History

Fact Explanation
Persistent itching of the vulva [6] Patients may complain that itching is persistent may even disturb their sleep. [6]
History of vaginal discharge Vulvovaginal candidiasis [6] is a common reason for pruritus vulvae. [11]. There could be an associated curd like whitish discharge.
Abdominal discomfort, Itchiness around anus, irritability, behavioural changes and past history of threadworm infection. Threadworm infection [10] is also one of the causes which can induce vulval itching. However most patients with threadworm infestation has no symptoms.
History of genital lice, scabies or contact history with an infected person Local infestation [6] with genital lice [8], such as Phthirus pubis or Sarcoptes scabiei [7] may present as pruritus vulvae.
Rash in vulval area Vulval dermatoses [15] such as lichen sclerosus [1], [2], [5], vulval dermatitis, lichen planus [5], vulval psoriasis [3],[4] also leads to pruritus vulvae.
Ulcer or growth in vulval area. Vulval intraepithelial neoplasia and vulval carcinoma can present as pruritus vulvae. [6], [9]
History of urinary or fecal incontinence [18] Frequent wetness and irritation around vulva due to urinary/ fecal incontinence can lead to persistent itching.
Yellowish discoloration of eyes, generalized oedema, loss of weight, loss of appetite or a history of liver failure Liver failure or obstructive jaundice may induce pruritus [12], but this is usually generalized rather than localized.
Generalized oedema, malaise, reduced urine output or a history of renal failure Renal failure causes uraemia [13]. This is another systemic illness and this also leads to generalized itching. Uraemic symptoms are nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, mental status changes, visual disturbances and increased thirst.
Drug history Some drugs may induce pruritus [6],[14] as a side effect. This pruritus may be either acute in drugs such as morphine, sufentanil, fentanyl, butorphanol or chronic in drugs such as hydroxyethyl starch.
Allergy history Allergies may mimic this symptom. it can be due to systemic allergy or local allergic reaction to any externally applied[6] chemicals such as cream soaps, perfumes, deodorants or allergy to condoms or sanitary ware. [17]
Obstetric history Vulval engorgement and increased risk of vaginal discharge and thrush during pregnancy [15] cause itch in vulva. Lower oestrogen levels during breast feeding period may also cause an itch in vulva.
Menstrual history After reaching menopause [16], due to the lower oestrogen levels, vulval skin become thin and dry.
Past history of any psychiatric illness Some psychiatric illnesses like dementia, schizophrenia, primary depressive disorders, personality disorders and behavioral disorders may present with recurrent vulval pruritus.[6]
Social history Use of illicit drugs/ alcohol is important as recreational use of illicit drugs, such as opiates, amphetamines, and cocaine may induce generalized pruritus. [6]
Family history Family history of thyroid disease, haematological malignancy will be helpful in arriving at a diagnosis. [6]
References
  1. FISTAROL SK, ITIN PH. Diagnosis and treatment of lichen sclerosus: an update. Am J Clin Dermatol [online] 2013 Feb, 14(1):27-47 [viewed 24 July 2014] Available from: doi:10.1007/s40257-012-0006-4
  2. BUNKER CB, NEILL S, STAUGHTON RC. Topical tacrolimus, genital lichen sclerosus, and risk of squamous cell carcinoma. Arch Dermatol [online] 2004 Sep, 140(9):1169 [viewed 24 July 2014] Available from: doi:10.1001/archderm.140.9.1169-a
