What is pruritus vulvae?

Pruritus vulvae means itchy vulva. The vulva is the area of skin just outside the vagina. Most women have a slight vulval itch from time to time. However, pruritus vulvae means the itch is persistent, and causes distress. The itch may be particularly bad at night and may disturb your sleep. About 1 in 10 women sees a doctor about persistent vulval itch at some stage in her life. It can affect any woman, at any age.

What causes pruritus vulvae?

Pruritus vulvae is a symptom, not a condition in itself. Pruritus vulvae can be caused by many different conditions. Therefore, if you have a persistent vulval itch, you should see your doctor to find out the cause.

Causes of pruritus vulvae can include the following.

• Infections. For example: thrush, threadworms, scabies, and some sexually transmitted infections.
• Skin conditions may affect vulval skin. For example: eczema, psoriasis, lichen simplex, lichen planus and lichen sclerosus.
• Sensitisation of the vulval skin to soaps, perfumes, deodorants, excessive sweat, condoms, wet wipes, textile dyes, detergents, fabric conditioners, sanitary wear, etc.
• Urinary or faecal incontinence. This can make the skin of the vulva moist and irritated.
• Menopause. Because of lower oestrogen levels, the vulval skin tends to become thinner and drier after the menopause, which can make it prone to itch.
• Pregnancy can cause itch due to vulval engorgement. There is also an increased risk of vaginal discharge and thrush during pregnancy, which may cause itch.
• Breast-feeding can cause itch due to low oestrogen levels.
• Any cause of a generalised body itch may also cause itching of the vulva. For example, a generalised body itch may be a side-effect of some medicines or due to some blood disorders, thyroid problems or kidney or liver disease.
• Diabetes can cause itch in the vulval area.
• A cancer of the vulval skin is an uncommon cause.
• Unknown cause. In some cases, no cause can be found.

Do I need any investigations?

Often, your doctor will be able to find the cause of pruritus vulvae after talking to you and examining you. Examination may involve your doctor looking at the skin of your vulva and may also involve an internal (vaginal) examination. They may suggest that swabs be taken from your vulva and/or vagina if infection is suspected.

Sometimes, other tests may be suggested, including blood tests - for example, to look for diabetes, thyroid, kidney or liver problems, etc. Skin patch testing may be suggested in some cases to determine if there is something that may be sensitising and causing irritation of the vulval skin. A separate leaflet called 'Contact Dermatitis - Patch Testing' gives further details. Rarely, a biopsy of the vulval skin may be suggested. A small sample of the skin is taken and examined underneath a microscope.

What are the treatments for pruritus vulvae?

Treating the cause

Most of the time, when a cause can be found, the cause can be treated and pruritus vulvae improves. However, depending on the underlying cause, sometimes prolonged or repeated treatment may be needed. The treatment varies, depending on the cause. For example, identifying and stopping the use of anything that may be sensitising the vulval skin, antifungal cream for thrush, antibiotics for certain infections, steroid cream for various skin conditions, hormone cream or hormone replacement therapy (HRT) if the itch is related to the menopause. Your doctor will advise.

Moisturisers

Bland moisturisers (emollients) such as aqueous cream or emulsifying ointment can help to ease the itch, whatever the cause. You can use these in addition to most other treatments. Use them liberally. They can also be used as a soap substitute. Emollients such as aqueous cream can be stored in the refrigerator to keep them cool. If you are feeling particular irritation, using some cool emollient from the refrigerator on the skin may be soothing.

You can buy moisturisers at pharmacies, or get them on prescription. However - a slight word of caution. Occasionally, some people become sensitised to various ingredients that are in some moisturisers. This can make itch worse. This is unusual and bland moisturisers do help symptoms in most cases.

Try to avoid the itch-scratch cycle

The itch-scratch cycle is where scratching causes more itching - which causes more scratching - which causes more itching - etc. So, if you scratch, it may make the itch worse. Therefore, apart from any other treatment, try not to scratch if at all possible. Keep your nails cut short and don't wear nail varnish. Consider wearing cotton gloves at night to stop scratching in your sleep. (Scratching may also damage the vulval skin and increase the risk of the skin becoming infected with bacteria.)

General vulval skin care and other advice

The following may also help ease vulval itching, whatever the cause.

• Clothes:
  • Wear loose 100% cotton underwear. Avoid nylon or synthetic underwear material which tends to block fresh air, and causes you to sweat more.
  • Change your underwear daily.
  • Avoid wearing tight-fitting clothes such as cycling shorts or leggings. Skirts and dresses are probably better than trousers. Stockings are probably better than tights. The aim is to allow some air to get to the vulva, and not to allow it to become too sweaty.
  • Consider wearing no underwear - for example, when you are at home, or at night.
• Washing:
  • Wash your vulva gently, once a day. Do not scrub or wash vigorously and avoid using a sponge or flannel to wash with. Over-cleaning may make symptoms worse. Use a bland, unscented moisturiser as a soap substitute. (Using water alone may dry out the skin and make symptoms worse.)
  • Taking a shower is better than having a bath.
  • Do not put on your underwear until your vulva is fully dry. Dry the skin gently with a soft towel. A hairdryer may be useful to dry properly. Make sure it is on cool and held well away from the skin.
  • It may be best to wash your hair separately to the rest of your body, as shampoo which runs down your body in a shower may irritate your vulva.
• Other general advice:
  • Sometimes soaps, perfumes, bubble baths, deodorants, scented creams, the dye in toilet tissue, etc, can sensitise (irritate) the delicate vulval skin. Don't use any of these on your vulva or in your bath water or shower. Use plain, non-coloured toilet tissue. Use non-perfumed sanitary towels and panty liners and try to avoid using them on a regular basis. Avoid antiseptics or special vaginal washes.
  • Some people develop a skin sensitivity to a washing powder or fabric conditioner. This is uncommon, but it may be worth considering changing to a different brand of washing powder, and not using any fabric conditioner or biological washing powder for underwear.
  • Avoid condoms that are lubricated with spermicide, as they can be sensitising.
  • Do not shave pubic hair.

Help with sleep

An antihistamine medicine at bedtime may help if sleep is affected. Antihistamines do not have a great effect on the itch, but some cause drowsiness. For example, hydroxyzine. This may help you to sleep. A doctor or pharmacist can advise on which antihistamines are sedating.

What if no cause is found?

In most cases, a cause can be found for pruritus vulvae. Treatment is then aimed at the underlying cause. However, no cause can be found in some cases. The general advice given above on clothes, washing, etc, will usually help. In addition, your doctor may advise that you use a mild steroid ointment such as hydrocortisone for a week or so. This often settles the itch within a few days. It may also help to break any itch-scratch cycle that has developed. However, you should not use steroid ointment regularly on the vulva as it can have a thinning effect on the skin with long-term use.

Note: steroid ointments can make some conditions of the vulva worse. Therefore, you should see a doctor about persistent vulval itch before using any treatment.

Some women find pruritus vulvae embarrassing if it becomes a chronic (persistent) problem. It can make them feel quite down and may also interfere with their sex life. If you feel like this, do go to see your doctor. They may be able to help.

References

• Pruritus vulvae, Clinical Knowledge Summaries (February 2011)
• Management of Vulval Conditions, Clinical Effectiveness Group, British Association Sexual Health and HIV (2007)
• The Management of Vulval Skin Disorders, Royal College of Obstetricians and Gynaecologists (February 2011)