Irritant Vulvitis

Irritant vulvitis is non-allergic inflammation of the vulval skin caused by direct damage from substances or friction. It is a common cause of vulval dermatitis.

• Triggers include soaps, bubble baths, wipes, douches, panty liners, sanitary pads, urine, faeces, sweat, tight clothing and depilation.
• No prior sensitisation is needed, so it can occur on first exposure.
• Removing the irritant cures most cases.

Burning, soreness, itching and stinging of the vulva, worse after washing, urination or friction.

• Erythema, oedema, fissures, erosions and scaling; lichenification when chronic.
• Differential diagnosis: allergic contact dermatitis, vulvovaginal candidiasis, lichen sclerosus, lichen simplex chronicus, psoriasis, atrophic vaginitis, herpes genitalis, vulvodynia.
• Complications: secondary candidal or bacterial infection, chronic lichenification, pain with intercourse and sleep disturbance.

Diagnosis is clinical, by history of exposure and examination.

• Ask about soaps, wipes, pads, deodorants, depilation, incontinence and urinary leakage.
• High vaginal swab and potassium hydroxide preparation for candidiasis.
• Random blood glucose or urine glucose for diabetes.
• Biopsy for lesions that persist after 4 to 6 weeks of treatment or look white, ulcerated or thickened.

Remove the irritant, protect the skin, and use a short course of topical corticosteroid for inflammation.

• Supportive: stop all irritants; wash with water only or a soap substitute; avoid wipes, douches and scented products; use cotton underwear and avoid tight clothes; apply a thick emollient (petroleum jelly or emulsifying ointment) 2 to 3 times daily and as a barrier after urination; cool compresses for 10 minutes; manage incontinence and use barrier cream.
• Pharmacological: hydrocortisone 1 percent cream applied thinly to the vulva twice daily for 7 to 14 days; for severe cases use mometasone 0.1 percent ointment once daily for up to 14 days. For night itch give chlorphenamine 4 mg oral at night (adults; maximum 24 mg in 24 hours); children 2 to 5 years 1 mg 4 to 6-hourly (maximum 6 mg in 24 hours), 6 to 11 years 2 mg 4 to 6-hourly (maximum 12 mg in 24 hours). Treat secondary candidiasis with clotrimazole 1 percent cream twice daily for 2 weeks. Treat secondary bacterial infection with flucloxacillin 500 mg oral 6-hourly for 5 to 7 days (child 12.5 to 25 mg/kg 6-hourly, maximum 500 mg per dose).
• Procedures: none.
• Special groups: in children use hydrocortisone 1 percent only for up to 7 days; in diabetes control blood glucose to stop recurrent infection; in elderly women with incontinence use zinc oxide barrier cream and regular pad changes.
• Red flags: persistent ulcer, white plaque, bleeding lesion, no response after 4 to 6 weeks, spreading infection.
• Follow-up: review at 2 to 4 weeks; reassure that recovery follows avoidance of triggers; refer for biopsy if the lesion persists.