  3. ZAMIRSKA A, REICH A, BERNY-MORENO J, SALOMON J, SZEPIETOWSKI JC. Vulvar pruritus and burning sensation in women with psoriasis. Acta Derm Venereol [online] 2008, 88(2):132-5 [viewed 24 July 2014] Available from: doi:10.2340/00015555-0372
  4. BILAC C, ERMERTCAN AT, BILAC DB, DEVECI A, HORASAN GD. The relationship between symptoms and patient characteristics among psoriasis patients. Indian J Dermatol Venereol Leprol [online] 2009 Sep-Oct, 75(5):551 [viewed 24 July 2014] Available from: doi:10.4103/0378-6323.55426
  5. THORSTENSEN KA, BIRENBAUM DL. Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus. J Midwifery Womens Health [online] 2012 May-Jun, 57(3):260-75 [viewed 24 July 2014] Available from: doi:10.1111/j.1542-2011.2012.00175.x
  6. COHEN KR, FRANK J, SALBU RL, ISRAEL I. Pruritus in the Elderly: Clinical Approaches to the Improvement of Quality of Life P T [online] 2012 Apr, 37(4):227-239 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351862
  7. KARTHIKEYAN K. Crusted scabies. Indian J Dermatol Venereol Leprol [online] 2009 Jul-Aug, 75(4):340-7 [viewed 24 July 2014] Available from: doi:10.4103/0378-6323.53128
  8. ANDERSON AL, CHANEY E. Pubic lice (Pthirus pubis): history, biology and treatment vs. knowledge and beliefs of US college students. Int J Environ Res Public Health [online] 2009 Feb, 6(2):592-600 [viewed 24 July 2014] Available from: doi:10.3390/ijerph6020592
  9. HEROD JJ, SHAFI MI, ROLLASON TP, JORDAN JA, LUESLEY DM. Vulvar intraepithelial neoplasia with superficially invasive carcinoma of the vulva. Br J Obstet Gynaecol [online] 1996 May, 103(5):453-6 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8624319
  10. WHITE RH. Threadworms Br Med J [online] 1954 Jun 5, 1(4874):1322-1323 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2085201
  11. HOFFSTETTER S, BARR S, LEFEVRE C, GAVARD JA. Telephone triage: diagnosis of candidiasis based upon self-reported vulvovaginal symptoms. J Low Genit Tract Dis [online] 2012 Jul, 16(3):251-5 [viewed 24 July 2014] Available from: doi:10.1097/LGT.0b013e31823f9068
  12. BERALDO DO, MELO JF, BONFIM AV, TEIXEIRA AA, TEIXEIRA RA, DUARTE AL. Acute cholestatic hepatitis caused by amoxicillin/clavulanate. World J Gastroenterol [online] 2013 Dec 14, 19(46):8789-92 [viewed 24 July 2014] Available from: doi:10.3748/wjg.v19.i46.8789
  13. MANENTI L, TANSINDA P, VAGLIO A. Uraemic pruritus: clinical characteristics, pathophysiology and treatment. Drugs [online] 2009, 69(3):251-63 [viewed 24 July 2014] Available from: doi:10.2165/00003495-200969030-00002
  14. MALEKI K, WEISSHAAR E. [Drug-induced pruritus]. Hautarzt [online] 2014 May, 65(5):436-42 [viewed 24 July 2014] Available from: doi:10.1007/s00105-013-2700-4
  15. LAMBERT J. Pruritus in Female Patients Biomed Res Int [online] 2014:541867 [viewed 24 July 2014] Available from: doi:10.1155/2014/541867
  16. RIMOIN LP, KWATRA SG, YOSIPOVITCH G. Female-specific pruritus from childhood to postmenopause: clinical features, hormonal factors, and treatment considerations. Dermatol Ther [online] 2013 Mar-Apr, 26(2):157-67 [viewed 24 July 2014] Available from: doi:10.1111/dth.12034
  17. EASON EL, FELDMAN P. Contact dermatitis associated with the use of Always sanitary napkins. CMAJ [online] 1996 Apr 15, 154(8):1173-6 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8612252
  18. HILTON P. Urinary incontinence in women. Br Med J (Clin Res Ed) [online] 1987 Aug 15, 295(6595):426-432 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1247282

