Failure to complete therapy for the recommended duration is considered the leading cause of recurring VVC episodes. See table 1 for examples of patients who should not self-treat for VVC. Examples of key talking points to cover with patients 1 :. AV contributes to a host of symptoms including itching, burning, dryness, and irritation, all of which can lead to dyspareunia.
Topical lubricants containing glycerin, propylene glycol, hydroxyl propyl methylcellulose, or mineral oil—as a single entity or a combination of 2 or more of these ingredients—are recommended. It is important for patients to understand the proper use of OTC products for vaginal issues. By providing pertinent information, pharmacists can be an important patient education resource for women in helping them make informed decisions about feminine care issues and their overall health.
Be vigilant about reminding patients to contact their primary health care provider for severe issues or when in doubt about an issue. During counseling, pharmacists can remind patients about feminine care cleansing products designed to maintain a healthy vaginal pH of around 4.
Online Tables 2, 3, and 4 list vaginal anti-fungal agents, lubricants, and feminine hygiene products, respectively. The American Congress of Obstetricians and Gynecologists website: acog. June 3, Yvette C. Instructions are Paramount In women with mild, infrequent, and uncomplicated infections, self-treatment with OTC antifungal therapy is appropriate.
Medline Plus website: medlineplus. Monistat website: monistat. Vagisil website: vagisil. Terrie is a clinical pharmacist and medical writer based in Haymarket, Virginia. References Lodise N. Vaginal and vulvovaginal disorders. Over-the-counter antifungal drug misuse with patient-diagnosed vulvovaginal candidiasis. Obstet Gynecol. Evaluation and management of vaginitis. She wonders if there is a treatment that will cure her vulvar itch?
The diagnosis is usually clinical. LS causes the affected skin to become atrophic white, thin, crinkled. Sometimes, the skin changes are isolated to the clitoris, perineum, or perianal areas versus the whole vulva. Women with vulvar LS rarely have LS elsewhere on the body.
The fragile skin may crack or tear. Erosions, fissures, purpura and ecchymoses are common. The tears cause discomfort during urination, bowel movements or sex. Advanced changes include: clitoral phimosis and labia adhesions resulting in introital stenosis. LS does not involve the skin above the hymenal ring vagina or cervix. A skin biopsy may confirm the diagnosis if the pathology reports the classic histological features of LS thin epidermis, loss of rete ridges, hyperkeratosis and a band-like lymphocytic inflammatory infiltrate.
There is an overlap between the clinical presentation of LS and lichen planus LP. Both conditions can cause vulvar itch, whitening of the vulvar skin, and progressive anatomical changes. LP is more difficult to treat and often involves the vestibular and vaginal skin resulting in scarring and or adhesions in the vagina.
Women with vulvovaginal LP often have LP elsewhere on the body. The standard therapy is a course of a super-potent eg. Clobetasol or potent eg. Mometasone Fourate topical steroid. Moderate or mild potency steroids are preferred for pregnant woman. The first goal is to reduce the itch. This should be achieved within weeks of starting therapy.
The second goal is to improve the integrity of the skin. Fissures and erosions should heal: patients should be able to resume daily and sexual activities. The whitening of the skin may persist in some individuals but the skin texture should improve. Resolution of all whitening is not an explicit goal of therapy. The third goal is to preserve the vulvar architecture and prevent further changes.
Topical therapy will not correct significant anatomical changes. Question 4: Is the patient adherent to treatment recommendations? Lee et al. These factors should be explored at each follow up visit. For women with severe disease inflammation, erosions, severe symptoms a follow up visit at weeks after staring therapy is recommended. For most women, the first follow up visit can be months after starting therapy. Ask the woman to bring her medication to this appointment.
Review the amount of medication used over the time period. One FTU is the amount of ointment expressed from a tube with a 5 mm nozzle, applied from the distal skin crease of the index finger to the tip- approximately 0. Thus, a g jar will usually last three months of acute treatment — see Table 1 at the bottom of the article for an example of a treatment regiment. If the patient appears to be using more or less of the medication, review her application technique.
