Vulvovaginal symptoms are often best diagnosed by a dermatologist, an expert says.
Therefore, the dermatologist who takes on these patients is the recipient of heartfelt gratitude, says Libby Edwards, M.D., a dermatologist in private practice in Charlotte, N.C., and clinical associate professor of dermatology, University of North Carolina, Chapel Hill, N.C.
"So much of genital itching and burning is not skin disease, but the dermatologist is often the best person to deal with the symptoms," Dr. Edwards says.
"We need providers who know about vulvovaginal symptoms very badly," she says.
The most common causes of chronic itching are eczema, irritant contact dermatitis and lichen sclerosis. If a patient has been referred by a gynecologist and has been diagnosed with lichen simplex chronicus, the patient probably has eczema.
If a patient has irritant contact dermatitis, a thorough history will help the dermatologist identify the environmental triggers. A thorough examination of the genital tissues is important for a correct diagnosis, she adds.
However, further detective work may still be required.
"Irritant contact dermatitis and eczema can look alike," Dr. Edwards says. "When full-blown, both are characterized by red, poorly defined plaques."
Because the vulva is normally pink and can be puffy even when the patient is healthy, it may be difficult to tell whether the patient's tissues are inflamed.
In such cases, symptoms trump appearance, Dr. Edwards says. "If people are itching, even if they look good, treat presumptively with an ultrapotent topical corticosteroid, such as clobetasol," she says.
Regardless of cause, genital itching is generally treated similarly, with topical applications of high-potency corticosteroids, an approach that Dr. Edwards acknowledges is counter-intuitive.
For reasons that are not fully understood, the modified mucous membranes of the vulva, which are delicate and would seem too vulnerable to treat so aggressively, do not respond to low-potency steroids.
Control of nocturnal scratching is also important.
"As long as patients rub and scratch, they won't recover," Dr. Edwards says.
Therefore, she prescribes a sleep aid for patients with nocturnal scratching, typically a sedating tricyclic agent such as amitriptyline. It also allows for deeper sleep than a sedating antihistamine, such as diphenhydramine hydrochloride (Benadryl, McNeil).
Unlike eczema and irritant contact dermatitis, lichen sclerosis needs to be treated with topical corticosteroids for the rest of the patient's life.
"If the disease recurs, it can cause ongoing scarring, progress to squamous cell carcinoma, or both," Dr. Edwards says.
"Unlike squamous cell carcinoma of the skin, this cancer is very aggressive on mucous membranes," she says.
With lichen sclerosis, the patient can use either mid-potency corticosteroids daily or ultrapotent steroids three times weekly.