Examination

Fact Explanation
Excoriation marks Scratching due to pruritus can damage the skin. [3] Depending on the reason, the area of excoriation can differ: limited to vulva in vulval carcinoma, can extend to the anus in fecal incontinence, is generalized in liver failure.
Curd like whitish vaginal discharge In vulvovaginal candidiasis [6] there will be a curd like whitish vaginal discharge that is visible on speculum examination.
Infestation with genital lice or scabies mite Various developmental stages of pubic lice can be seen in the pubic hair [5] while scabies affects the skin. [4]
Skin dermatoses [9],[10] Lichen sclerosus, commonly affects vulvogenital and perianal areas causing white thickening of the skin. It can lead to permanent scarring [1]. Vulval dermatitis is a rash causing red, swollen, and hot skin, excessive dryness of the skin, fluid-filled/ oozing blisters leaving crusts and scales. Lichen planus is a shiny, firm, reddish purple bumps. These bumps may have tiny white lines (Wickham’s striae) running through them. Vulval psoriasis causes a raised, reddish, scaly plaque. [2]
Ulcers, growths or bleeding [3] over the vulval area [11] In vulval carcinoma, patients commonly present with pruritus vulvae (70%), a mass or an ulcer (57%) and bleeding (25%). These patients are also likely to have palpable inguinal lymph nodes.
Evidence of chronic liver failure[13] Jaundice[3], generalized oedema, ascites, Features of hepatic encephalopathy such as drowsiness, confusion. In these patients polished nails can be seen due to recurrent scratching all over the body.
Evidence of uraemia[12] Uraemic features like recurrent vomiting, mental status changes and generalized oedema, wasting, anaemia can be identified during physical examination.
Evidence of thyroid disease [3] Look for a thyroid goitre. According to several studies generalized pruritus can be associated with[3], thyroiditis( in the presence of antithyroid antibodies), hyperthyroidism( with warm, sweaty skin) and hypothyroidism( due to xerosis).
Evidence of haematological malignancy [3] Anemia, bleeding manifestations, lymphadenopathy may give a clue towards the diagnosis of a hematological malignancy. Haematological malignancies such as Hodgkin’s disease is often preceded by an intense, burning itch. [16] Polycythemia vera[15] in majority of cases pruritus was triggered by water. In leukemia[17] pruritus can be the presentation of the disease.
Mental state examination This will help to identify any associated psychiatric illness[3].
Evidence of complications During the examination evidence of secondary bacterial infection[14] such as tender,red, swollen skin with pus formation or bleeding are helpful in identifying secondary bacterial infection.
Temperature measurement This is also helpful especially in the presence of secondary bacterial infection[3].
References
  1. BUNKER CB, NEILL S, STAUGHTON RC. Topical tacrolimus, genital lichen sclerosus, and risk of squamous cell carcinoma. Arch Dermatol [online] 2004 Sep, 140(9):1169 [viewed 24 July 2014] Available from: doi:10.1001/archderm.140.9.1169-a
  2. PARDASANI AG, FELDMAN SR, CLARK AR. Treatment of psoriasis: an algorithm-based approach for primary care physicians. Am Fam Physician [online] 2000 Feb 1, 61(3):725-33, 736 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10695585