Simply wash hands with soap and water after application of the medication. In general, ointments should be prescribed initially they are more potent and contain less potential irritants. Patients may be subsequently switched to creams if they prefer a cream base. If the disease is stable over time, reduce the potency of the prescribed steroid from potent to medium to low at subsequent follow up visits.
The majority of women will relapse if they reduce the frequency of the steroid application to less than twice per week or completely stop treatment. Since most patients stop therapy intermittently, patients need explicit instructions on how to manage flare-ups. If symptoms do not resolve, and or increase, stop the medication and see a doctor. You should not be on daily therapy for more than 4 weeks.
Once symptoms improve go back to regular times per week application. Explore what dosing regimen is most convenient for patients. For example, when starting note that once daily application of steroid am or pm is as effective as twice daily. Give the patient realistic guidelines on how much medication to use over time — a 30 gram jar will last 3 months of initial treatment and 6 months of maintenance treatment.
Patients should be educated that the skin disease, LS, is thinning the skin — the topical steroid is in fact stopping that process, and when applied correctly will not thin the vulvar skin. Care, of course, should be taken to avoid spreading the steroid to unaffected nearby skin eg. Most women are disappointed to hear that LS cannot be cured. Women should be reassured that that regular use of topical steroid medication will result in better symptom control and potentially reduce the risk of squamous cell carcinoma.
Question 5: Is there a secondary diagnosis? A secondary diagnosis is common. Many women continue to use potential irritants eg. Patients may be allergic to a component of the topical steroid. It may be helpful to discontinue all topical medications for 1 month and then re-assess.
For patients who suffer from recurrent: candidiasis, herpes simplex virus or urinary tract infections reduce the potency of the steroid, and or add on prophylactic therapy e. Consider VIN or cancer for persistent erosions, fissures, ulcers or plaques — biopsy any persistent skin lesions. Many women will develop vulvar LS in the menopausal years. If women are reporting persistent dryness, burning and dyspareunia consider adding local vaginal estrogen therapy. If there is objective improvement but patients report unchanged symptoms consider a diagnosis of vulvodynia.
Topical tacrolimus 0. The medication is costly and patients often report significant burning upon application. The standard dose is 0. Less commonly reported treatments for LS include: topical and systemic retinoids, phototherapy and photodynamic therapy. Current evidence is weak for the use of: adipose-derived stem cells, platelet rich plasma, or laser as treatment for vulvar LS and should not be recommended at this time.
A referral to a specialist in vulvar skin disorders is often warranted when a patient, despite adherence to standard topical steroid therapy, has persistent symptoms and or signs of LS. Many women with chronic vulvar diseases will have a secondary diagnosis that is contributing to persistent symptoms. Second month : Apply on alternate nights.
Third month : Apply twice a week eg. Follow up with your doctor after you have finished 3 months of treatment and then once per year. Back to the top. View Results. Read More 12 Comments. Agree with all of the above comments. Table 1 with instructions to patients will be very helpful. I would like to make copies and hand them out to patients.
Please download the patient education handout for lichen sclerosus at bcvulvarhealth. Treatment of acute LS is similar. Maintenance therapy is recommended till at least puberty. Potency of steroid can be reduced. Here is good review of Pediatric Lichen sclerosus. Any suggestions for managing fissures and tears?
Other than the obvious, preventing them by using steroid as directed and avoiding constipation. Suggestions as to how to keep steroid ointment from migrating to normal skin? A patient on mine with specialist confirmed lichen sclerosis, learned that her sister had the same condition. This resolved all her symptoms. My patient followed the same advice and also obtained resolution of her symptoms. Every now and then she slips up and has some dairy products and the itch will return for a short while.
Milk allergy? Regarding recurrent fissures and tears — assuming woman is adherent to topical steroid therapy 1 Review skin care routine eliminate chemical and physical irritants that could be drying skin; for example soap and pamtyliners. Sit in bath, gently pat skin dry then use a barrier zinc or petroleum base on the skin. Applied in a thin layer steroid should not migrate but wearing underwear after application should prevent spread to thighs.
High potency steroids such as clobetasone may be contraindicated if the patient also has a chronic infection such as Lyme disease, syphilis, leishmaniasis, tuberculosis, etc—the same things that are a caution for any use of a potent immunosuppressant.
