Vulvar Eczema

Vulvar eczema is inflammation of vulval skin with itching, redness and scaling. It includes atopic, irritant, allergic contact and seborrhoeic types.

• Atopic eczema often affects the vulva in women with eczema, asthma or hay fever.
• Scratching worsens the rash and leads to thickened skin.
• Treatment is by trigger avoidance, emollients and a short steroid course.

Intense itching, burning and dryness of the vulva.

• Acute: red, swollen, weeping skin with vesicles. Chronic: dry, scaly, thickened, fissured skin with excoriation.
• Differential diagnosis: lichen simplex chronicus, lichen sclerosus, psoriasis, candidiasis, tinea cruris, contact dermatitis, Paget disease, vulval intraepithelial neoplasia.
• Complications: secondary infection, lichenification, sleep loss, sexual dysfunction.

Diagnosis is clinical, with exclusion of candidiasis and bacterial infection.

• Clinical diagnosis with history of atopy, exposures and skin elsewhere.
• Potassium hydroxide 10 percent preparation and swab culture to exclude candidiasis and bacterial infection.
• Random blood glucose.
• Patch testing for suspected allergic contact dermatitis.
• Biopsy for lesions lasting beyond 6 weeks of treatment.

Remove triggers, restore the skin barrier, and use a short course of topical corticosteroid.

• Supportive: avoid soaps, wipes, douches and scented products; wash with water or a soap substitute; emollient (petroleum jelly or emulsifying ointment) applied 2 to 3 times daily and after washing; cotton underwear; cool compresses; short nails.
• Pharmacological: mometasone 0.1 percent ointment thinly once daily for 7 to 14 days, then on alternate days for 1 to 2 weeks, then stop; hydrocortisone 1 percent cream twice daily for 7 days for mild disease. Night itch: chlorphenamine 4 mg oral at night (maximum 24 mg in 24 hours) or cetirizine 10 mg oral at night. Steroid-sparing: tacrolimus 0.1 percent ointment twice daily where available. Secondary candidiasis: clotrimazole 1 percent cream twice daily for 2 weeks. Secondary bacterial infection: 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; punch biopsy under local anaesthesia for atypical lesions.
• Special groups: in children use hydrocortisone 1 percent cream for up to 7 days; in pregnancy mild to moderate steroids and cetirizine are acceptable; in diabetes keep glucose controlled to limit infection.
• Red flags: eczema herpeticum (punched-out vesicles with fever), spreading infection, white plaque, ulcer, no response at 4 to 6 weeks.
• Follow-up: review at 2 to 4 weeks; reduce steroid use to the lowest effective amount; refer for patch testing if recurrent.