Sexually Transmissible Infections in Clinical Practice

11. Pruritus Vulvae

Alexander McMillan1, 2  

(1)

Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk

(2)

University of Edinburgh, Edinburgh, Uk

Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer

Email: a.amcmm@btinternet.com

Abstract

Margaret is a 25-year-old solicitor who has been married for 5 years, her husband having been her first and only sexual partner. She presents to you as her General Practitioner with a 4-day history of itch in the vulva and a little vaginal discharge. Her general health is good and she has not had similar symptoms before. Her last menstrual period had ended 8 days previously; she uses the combined oral contraceptive pill. She tells you that her husband has had mild itch and redness of his penis, these symptoms developing a few hours after most recent sexual intercourse 2 days previously.

Margaret is a 25-year-old solicitor who has been married for 5 years, her husband having been her first and only sexual partner. She presents to you as her General Practitioner with a 4-day history of itch in the vulva and a little vaginal discharge. Her general health is good and she has not had similar symptoms before. Her last menstrual period had ended 8 days previously; she uses the combined oral contraceptive pill. She tells you that her husband has had mild itch and redness of his penis, these symptoms developing a few hours after most recent sexual intercourse 2 days previously.

11.1 What is the Most Likely Diagnosis?

Pruritus vulvae is the most common symptom in women with candidiasis, and this diagnosis must be high on the list of probabilities. There are, however, other causes of acute pruritus vulvae that you may wish to consider (Table 11.1)

Table 11.1.

Some causes of pruritus vulvae other than candidiasis.

Condition

Comments

Herpes simplex virus infection

Pain is the usual feature of primary infection

Trichomoniasis

Vaginal discharge is the most common symptom

Irritant contact dermatitis

Most common irritants are soap and infected vaginal secretions. Patients should be asked about use of possible irritants

Eczema

Secondary infection with Candida spp. or less commonly by bacteria may complicate eczema

Allergic contact dermatitis

Usually occurs 1–2 days after exposure to the allergen. Indistinguishable morphologically from irritant contact dermatitis. Allergens include topical antifungal creams and preservatives

Lichen planus

 

Psoriasis

Usually lesions elsewhere, e.g., finger nail pitting, scalp lesions.

Lichen sclerosus

 

Depression and anxiety

Often exacerbate pruritus

Vulva intraepithelial neoplasia

 

As you do not have a chaperone available, you do not examine Margaret, but you consider the most likely diagnosis to be candidiasis.

11.2 What Treatment Do You Offer?

With respect to efficacy in the treatment of acute vulvovaginal candidiasis, there is little difference between the various antifungal drugs and their route of administration. In the selection of an agent, however, several factors should be taken into consideration:

·               patient choice between a topical or oral preparation;

·               pregnancy, or the possibility of pregnancy at the time of treatment;

·               in the case of topical preparations, the possibility of damage to latex condoms or contraceptive diaphragms;

·               in the case of oral antifungal drugs, the possibility of drug interactions, although the risk is small with single-dose therapy;

·               cost.

Tables 11.2 and 11.3 summarize the available agents. With the possible exception of clotrimazole preparations for which data are lacking, the topical antifungal agents may alter the latex of condoms and contraceptive diaphragms, leading to failure. It is important that the patient is aware of this possibility. Although there is no evidence for any adverse effect in pregnancy, all topical agents should be used with caution, and only when the benefits of treatment are likely to outweigh any potential risk. The patient should be fully involved in the discussions. The oral antifungal drugs should be avoided in the treatment of pregnant women with vulvovaginal candidiasis.

Table 11.2.

Topical agents for use in acute vulvovaginal candidiasis.

Antifungal agent

Formulation

Dosage

Clotrimazole

Vaginal pessary, containing 500 mg clotrimazole.

One inserted at night for one night

 

Vaginal pessary, containing 200 mg clotrimazole,

One inserted nightly for 3 nights

 

Vaginal pessary, containing 100 mg clotrimazole

One inserted nightly for 6 nights

 

Vaginal cream, containing 10% clotrimazole

5 g inserted at night for one night

Miconazole

Capsule, containing 1200 mg miconazole

One inserted vaginally for one night

 

Cream, containing miconazole 2% w/w

5 g inserted nightly for 10–14 days, OR, twice daily for 7 days

Econazole

Vaginal pessary for single-dose use, containing 150 mg econazole

One inserted at night for one night

 

Cream, containing econazole 1% w/w

5 g inserted nightly for 14 days

Nystatin

Vaginal tablet containing 100,000 units nystatin

One inserted nightly for 14 nights

Table 11.3.

Oral antifungal agents for the treatment of acute vulvovaginal candidiasis.

Drug

Dosage

Fluconazole

150 mg capsule as single dose

Itraconazole

Two 100 mg capsules twice daily for 1 day

Margaret opts for treatment with a single clotrimazole pessary.

11.3 What Conditions May Pre-dispose to Acute Vulvovaginal Candidiasis?

In the majority of women with acute vulvovaginal candidiasis, there are no obvious predisposing factors; Table 11.4, however, indicates some such factors.

Table 11.4.

Factors pre-disposing to acute vulvovaginal candidiasis.

Pregnancy

Uncontrolled diabetes mellitus

Immunosuppressive states, e.g., HIV infection

Immunosuppressive drugs, e.g., corticosteroids

Antibiotic use

 

Margaret is informed that if her symptoms do not resolve rapidly that she should re-attend the G.P.

Although the most likely diagnosis is candidiasis, failure to respond to antifungal therapy signals reconsideration of the diagnosis (but see Case 26).

The management of balanoposthitis is discussed in Case 12.