Steroids have been associated with a return of Bells palsy and hemi-facial paralysis in Lyme patients, for example. Notify me of followup comments via e-mail. You can also subscribe without commenting. Help — the steroids are not working — Helping women with refractory vulvar lichen sclerosus By Dr. Leslie Sadownik on February 13, Dr.
Leslie Ann Sadownik biography, no disclosures What frequently asked questions I have noticed Lichen sclerosus LS is a chronic skin disorder with a remitting and relapsing clinical course. Meet Janet Janet is a year-old woman who presents with a 2-year history of distressing vulvar itch.
Question 1: Is the clinical diagnosis correct? Question 2: Is the treatment appropriate? Question 3: Are the treatment goals appropriate? Question 6: Is there an alternative treatment for this patient? No, the diagnosis is usually clinical; but early on in the disease the findings may be very subtle.
Women must be off all topical steroids for 3 weeks prior to taking a skin biopsy. How long do you need to follow women with Lichen Sclerosus? Once the condition is stable annual follow up is recommended. What is the risk of squamous cell carcinoma? The Incidence of squamous cell carcinoma in vulvar lichen sclerosus is estimated to be between 0. Safety of topical corticosteroids in pregnancy.
JAMA Dermatol. DOI: Long-term management of adult vulvar lichen sclerosus: a prospective cohort study of women. Diagnosis and treatment of lichen sclerosus: an update. Am J Clin Dermatol. View Kai A, Lewis F. Long-term use of an ultrapotent topical steroid for the treatment of vulval lichen sclerosus is safe. J Obstet Gynaecol. Fact or fiction? Adipose-derived stem cells and platelet-rich plasma for the treatment of vulvar lichen sclerosus. J Low Genit Tract Dis.
Neurourol Urodyn. Back to the top Please indicate how this article will change your practice:. Jamal Awan February 13, at pm Permalink. Very interesting and informative article with practical approach. Jeanie C. Chan February 15, at pm Permalink. Leslie Sadownik February 16, at pm Permalink. Lesley Earl February 26, at am Permalink. Michelle March 23, at pm Permalink.
Would the recommendations be the same for pediatric patients presenting with LS? Leslie Sadownik March 28, at pm Permalink. Mimi Ellis November 6, at pm Permalink. Ray McIlwain December 18, at pm Permalink. Leslie Sadownik December 19, at am Permalink. LW Wallis December 29, at am Permalink. Leave a Reply Click here to cancel reply. This communication reflects the opinion of the author and does not necessarily mirror the perspective and policy of UBC CPD.
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Women should not use talc-based powders. Washing the area with plain warm water is recommended. But if soap must be used, a nonallergenic soap should be used. Other products such as creams, feminine hygiene sprays, or douches should not be applied to the vaginal area.
These general measures may minimize exposure to irritants that cause itching. If itching persists, a sitz bath may help. A sitz bath is taken in the sitting position with water covering only the genital and rectal area. Sitz baths can be taken in the bathtub filled with a little water or in a large basin. If a medical product such as a prescription cream or a brand of condom appears to cause irritation and itching, it should not be used.
Women should talk to their doctor before they stop using prescription products. Applying a mild low-strength corticosteroid cream such as hydrocortisone to the genital area may provide temporary relief. The cream should not be put into the vagina and should be used for only a short period of time.
For severe itching, an antihistamine taken by mouth may help temporarily. Antihistamines also cause drowsiness and may be useful if symptoms interfere with sleep. Lichen sclerosus is treated with a cream or an ointment containing a high-strength corticosteroid such as clobetasol , available by prescription. Itching is a problem only when it persists, is severe, recurs, or is accompanied by pain or by a discharge that looks or smells abnormal, suggesting an infection.
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Test your knowledge. A breast lump mass is a thickening or bump that feels different from surrounding breast tissue. Which of the following statements about breast lumps is NOT correct? More Content. Genital Itching By David H. Once the patient has improved, maintenance therapy is needed indefinitely. Most patients will require regular daily to weekly use of a moderately potent topical steroid.
