Vulvovaginal Pruritus

Vulvovaginal pruritus, or itching in the vulva and vagina, is a common symptom that affects many women and can significantly impact quality of life, interfering with sleep, relationships, and daily activities.

Table of contents

• What is vulvovaginal pruritus?
• How common is this condition?
• Symptoms and related signs
• What causes vulvovaginal pruritus?
• How is it diagnosed?
• Treatment approaches
• Prevention and self-care

What is vulvovaginal pruritus?

Vulvovaginal pruritus refers to itching and discomfort affecting the female genital area^[1]. The condition can involve the vulva (the external part of the female genitals, including the folds of skin that surround the vagina) or the vagina itself (the internal canal)^[1]. When both areas are affected, healthcare providers may refer to it as vulvovaginitis^[1].

The vulva includes several structures: the labia majora (outer folds), labia minora (inner vaginal lips), and the clitoris^[1]. This area is particularly moist and warm, making it vulnerable to irritation and infection^[1].

• Vulva
• Vagina
• Labia majora
• Labia minora
• Clitoris

How common is this condition?

Vulvovaginal pruritus is a frequent symptom that many women experience. Studies show that between 5% and 10% of women in the general population report experiencing vulvar itching or burning^[3]. In specialized vulvar clinics, itching is the most common complaint, occurring in about 70% of patients^[3].

Research from Germany indicates that 5% to 10% of the female population experiences vulvar pruritus^[3]. In the United Kingdom, general practitioners report seeing more than five patients per month with vulvar symptoms, with itching being the most frequent complaint^[3].

Anyone with a vulva can experience this condition, but it is more common in children before puberty and in women who have gone through menopause^[1]. This is because estrogen levels are lower during these life stages, leading to thinner, drier vulvar tissues that are more prone to injury and inflammation^[1].

Symptoms and related signs

The symptoms of vulvovaginal pruritus can vary depending on the underlying cause. The main symptom is itching, but other signs may include^[1][2]:

• Burning sensation
• Vaginal discharge (which may be abnormal)
• Small cracks on the skin of the vulva
• Blisters that may burst, ooze, and form crusts
• Redness and swelling, particularly on the inner labia
• Thick, whitish patches of skin that feel scaly
• Irritation
• Pain during sexual intercourse (dyspareunia)
• Pain or burning during urination

These symptoms are common enough that they may indicate various disorders affecting the genital area^[1]. Persistent or recurrent pain, irritation, burning, and itching are not normal and require medical evaluation^[2].

What causes vulvovaginal pruritus?

Vulvovaginal pruritus results from infectious or non-infectious inflammation of the skin or mucosa (moist tissue lining)^[2]. The causes vary depending on a woman’s reproductive phase or hormonal status^[2].

Infectious causes

In women of reproductive age, vaginitis (inflammation of the vagina) is a common cause^[2]. The most common types include:

• Bacterial vaginosis: An imbalance in the bacteria naturally found in the vagina^[2]
• Candidal vulvovaginitis: A yeast infection caused by overgrowth of Candida, typically Candida albicans^[7]
• Trichomonal vaginitis: A parasitic infection usually transmitted sexually^[2]

About 75% of women will have at least one episode of yeast infection, and 40% to 45% will have two or more episodes^[7]. Other infections such as genital herpes, gonorrhea, and chlamydia can also cause vaginal itching^[2].

Non-infectious causes

Non-infectious inflammation accounts for up to one-third of cases^[2]. These may result from:

• Irritants: Dyed or perfumed toilet paper, scented pads or tampons, bubble baths, vaginal sprays, douches^[1]
• Allergic reactions: Laundry detergents, fabric softeners, spermicides^[1]
• Physical irritation: Wearing wet bathing suits or sweaty workout clothes for extended periods, synthetic underwear that traps moisture, activities like cycling or horseback riding^[1]
• Skin conditions: Eczema, dermatitis, psoriasis^[1]
• Chronic dermatoses: Lichen sclerosus, lichen planus, vulvar eczema^[10]
• Foreign bodies: A forgotten tampon or vaginal pessary^[2]

Hormonal factors

In postmenopausal women, genitourinary syndrome of menopause (formerly called atrophic vaginitis) is a common cause^[2]. Low estrogen levels lead to thin vaginal epithelium (tissue lining) and changes in vaginal pH, making the area more susceptible to irritation^[2].