  3. COHEN KR, FRANK J, SALBU RL, ISRAEL I. Pruritus in the Elderly: Clinical Approaches to the Improvement of Quality of Life P T [online] 2012 Apr, 37(4):227-239 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351862
  4. KARTHIKEYAN K. Crusted scabies. Indian J Dermatol Venereol Leprol [online] 2009 Jul-Aug, 75(4):340-7 [viewed 24 July 2014] Available from: doi:10.4103/0378-6323.53128
  5. ANDERSON AL, CHANEY E. Pubic lice (Pthirus pubis): history, biology and treatment vs. knowledge and beliefs of US college students. Int J Environ Res Public Health [online] 2009 Feb, 6(2):592-600 [viewed 24 July 2014] Available from: doi:10.3390/ijerph6020592
  6. HOFFSTETTER S, BARR S, LEFEVRE C, GAVARD JA. Telephone triage: diagnosis of candidiasis based upon self-reported vulvovaginal symptoms. J Low Genit Tract Dis [online] 2012 Jul, 16(3):251-5 [viewed 24 July 2014] Available from: doi:10.1097/LGT.0b013e31823f9068
  7. KARTHIKEYAN K. Crusted scabies. Indian J Dermatol Venereol Leprol [online] 2009 Jul-Aug, 75(4):340-7 [viewed 24 July 2014] Available from: doi:10.4103/0378-6323.53128
  8. ANDERSON AL, CHANEY E. Pubic lice (Pthirus pubis): history, biology and treatment vs. knowledge and beliefs of US college students. Int J Environ Res Public Health [online] 2009 Feb, 6(2):592-600 [viewed 24 July 2014] Available from: doi:10.3390/ijerph6020592
  9. THORSTENSEN KA, BIRENBAUM DL. Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus. J Midwifery Womens Health [online] 2012 May-Jun, 57(3):260-75 [viewed 24 July 2014] Available from: doi:10.1111/j.1542-2011.2012.00175.x
  10. BILAC C, ERMERTCAN AT, BILAC DB, DEVECI A, HORASAN GD. The relationship between symptoms and patient characteristics among psoriasis patients. Indian J Dermatol Venereol Leprol [online] 2009 Sep-Oct, 75(5):551 [viewed 24 July 2014] Available from: doi:10.4103/0378-6323.55426
  11. HEROD JJ, SHAFI MI, ROLLASON TP, JORDAN JA, LUESLEY DM. Vulvar intraepithelial neoplasia with superficially invasive carcinoma of the vulva. Br J Obstet Gynaecol [online] 1996 May, 103(5):453-6 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8624319
  12. MANENTI L, TANSINDA P, VAGLIO A. Uraemic pruritus: clinical characteristics, pathophysiology and treatment. Drugs [online] 2009, 69(3):251-63 [viewed 24 July 2014] Available from: doi:10.2165/00003495-200969030-00002
  13. HEATHCOTE EJ. Diagnosis and management of cholestatic liver disease. Clin Gastroenterol Hepatol [online] 2007 Jul, 5(7):776-82 [viewed 24 July 2014] Available from: doi:10.1016/j.cgh.2007.05.008
  14. CAREY E, ZEDEK D, LEWIS J, ZOLNOUN D. Superimposed methicillin-resistant Staphylococcus aureus infection of vulvar eczematous dermatitis: a case report. J Reprod Med [online] 2013 May-Jun, 58(5-6):261-3 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23763013
  15. SAINI KS, PATNAIK MM, TEFFERI A. Polycythemia vera-associated pruritus and its management. Eur J Clin Invest [online] 2010 Sep, 40(9):828-34 [viewed 25 July 2014] Available from: doi:10.1111/j.1365-2362.2010.02334.x
  16. BARTUS CL, PARKER SR. Hodgkin lymphoma presenting as generalized pruritus in an adolescent. Cutis [online] 2011 Apr, 87(4):169-72 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21644488
  17. MALLO S, COTO P, CAMINAL L, RAYóN C, BALBíN M, SáNCHEZ-DEL RíO J, SANTOS-JUANES J. Generalized pruritus as presentation of T-cell large granular lymphocyte leukaemia. Clin Exp Dermatol [online] 2008 May, 33(3):348-9 [viewed 25 July 2014] Available from: doi:10.1111/j.1365-2230.2007.02651.x

