Patients complain of vulvar itching and swelling. Occationally there will be tenderness, pain, burning and dysuria severe enough at times to cause urinary retention. The vulvovaginal area is inflammed, erythematous and edematous. In more severe cases there may be vesiculation and ulceration and in cases where there is a chronic contact dermatitis there may be lichenification, scaling and skin thickening.
What to do:
try to identify an offending agent and have the patient stop using it. Most reactions are caused by agents that the patient unknowingly applies or uses for hygenic or therapeutic purposes. Chemically scented douches, soaps. bubble baths, deodorants and perfumes as well as dyed or scented toilet paper, dyed underwear, scented tampons or pads and feminine hygene products are the most common causative agents. Less commonly, plant allergens such as poison oak or poison ivy may be the inadvertently-applied substances that trigger the reaction.
Rule out an alternate cause of vulvar puritis such as pinworms or trichomonas. Candida albicans may also be the cause of pruritis but it may present as an overgrowth when contact vulvovaginitis is the primary problem.
Instruct the patient in the use of cool baths and wet compresses using boric acid or Burow's solution (Domboro).
Prescribe liberal amounts of topical corticosteroids like fluocinolone (Synalar cream 0.025%) or triamcinolone (Stistocort 0.025% cream) bid to qid (dispense 15-60 grams).
In more severe cases, also prescribe oral steroids in a tapering dose-pack schedule like prednisone (Sterapred DS or Sterapred DS 12 day), methylprednisolone (Medrol Dosepack) or triamcinolone (Aristo-Pak) for six days of systemic therapy.
What not to do:
Do not have the patient use hot baths or compresses. This will usually exacerbate the burning and pruritis.
Do not prescribe antihistamines. They are relatively ineffective in treating contact vulvitis and may increase discomfort by drying the vaginal mucose.
The major problem with managing contact vulvovaginitis is identifying the primary irritant or allergen. In many cases, more than one substance is involved or potentially involved and may be totally unsuspected by the patient (such as the use of scented toilet paper). For this reason, a thorough investigative history is very important.