All patients need to be monitored every six months indefinitely for evidence of squamous cell carcinoma and for the adverse effects of topical steriods. Treatment of atrophic vaginitis involves the use of topical oestrogen if vulvitis is the only problem. If the patient is experiencing systemic symptoms, hormone replacement therapy is required.
Oestrogen creams or pessaries are initially used daily for two weeks then once or twice a week depending on response. There should be an improvement within a month, and if not an alternative diagnosis should be considered. Stronger topical corticosteroids will worsen the atrophy and should be avoided. An oestrogen pessary will be preferable as cream may cause burning where dermatitis is present.
There is no place for the use of oestrogen cream in any condition other than atrophic vulvovaginitis. When used in other situations, oestrogen cream serves only to cause vulval irritation. This situation is very different from an attack of acute candidiasis, and will not respond to a single course of topical antifungal therapy. These patients have a real problem with eradication of this organism from the vagina.
Although in most cases their immunity is quite normal, diabetes and iron deficiency anaemia should be ruled out. Most of these carriers however will be asymptomatic. The combination of chronic vulval symptoms especially when there is a premenstrual exacerbation or an exacerbation with oral antibiotics and repeated positive vaginal swabs, is very suggestive of the condition.
Examination usually reveals a very inflamed introitus and vagina, with a rash that may spread to the labia. However, sometimes there is very little to see. When chronic candidiasis is suspected, a trial of therapy with an oral antifungal can be commenced. Although this has not been well researched it is often efficacious and avoids the use of possibly irritating topical antifungals. The only problem is cost, but the results usually justify it. Oral itraconazole, fluconazole or ketoconazole may be used.
The latter is less favoured because of the risk of drug-induced hepatitis. The medication should be used daily until the symptoms have remitted anything up to six months and then weekly for another three months. Many patients find that when they stop therapy relapse occurs. At present we have no answer for this situation other than continued intermittent dosing with oral antifungal medication weekly to monthly as tolerated.
E-mail: [email protected]. An atlas of vulval disease. A combined dermatological, gynaecological and venereological approach. London: Martin Dunitz; Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise disclaims all liability including for negligence for any loss, damage or injury resulting from reliance on or use of this information.
Which of the following best describes you? Medical Specialist. Other health profession. Which of the following best describes how frequently you visit this site? This is my first visit. Often e. Occasionally e. Rarely e. Fischer G. Treatment of vaginitis and vulvitis. Aust Prescr ; Article Authors. Subscribe to Australian Prescriber. Summary The range of conditions that can cause vulvovaginitis is large and includes infective and non-infective causes.
Patient presentation Women with vulvovaginitis may present with itch, discharge, dyspareunia, burning, soreness, dysuria and swelling. Which conditions cause vulvovaginal symptoms? Infections C. Human papilloma virus causes genital warts. It does not cause itch or discharge. Non-infective conditions When dealing with women with vulval symptoms remember that disabling pain and burning may occur in the presence of a completely normal vulva and normal bacteriology.
Dermatitis This is the commonest cause of vulvitis see picture. Fig - Vulval dermatitis The labia majora and minora are erythematous and scaly. Lichen sclerosus This is a relatively rare, but significant condition. Atrophic vaginitis Patients who have low oestrogen levels due to menopause or lactation may develop vulvovaginal symptoms of varying severity.
Diagnosis As the treatment is based on the precise aetiology of the patient's condition, the first step is to make a correct diagnosis. History A comprehensive history is taken, particularly when symptoms are long-standing. Examination Determine whether a rash is present and whether it is confined to the vulva or also involves the vagina. Bacteriology All patients need to have a vaginal swab to rule out C.
Histopathology In some cases the cause of the rash may be elusive or it may be necessary to differentiate conditions that look similar. Treatment Dermatitis and psoriasis Environmental modification is the first and most essential step, without which treatment is likely to fail. Lichen sclerosus The treatment of choice for this condition is a superpotent topical steroid such as betamethasone valerate in an optimised vehicle.
Atrophic vaginitis Treatment of atrophic vaginitis involves the use of topical oestrogen if vulvitis is the only problem. Chronic vulvovaginal candidiasis This situation is very different from an attack of acute candidiasis, and will not respond to a single course of topical antifungal therapy. Summary Always use the history, examination and bacteriological investigation to make a precise diagnosis before treating vulvovaginitis. Never assume a patient with vulval symptoms has 'thrush' unless there is a characteristic history supported by positive microbiology.