Differential Diagnoses

Fact Explanation
Valvovaginal candidiasis[3][7] This is associated with immunodeficiency conditions (diabetes mellitus, following immunosuppression treatments, in long term use of antibiotics), in old age, during pregnancy and with poor hygienic conditions,
Local infestations with genital lice/ Scabies Local infestation with genital lice( Phthiru pubis)[2] / scabies[4]( Sarcoptes scabiei) may present as pruritus vulvae.
Vulval dermatosis[1][7] Vulval dermatoses such as lichen sclerosus, vulval dermatitis, lichen planus, vulval psoriasis also leads to pruritus vulvae[5].
Vulval intraepithelial neoplasia or vulval carcinoma[6][7] 70% of patients with vulval carcinoma present with pruritus vulvae.
Urinary[8] or fecal incontinence Frequent wetness and irritation around vulva due to urinary/ fecal incontinence also lead to this.
Drug induced reaction[7] Pruritus can be associated with several groups of drugs.
Allergic reaction[7] Allergens can be of various kinds such as cream, soaps, perfumes, deodorants, condoms and sanitary wear[9].
Systemic illness[7] Mainly cholestatic liver disease and renal failure with uraemic features cam cause pruritus. Other than that many other medical disorders such as thyroid disease, haematological malignancies can manifest as this.All causes leads to generalized pruritus.
References
  1. THORSTENSEN KA, BIRENBAUM DL. Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus. J Midwifery Womens Health [online] 2012 May-Jun, 57(3):260-75 [viewed 24 July 2014] Available from: doi:10.1111/j.1542-2011.2012.00175.x
  2. ANDERSON AL, CHANEY E. Pubic lice (Pthirus pubis): history, biology and treatment vs. knowledge and beliefs of US college students. Int J Environ Res Public Health [online] 2009 Feb, 6(2):592-600 [viewed 24 July 2014] Available from: doi:10.3390/ijerph6020592
  3. HOFFSTETTER S, BARR S, LEFEVRE C, GAVARD JA. Telephone triage: diagnosis of candidiasis based upon self-reported vulvovaginal symptoms. J Low Genit Tract Dis [online] 2012 Jul, 16(3):251-5 [viewed 24 July 2014] Available from: doi:10.1097/LGT.0b013e31823f9068
  4. KARTHIKEYAN K. Crusted scabies. Indian J Dermatol Venereol Leprol [online] 2009 Jul-Aug, 75(4):340-7 [viewed 24 July 2014] Available from: doi:10.4103/0378-6323.53128
  5. BILAC C, ERMERTCAN AT, BILAC DB, DEVECI A, HORASAN GD. The relationship between symptoms and patient characteristics among psoriasis patients. Indian J Dermatol Venereol Leprol [online] 2009 Sep-Oct, 75(5):551 [viewed 24 July 2014] Available from: doi:10.4103/0378-6323.55426
  6. HEROD JJ, SHAFI MI, ROLLASON TP, JORDAN JA, LUESLEY DM. Vulvar intraepithelial neoplasia with superficially invasive carcinoma of the vulva. Br J Obstet Gynaecol [online] 1996 May, 103(5):453-6 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8624319
  7. COHEN KR, FRANK J, SALBU RL, ISRAEL I. Pruritus in the Elderly: Clinical Approaches to the Improvement of Quality of Life P T [online] 2012 Apr, 37(4):227-239 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351862
  8. HILTON P. Urinary incontinence in women. Br Med J (Clin Res Ed) [online] 1987 Aug 15, 295(6595):426-432 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1247282
  9. EASON EL, FELDMAN P. Contact dermatitis associated with the use of Always sanitary napkins. CMAJ [online] 1996 Apr 15, 154(8):1173-6 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8612252

