Vulvar dystrophies

If it itches it must be a vaginal yeast infection. Certainly yeast infections are a common cause of vulvar itching but there are a multitude of other skin conditions that can cause itching. Causes include other infections, a group of skin conditions called vulvar dystrophies, eczema (called lichen simplex), overuse of steroid creams, vulvar cancer and contact dermatitis (sensitivity to a chemical or substance that comes into contact with the affected skin).

One of the vulvar dystrophies that cause vulvar skin itching is a condition called lichen sclerosis. The typical patient I see in the office who is ultimately diagnosed with lichen sclerosis has had significant itching for months, has tried innumerable over the counter remedies without any success and has become extremely uncomfortable. When they are examined in the office they will have patchy white areas on the vulva and the skin has become thinned and crinkled. Often there are skin tears and discoloration from bleeding inside the skin. Lichen sclerosis can cause scarring that results in shrinking of the normal vulva tissues and can even narrow the opening to the vagina. Often just looking at the affected area can make a diagnosis but sometimes a biopsy is needed to confirm the diagnosis and, importantly, to rule out other causes of itching and pain.

It is unknown what causes lichen sclerosis. The most effective treatment is topical high potency steroid creams, which are only available by prescription. This will stop the itching and help the skin regain its texture however it will not remove any scarring that has already occurred. Therefore it is important for lichen sclerosis to be diagnosed and treated in an early stage before scarring has occurred. In the past testosterone preparations were used to treat lichen sclerosis but it turns out the medication is no more effective than the petrolatum jelly it was mixed with. Occasionally other vulvar skin conditions, such as infections or more commonly atrophic change associated with low estrogen levels, may coexist with lichen sclerosis and also need to be treated to achieve complete relief of symptoms.

Lichen sclerosis is not contagious and does not cause cancer. However women with untreated lichen sclerosis are at an increased risk for developing a skin cancer. Therefore it is important that the vulva be examined on a regular basis and any suspicious areas biopsied.

Vulvar cancer tends to be a disease found in elderly women but can occur at any age. There is also a precancerous stage called Vulvar Intraepithelial Neoplasia (VIN). Again a common presenting symptom is itching. White patches similar to those seen in lichen sclerosis may also be present. In vulvar cancer a mass or ulceration is often noted. Performing a biopsy of the lesion makes the diagnosis. VIN is treated with excision of the affected area or with topically applied medications. Vulvar cancer is typically treated with a combination of surgery and radiation.

Vulvar itching caused by yeast can be treated by over the counter vaginal yeast preparations. However these should only be used if a physician or other provider has made a previous diagnosis of yeast. All the preparations available have about the same efficacy and will readily treat a simple yeast infection. If the itching persists, recurs or a yeast infection has not been previously diagnosed by a physician it is important to have the vulva evaluated for other conditions. Early detection and treatment of the cause of the itching not only provides more timely relief of itching and pain but also may prevent permanent scarring.