Additional factors

Several factors can increase the risk of developing vulvovaginal pruritus^[2]:

• Use of antibiotics (which decrease beneficial bacteria)
• Vaginal douching
• Pregnancy
• Diabetes

Vulvitis resulting from an allergy or skin irritation is not contagious, but some bacterial and viral causes are highly contagious^[1].

How is it diagnosed?

To diagnose the cause of vulvovaginal pruritus, healthcare providers conduct a thorough evaluation^[1]:

The provider will review your medical history and ask about symptoms and hygiene habits. A physical examination and complete pelvic exam are performed to look for skin changes such as redness, blisters, or lesions^[1].

Diagnostic tests may include^[1]:

• Examination of vaginal fluid under a microscope
• Urine tests
• Blood tests
• Tests for sexually transmitted infections (STIs)
• Pap smear

For yeast infections, the diagnosis is made when a wet preparation of vaginal discharge shows budding yeasts, hyphae, or pseudohyphae, or when a culture yields a positive result for a yeast species^[7]. The examination with a potassium hydroxide (KOH) preparation can improve visualization of yeast^[7].

In some cases, especially refractory cases, a biopsy may be needed to rule out invasive or preinvasive lesions such as vulvar intraepithelial neoplasia (VIN)^[10].

Treatment approaches

Treatment depends on the underlying cause of the itching^[1][2].

For infections

Bacterial vaginosis is treated with antibiotics, which may be pills to swallow or cream or gel applied in the vagina^[6].

For yeast infections, short-course topical treatments are effective. Over-the-counter options include clotrimazole, miconazole, and tioconazole creams or suppositories^[7]. Prescription options include terconazole and butoconazole^[7]. Oral treatment with fluconazole 150 mg in a single dose is also available^[7]. Treatment with azoles results in relief of symptoms and negative cultures in 80% to 90% of patients who complete therapy^[7].

Trichomoniasis is usually treated with a single-dose antibiotic, and both the patient and sexual partners should be treated^[6].

For non-infectious causes

Treatment may include^[1]:

• External medicated creams, barrier creams, and gels
• Vaginal creams, gels, tablets, and pessaries
• Oral medications

High-potency glucocorticoids (steroid creams) are commonly used along with basic moisturizing care^[10]. For chronic dermatoses such as lichen sclerosus, topical steroids are essential^[10].

General treatment principles

Successful management depends on more than just medication. Key elements include^[14]:

• Elimination of irritants
• Comfort measures and general skin therapy
• Understanding proper use of medications
• Correct application of treatments

Prevention and self-care

Several lifestyle measures can help prevent and manage vulvovaginal pruritus^[1][14]:

Clothing choices

• Wear white, all-cotton underwear
• Avoid tight clothing and synthetic fabrics
• Do not wear underwear when sleeping
• Remove wet clothing as soon as possible
• Avoid thongs and tight pantyhose

Hygiene practices

• Use unscented, gentle soaps (such as Dove for Sensitive Skin, Neutrogena, or Basis)
• Do not use soap directly on vulvar skin; use warm water instead
• Avoid bubble baths, bath salts, and scented oils
• Do not douche
• Do not use hygiene sprays, perfumes, or adult wipes
• Use white, unscented toilet paper
• Pat the area dry rather than rubbing

Laundry care

• Use hypoallergenic, fragrance-free detergent
• Rinse clothes twice
• Do not use fabric softeners or dryer sheets

Comfort measures

Baking soda soaks can help relieve itching and burning. Use 4 to 5 tablespoons of baking soda in warm (not hot) water, and soak for 10 minutes, 1 to 3 times a day^[14].

When to see a doctor

You should contact your healthcare provider if^[8]:

• You develop vaginal discomfort with a particularly unpleasant odor, discharge, or itching
• You’ve never had a vaginal infection before
• Your symptoms are not improving with self-care measures
• You have unusual vaginal discharge

It is important not to use creams you already have without discussing your symptoms with your doctor or pharmacist^[14].