Investigations - for Diagnosis

Fact Explanation
vaginal pH test Microscopy examination- low vaginal swab[3][5] Fungal culturing The most common species causing Vulvovaginal candidiasis is C.albicans[1]. Demonstration of a species of Candida with a wet-mount test/potassium hydroxide (KOH) preparation in a clinically suspected patient will helpful to confirm the diagnosis. Vaginal pH usually normal in vulvovaginal candidiasis. Fungal cultures is not use in initial stage but useful in asymptomatic patients but at risk of colonizing.
Biopsy from lesion Histological examination will help in differentiating vulval dermatitis[2] and help to diagnose vulval carcinoma. Biopsy appearance in Vulval Intraepithelial Neoplasia(VIN)[8]: VIN 1-loss of differentiation in lower 1/3 of the epidermis VIN 2- loss of differentiation in lower 2/3 of the epidermis VIN 3- loss of differentiation in the entire epidermis, but the basement membrane is intact.
AST, ALT, Serum protein, Direct/ indirect billirubin levels These tests are useful for medical management if the primary cause is liver failure[6].
Serum creatinine, Serum electrolytes, Blood urea These tests are useful for medical management if the primary cause is kidney failure[6].
Urodynamic studies and voiding diaries This helpful in identifying associated urinary incontinence[4]
TSH, free T4 [7] These tests are useful for medical management if the primary cause is thyroid disease[6].
Full Blood Count, Bone marrow biopsy These tests useful in a haematological malignancy[6].
References
  1. SHAN Y, FAN S, LIU X, LI J. Prevalence of Candida albicans-closely related yeasts, Candida africana and Candida dubliniensis, in vulvovaginal candidiasis. Med Mycol [online] 2014 Aug 1, 52(6):636-40 [viewed 24 July 2014] Available from: doi:10.1093/mmy/myu003
  2. OZALP SS, TELLI E, YALCIN OT, OGE T, KARAKAS N. Vulval pruritus: The experience of gynaecologists revealed by biopsy. J Obstet Gynaecol [online] 2014 Jul 10:1-4 [viewed 24 July 2014] Available from: doi:10.3109/01443615.2014.935711
  3. WELSH B, HOWARD A, COOK K. Vulval itch. Aust Fam Physician [online] 2004 Jul, 33(7):505-10 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15301167
  4. HADIJI N, PREVINAIRE JG, BENBOUZID R, ROBAIN G, LEBLOND C, MIEUSSET R, ENJALBERT M, SOLER JM. Are oxybutynin and trospium efficacious in the treatment of detrusor overactivity in spinal cord injury patients? Spinal Cord [online] 2014 Jul 22 [viewed 24 July 2014] Available from: doi:10.1038/sc.2014.113
  5. WELSH B, HOWARD A, COOK K. Vulval itch. Aust Fam Physician [online] 2004 Jul, 33(7):505-10 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15301167
  6. COHEN KR, FRANK J, SALBU RL, ISRAEL I. Pruritus in the Elderly: Clinical Approaches to the Improvement of Quality of Life P T [online] 2012 Apr, 37(4):227-239 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351862
  7. SURKS MI, ORTIZ E, DANIELS GH, SAWIN CT, COL NF, COBIN RH, FRANKLYN JA, HERSHMAN JM, BURMAN KD, DENKE MA, GORMAN C, COOPER RS, WEISSMAN NJ. Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. JAMA [online] 2004 Jan 14, 291(2):228-38 [viewed 24 July 2014] Available from: doi:10.1001/jama.291.2.228
  8. KAUFMAN RH. Intraepithelial neoplasia of the vulva. Gynecol Oncol [online] 1995 Jan, 56(1):8-21 [viewed 25 July 2014] Available from: doi:10.1006/gyno.1995.1003

Investigations - Fitness for Management

Fact Explanation
Low vaginal/ vulval Swab for culture and Anti biotic sensitivity test If there is any evidence of secondary bacterial[2] infection this test will be useful in further treatment.
Full blood count High neutrophil count- bacterial infection[1] Increased eosinophil count-an allergic reaction/ presence of a parasitic infection[1] High lymphocyte count- viral infection[1] Abnormal WBC counts-a neoplastic process[1] Low haemoglobin level- Chronic renal failure
Erythrocyte sedimentation rate (ESR) This is a nonspecific investigation but increased in infectious diseases and may be extremely high in neoplastic disease[1]
References
  1. COHEN KR, FRANK J, SALBU RL, ISRAEL I. Pruritus in the Elderly: Clinical Approaches to the Improvement of Quality of Life P T [online] 2012 Apr, 37(4):227-239 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351862
  2. CAREY E, ZEDEK D, LEWIS J, ZOLNOUN D. Superimposed methicillin-resistant Staphylococcus aureus infection of vulvar eczematous dermatitis: a case report. J Reprod Med [online] 2013 May-Jun, 58(5-6):261-3 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23763013

