Desquamative Inflammatory Vaginitis

Desquamative inflammatory vaginitis is a chronic purulent vaginitis of unclear cause, with massive vaginal epithelial desquamation, inflammation and loss of lactobacilli, in women who are not atrophic.

• It is a diagnosis of exclusion after infection and mucosal disease are ruled out.
• It is commonly mistaken for recurrent candidiasis or bacterial vaginosis and treated repeatedly without success.
• It responds to topical clindamycin or corticosteroid.

Chronic copious yellow-green purulent discharge, vaginal burning, dyspareunia and vulval irritation.

• Diffuse vaginal erythema with ecchymotic spots, a raised pH above 4.5 and, sometimes, erosions.
• Symptoms persist despite repeated antifungal and metronidazole courses.
• Differential diagnosis: aerobic vaginitis, trichomoniasis, erosive lichen planus, atrophic vaginitis, pemphigus vulgaris, cervicitis, foreign body.
• Complications: chronic dyspareunia, vaginal adhesions, psychosexual distress.

Criteria: vaginal inflammation, pH above 4.5, and microscopy with increased parabasal cells and leucocytes with reduced lactobacilli.

• Wet mount: parabasal cells, many leucocytes, no trichomonads, no clue cells, no yeast.
• Culture and NAAT exclude trichomoniasis, gonorrhoea and chlamydia; group B Streptococcus culture is often positive.
• Vulval and vaginal biopsy when erosions or white striae suggest erosive lichen planus; check the mouth for lesions.
• HIV and syphilis tests.

Treatment is topical clindamycin first, then topical corticosteroid for non-response, with maintenance for relapse.

• Supportive: avoid douching and irritants, use a bland emollient on the vulva, cotton underwear.
• Pharmacological: clindamycin 2 percent cream 5 g intravaginal nightly for 2 to 4 weeks. If no response after 2 weeks or for severe disease, hydrocortisone 10 percent intravaginal cream 5 g (compounded) nightly for 4 weeks, then reduce to twice weekly for 4 to 8 weeks for maintenance. In postmenopausal women add oestriol 0.1 percent cream 0.5 g intravaginal nightly for 2 weeks then twice weekly. Recurrence is common and may need maintenance dosing for 3 to 6 months.
• Procedures: none; lysis of vaginal adhesions under anaesthesia when scarring has occurred.
• Special groups: in pregnancy avoid oestrogen and prolonged steroid use; clindamycin cream for 7 days is acceptable.
• Red flags: erosions with scarring, oral or skin lesions, blood-stained discharge, failure to respond after 6 weeks.
• Follow-up: review at 4 weeks with repeat microscopy; review at 3 and 6 months because relapse is common.