• 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:
• British Society for the Study of Vulval Disease.
• National Lichen Sclerosus Support Group.
• Vulval Pain Society.
• The International Society for the Study of Vulvovaginal Disease.

• 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.

• 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:
• Dermatological conditions.
• Infections and infestations.
• Possible neoplasm.
• Hormonal changes.
• Gastrointestinal disease and urinary incontinence.
• Systemic causes.

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
• For management information, see the section on Treatment in the CKS topic on 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:
• Topical corticosteroids: see the CKS topic on Corticosteroids - topical (skin), nose, and eyes.
• Emollients: see the section on Emollients in the CKS topic on Eczema - atopic.

• For information on the manage the underlying infection or infestation, see the CKS topics on:
• Bacterial vaginosis.
• Candida - female genital.
• Herpes simplex - genital.
• Pubic lice.
• Scabies.
• Threadworm.
• Trichomoniasis.

• 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.

• Manage the underlying cause:
• Atrophic vaginitis — see the CKS topic on Menopause.
• Pregnancy — see the CKS topic on Itch in pregnancy.

• 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.

• Manage the underlying cause:
• Anaemia (iron deficiency) —  see the CKS topic on Anaemia - iron deficiency.
• Anaemia (vitamin B₁₂ and folate deficiency) — see the CKS topic on Anaemia - B12 and folate deficiency.
• Diabetes type 2 — see the CKS topic on Diabetes - type 2.
• Hyperthyroidism — see the CKS topic on Hyperthyroidism.
• Hypothyroidism — see the CKS topic on Hypothyroidism.

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.

• 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).

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).