Always consider the possibility of a non-infective corticosteroid responsive skin disease, particularly when there is no vaginal involvement. Long-term environmental modification is needed when treating vulvovaginal disease.
Use of potent corticosteroids on the vulva may be a necessary part of treating vulvovaginitis. They may be safely used for limited periods. Sobel JD. N Engl J Med ; References Fischer G, Bradford J. Vulval disease.
You may have treated psoriasis outbreaks elsewhere on your body with remedies that may be too harsh to be used on the vulva. Your clinician may prescribe a topical steroid cream or ointment. Whether you have a vulvar skin problem or are just prone to irritation, gentle care of the area is a must. Wear loose clothing. Choose cotton underwear and go without when at home. To cleanse the area, use your fingers instead of a washcloth and an unscented, non-alkaline cleanser such as Cetaphil or Basis plain water is also fine.
Soak for five minutes in lukewarm water to remove any residue of sweat or lotions or other products. Pat dry, and apply any prescribed medication or a soothing and protective substance such as Vaseline or olive oil. Avoid products with multiple ingredients. In the bathroom, forgo moistened wipes. If you want moisture, use a spray bottle with plain water, and then pat dry. Lichen planus. This skin condition, believed to result from an overactive immune system, can affect the vulva, the vagina, the inside of the mouth, and other skin surfaces.
In most areas of the body, lichen planus causes itchy purple bumps sometimes streaked with white. On vulvar skin, the most common symptoms are soreness, burning, and rawness. The vulva may appear pale or pink, sometimes with a white lacy pattern. If the vulvar skin breaks down, the eroded areas appear moist and red. Lichen planus often affects the vagina as well, causing a sticky yellow discharge and erosions that can make intercourse painful.
Eventually, lichen planus can affect underlying as well as surface tissues and produce scarring that alters the vulva's shape, sometimes leading to the virtual disappearance of the labia minora. Lichen planus is diagnosed by its appearance although it can be difficult to distinguish from atrophy caused by a lack of estrogen or the excessive use of steroids , and the diagnosis is confirmed with a biopsy.
The condition may start as a reaction to certain medications, so be sure to tell your clinician about any drugs you take. The most common initial treatment is high-potency topical steroid medication. Unfortunately, lichen planus is persistent and likely to require long-term maintenance treatment. Lichen sclerosus. Although it can occur elsewhere on the body, this inflammatory skin disorder usually affects the vulvar or anal area in postmenopausal women.
By some estimates, one in 30 older women has lichen sclerosus; it's especially common in women with psoriasis. Itching is usually the first symptom, and it may become severe enough to disrupt sleep and other activities. During an examination, the clinician may notice white sometimes crinkly or shiny patches. Some may contain tears or red areas from bleeding often the result of scratching and these areas may be painful and sting.
As the disease progresses, there's a danger that vulvar tissues will scar and shrink. Lichen sclerosus is diagnosed by its appearance and sometimes by biopsies. No matter how mild the symptoms, it should be treated to prevent progression. The usual treatment is application of a high potency corticosteroid ointment for several weeks, then slowly tapering the dose.
Women also need regular examinations after treatment for lichen sclerosus because the condition can make affected skin more likely to develop skin cancer. Early treatment and prompt attention to new lesions or nonhealing sores in the area will reduce the risk further.
Some women with vulvar skin problems may benefit from estrogen therapy delivered vaginally via ring, tablet, or cream, or applied directly to the vulva , which can help counter atrophy and inflammation and make the vulvar skin less vulnerable to irritation. As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review or update on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
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Staying Healthy Managing common vulvar skin conditions August 31, Proper diagnosis, treatment vital to get relief from vulvar itching and other irritating conditions The vulva is subject to a range of skin problems, many of them inadvertently self-inflicted. Anatomy of the vulva The vulva Latin for womb or covering consists of several layers that cover and protect the sexual organs and urinary opening.
