The patient

A 30-year-old woman comes to see you with vulval itching. She has previously been told it was due to thrush infection and so has treated herself with antifungals intermittently over the last year but her symptoms have remained.

What issues you should cover

  • Ask about the duration of the pruritus and whether it is inside the vagina or outside on the vulva. Is there any irritation around the anus?
  • It is important to establish whether the primary symptom is itching or pain. Often a patient will have initial pruritus but develops pain secondary to skin damage caused by scratching, or if the skin has split. Vulvodynia tends to be intense burning that affects the vulval area and is difficult to localize. Pain secondary to splitting of the skin may be more specific in location.
  • Ask whether she has noticed any change in the appearance of the vulval skin. This may be change in colour or texture or appearance of discrete lesions.
  • Ask whether she has had any bleeding or abnormal discharge.
  • Ask whether any event has precipitated the symptoms and whether there are any exacerbating or relieving factors. Enquire as to whether new washing powder has recently been used or whether she has changed her soap or perfume.
  • Ask about previous treatment. It is not unusual for multiple topical treatments to have been used without success.
  • Ask whether her symptoms are affecting intercourse and whether her partner has any symptoms. Never assume that a woman is not sexually active because of her age.
  • Ask whether she has any itching elsewhere on the body and whether she has any known skin disorders.
  • Smear history and whether the patient smokes are important details as risk factors for vulval intraepithelial neoplasia, particularly in younger women are HPV infection and smoking.

What you should do

  • Examine the patient. Examine the entire vulval region, including the perianal region and crural folds. Look for changes in pigmentation, loss of architecture, fusion of labia, discrete lesions, ecchymosis, hyperkeratosis, scratch damage, and symmetry of lesions.
  • A speculum examination should be performed and swabs taken to exclude infection. This also allows examination of the vaginal skin.
  • Examination of the buccal membranes and other areas of abnormal skin should be performed.
  • If there is no evidence of thrush, it is worth a 6-week trial of topical steroids (e.g. Dermovate) to see if the condition resolves.
  • If lichen sclerosus is suspected clinically or if symptoms persist despite a trial of topical steroids, then referral is appropriate.
  • Biopsy of abnormal areas may be indicated and any suspicious areas warrant immediate referral.

Fluconazole

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