulva liberally as a moisturiser 3 to 4 times a day, and after bathing. If the condition is inflammatory, also use as a soap substitute.
Supply 500 grams.
Emulsifying Oint: Apply to the vulva 3 to 4 times a day
Emulsifying ointment
Apply to the vulva liberally as a moisturiser 3 to 4 times a day, and after bathing. If the condition is inflammatory, also use as a soap substitute.
Supply 100 grams.
Emulsifying ointment: Apply to the vulva 3 to 4 times a day
Emulsifying ointment
Apply to the vulva liberally as a moisturiser 3 to 4 times a day, and after bathing. If the condition is inflammatory, also use as a soap substitute.
Supply 500 grams.
Sedating antihistamines (for sleep disturbance)
Age from 16 years onwards
Chlorphenamine tablets: 4mg at night when required
Chlorphenamine 4mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Hydroxyzine tablets: 25mg at night when required
Hydroxyzine 25mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Topical corticosteroid - short trial
Age from 16 years onwards
Hydrocortisone 0.5% ointment: Apply once or twice a day
Hydrocortisone 0.5% ointment
Apply thinly to the vulva once or twice a day when required for relief of itching. Use for 7 to 14 days.
Supply 15 grams.
Hydrocortisone 1% ointment: Apply once or twice a day
Hydrocortisone 1% ointment
Apply thinly to the vulva once or twice a day when required for relief of itching. Use for 7 to 14 days.
Supply 15 grams.
Potent corticosteroids (lichen simplex)
Age from 16 years onwards
Betamethasone valerate 0.1% ointment: apply once or twice a day
Betamethasone valerate 0.1% ointment
Apply thinly to the affected area(s) once or twice a day.
Supply 100 grams.