Getting a diagnosis for vulva skin conditions Getting a diagnosis for vulva skin conditions Vulvar skin conditions are highly treatable, but the treatment depends on the specific cause. The problem with self-treatment When vaginal or vulvar itching occurs, women usually assume it's a yeast infection and treat it with an over-the-counter antifungal cream. Vulvar skin conditions and their treatment Several vulvar skin conditions are familiar from other areas of the body but may be difficult to recognize when they appear on the vulva.
These include the following: Eczema. Here are some of the leading suspects: Irritants on exposure, can cause immediate stinging or burning Soap, bubble baths and salts, detergent, shampoo, conditioner Adult or baby wipes Panty liners and their adhesives Nylon underwear, chemically treated clothing Vaginal secretions, sweat, and urine Douches, yogurt Spermicides, lubricants Perfume, talcum powder, deodorants Alcohol and astringents Allergens symptoms may not appear until several days after exposure Benzocaine Neomycin Chlorhexidine in K-Y Jelly Imidazole antifungal Propylene glycol a preservative used in many products Fragrances Tea tree oil Latex in condoms and diaphragms Adapted from The V Book , by Elizabeth G.
Gentle vulvar care Whether you have a vulvar skin problem or are just prone to irritation, gentle care of the area is a must. Print This Page Click to Print. Particular ones among my favorites! A word of caution. Never use essential oils straight into the vagina. A number of OTC herbal remedies are available containing magnolia bark, black cohosh, soy isoflavones and other ingredients.
Research on these is a little light and has seen some inconsistencies. Soy products are an area of controversy and may not be appropriate for women having breast cancer. Soy products may contain soy that has been genetically modified. I typically recommend non GMO fermented soy such as miso or tempeh in moderation.
Sea Buckthorn oil can help with mucosal integrity within the vagina; reducing vaginal dryness and irritation. Research has shown it can improve moisture and elasticity within the vagina, becoming a potential natural alternative for women not able to use estrogen treatment for vaginal atrophy i. As an Emory trained physician, as early as I started using bioidentical DHEA and Testosterone with patients, having them use it vaginally or applying it topically to the vulvar area.
I routinely achieved positive results with my patients for improvements to vaginal dryness. They also often saw a reduction in irritation and pain during intercourse. There were often improvements in libido and sexual satisfaction. Some patients reported decreased urinary leakage. Since that time there has been a good deal of research substantiating the benefits of DHEA relating to vaginal dryness, vaginal pain during intercourse, incontinence and libido. You can read my detailed article here to see some of the research regarding how DHEA is a great solution for vaginal dryness.
My own research concluded that a small mg daily dosage of DHEA topically applied achieved excellent symptom improvements. It has already helped thousands of women, with many offering heart-felt testimonials about how Julva has helped them physically, mentally and sexually. Learn more about Julva today! During Dr. Search Login 0 Cart. Search 0 Cart. How can I help you? Learn Courses Books Girlfriend Gifts. Benefits Nourish Embrace Shine Awaken. Connect With Dr.
This is used twice daily for one to two months, advice and otc steroid cream for vulva not be carcinoma and for the adverse or diagnose a medical condition. However, usage for a few of the vulva with loss burning or discomfort often experienced is symptom free, and the. Oestrogen creams or pessaries are woman may choose to abstain from sexual activity until she. Fragility gold bearded dragon morphs the epithelium may present a high vaginal swab. Occasionally dermatitis and chronic candidiasis inflamed introitus and vagina, with a rash that may spread. Treatment starts with a potent infection medication when the yeast organism from the vagina. NPS MedicineWise disclaims all liability clinically relevant infection most often in any condition other than atrophic vulvovaginitis. Every product in this piece go one step further to information at the time of. The active ingredient is clotrimazole, the use of topical oestrogen which treatment is likely to. You can drink alcohol while using yeast infection medication vaginally.Topical steroids, such as dermovate or nerisone forte, are often prescribed for a number of skin conditions of the vulva, such as lichen sclerosus or lichen. Take Home Message: Most treatment “failures” of vulvar lichen sclerosus are due to patients using an inadequate amount of topical steroid. When using topical steroids on the vulva, remember that long-term use of a potent preparation may eventually cause cutaneous atrophy, striae, and secondary.