Kembara Xtra - Medicine - Pruritus Vulvae

Kembara Xtra - Medicine - Pruritus Vulvae 
​If pruritus vulvae is the major diagnosis, alternative etiologies must be ruled out if it is a symptom.
As a main diagnosis, pruritus vulvae may also be more correctly diagnosed as burning vulva syndrome or vulvodynia (see "Vulvodynia" subject).


Epidemiology 
 Symptoms can appear at any age throughout a woman's lifespan; young girls are most frequently at risk for infectious or hygiene-related causes; postmenopausal women are more likely to get the initial diagnosis.
Incidence
Although the precise incidence is unknown, the majority of women have vulvar pruritus at some point in their lives.

Pathophysiology and Etiology 
Because of changes in structure, occlusion, moisture, and friction susceptibility, vulvar tissue is more permeable than exposed skin. It is especially sensitive to irritants like perfumes, soaps, feminine hygiene items, topical medications, dyes, and bodily fluids.

Risk factors include immune suppression, obesity, and high-risk sexual behavior.

Prevention 
Keep irritants at bay.
Only cotton underwear should be used, and tight-fitting apparel should be avoided.

Accompanying Conditions 

Gardnerella vaginalis, Trichomonas, Human Papillomavirus, Herpes simplex virus, Vaginal or Vulvar Candida, and
Malignant or premalignant conditions, psoriasis, fecal or urinary incontinence, lichen sclerosus, lichen planus, lichen simplex chronicus (squamous cell hyperplasia), extramammary paget, methylxanthines (coffee, cola), tomatoes, and peanuts in the diet, autoimmune progesterone dermatitis with perimenstrual eruptions, irritant or allergic


Diagnosis 
An exclusionary diagnosis is pruritus vulvae. Common causes of diagnosis delays include patient reluctance to seek therapy or provider holdups with biopsies. Delays in diagnosis can significantly harm women's quality of life and sexual comfort.


History 
Changes in vaginal discharge Persistent itching Persistent burning feeling over the vulva or perineum Postcoital bleeding Dyspareunia


clinical assessment 
Visual examination of the anus, vulva, vagina, and perineum The labia majora's superior surfaces, which run from the mons to the anal opening, are the most affected.
- The look of vulvar skin is leathery or lichenified.
Papillomatosis could be an indication of ongoing inflammation.
Applying pressure with a cotton swab to the vestibular glands and the area of pain  A musculoskeletal evaluation to determine that it is not the cause of any lingering vulvar pain 

Laboratory Results: 10% potassium hydroxide: Candida; sodium chloride: Gardnerella or Trichomonas Herpes simplex virus is detected by viral culture or polymerase chain reaction. Human papillomavirus, lichen, malignancy, and chronic inflammation are advised for directed biopsy. Colposcopy with acetic acid or Lugol solution of the vagina and vulva is performed.

 Tests in the Future & Special Considerations
If contact dermatitis or topical products are suspected as the cause of the dermatitis, a dermatologist may provide a patch test to help determine the cause.
To rule out cancer in the postmenopausal population, exam-directed tissue samples are crucial.

Biopsies should be taken for diagnostic purposes from any ulcerations, discolorations, elevated or macerated areas, and the pruritic area that is itchiest.


Test Interpretation 
The primary diagnosis of pruritus vulvae may only be made in the absence of pathologic evidence.
 Lichen simplex chronicus (25%), lichen sclerosus (20%), or chronic inflammation (15%) are most frequently seen in biopsies of visible lesions.


Management 

Determine the disease or underlying cause in order to focus treatment.
Stop any potential annoyances.
 Get rid of any bacterial or fungal infections.
Cool the injured area by applying cool gel packs (as opposed to ice packs, which could aggravate the injury).
 Sitz baths and mild emollients to calm damaged or fissured skin

Medication 


Initial Line

Topical steroids: Hydrocortisone 1-2.5% cream used 2 to 4 times per day; Triamcinolone 0.1% cream applied twice weekly for the first two to four weeks; and avoid long-term use due to the danger of atrophy.
 Hydroxyzine, a first-generation antihistamine: Start with 10 mg before bedtime and gradually increase to 100 mg.
- Doxepin: Start by taking 10 mg before bed.
- Second-generation antihistamines don't do much good.

Next Line

SSRI, such as citalopram 20–40 mg, for situations of resistance (6)
Inhibitors of calcineurin, such as 1% pimecrolimus (5)[A]
QUESTIONS FOR REFERENCE
 Prolonged symptoms should be investigated further, and a gynecologist or gynecologic oncologist should be consulted.
Referrals to dermatology for patch testing to check for contact dermatitis and referrals to gynecologic oncology for confirmed or suspected malignancy

Additional therapies include naltrexone, laser therapy, GnRH analogues, and sacral neuromodulation devices.

Continuous Care
Cases with treatment resistance require ongoing examination, repeated cultures, and biopsies.
Referrals for refractory cases to gynecologists or gynecologic oncology may be necessary for further care.

Diet 

Avoiding the following foods on a diet includes avoiding coffee and other caffeinated beverages, tomatoes, and peanuts.


Prognosis The majority of patients' symptoms are controlled by conservative treatments and short-term topical steroids.

Malignancy as complications