Investigations - Followup

Fact Explanation
Low vaginal/ vulval swab for culture and ABST secondary infection screening[1]
Urine full report (UFR), Urine culture and ABST Scratching of the vulvae damage to local skin and may lead to dysuria. these tests can be used to exclude any urinary tract infection[2] in this condition.
Full blood count (FBC)[3] Can get an idea about patient's improvement.
References
  1. CAREY E, ZEDEK D, LEWIS J, ZOLNOUN D. Superimposed methicillin-resistant Staphylococcus aureus infection of vulvar eczematous dermatitis: a case report. J Reprod Med [online] 2013 May-Jun, 58(5-6):261-3 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23763013
  2. SCHMIEMANN G, KNIEHL E, GEBHARDT K, MATEJCZYK MM, HUMMERS-PRADIER E. The Diagnosis of Urinary Tract Infection: A Systematic Review Dtsch Arztebl Int [online] 2010 May, 107(21):361-367 [viewed 24 July 2014] Available from: doi:10.3238/arztebl.2010.0361
  3. COHEN KR, FRANK J, SALBU RL, ISRAEL I. Pruritus in the Elderly: Clinical Approaches to the Improvement of Quality of Life P T [online] 2012 Apr, 37(4):227-239 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351862

Investigations - Screening/Staging

Fact Explanation
Fungal culturing Fungal cultures is not use in initial stage but useful in asymptomatic patients who are at risk of colonizing. When a primary cause can not be found, this will be helpful to exclude any fungal infection[1].
Biopsy from lesion[2] If the primary cause is vulval carcinoma, this will be helpful in staging.
References
  1. SHAN Y, FAN S, LIU X, LI J. Prevalence of Candida albicans-closely related yeasts, Candida africana and Candida dubliniensis, in vulvovaginal candidiasis. Med Mycol [online] 2014 Aug 1, 52(6):636-40 [viewed 24 July 2014] Available from: doi:10.1093/mmy/myu003
  2. OZALP SS, TELLI E, YALCIN OT, OGE T, KARAKAS N. Vulval pruritus: The experience of gynaecologists revealed by biopsy. J Obstet Gynaecol [online] 2014 Jul 10:1-4 [viewed 24 July 2014] Available from: doi:10.3109/01443615.2014.935711

Management - General Measures

Fact Explanation
Stopping/ reducing the itchiness using moisturisers[1] Emollients such as aqueous cream, emulsifying ointment will help to get rid of itchiness for a certain extend despite of the cause.
Prevent further damaging to skin by avoiding the itch-scratch cycle[1] Scratching causes itching and it causes more scratching which again causes more itching. This goes as a cycle because excessive scratching cause thickening of the skin and then it becomes even itchier. Better thing is describe the patient about this cycles and advice try not to scratch if at all possible. It is important to keep nails cut short to minimize the damage causing to skin during scratching.
Modifications in under wears - Important to use cotton under wears which quickly absorb wetness around genital areas and avoid nylon/ synthetic underwear material which tends to block fresh air, and causes more sweating. - Wear loose, light color under wears which reduce heat and sweating[1]. - Change underwear daily. - Wash and dry under wears in sunlight which helps to reduce fungal infections - Consider wearing no underwear when possible(at home, at night)
Maintain vulval hygiene - Wash vulva gently as scrub/wash vigorously can further damage the skin. - Repeated cleaning of the area with soap may cause dryness, so wash with water, dry the area properly with a soft towel and apply some moisturiser. -Avoid hot water baths[1] - Prevent shaving the pubic hair, but cutting them in to short will help.
Help with sleep[1] Pruritic vulva often worse at night and will disturb the sleep. sedative antihistamine will be helpful in this condition( eg; Chlorphenamine)
References
  1. COHEN KR, FRANK J, SALBU RL, ISRAEL I. Pruritus in the Elderly: Clinical Approaches to the Improvement of Quality of Life P T [online] 2012 Apr, 37(4):227-239 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351862

Management - Specific Treatments

Fact Explanation
Anti fungal cream[5] If the primary reason is due to a fungal infection, local application of anti fungal cream and anti fungal vagina pessary is the specific treatment option.
Anthelmintic treatment If the primary reason is due to a worm infestation this is the treatment of choice (eg: Mebendazole - in threadworm infestation)
Parasiticidal treatment Scabies- Permethrin[7] is an effective parasiticide. Application of crotamine can be used to control itchiness after treatment. Topical corticosteroids will also reduce itch and inflammation after successful treatment. Genital lice- Permethrin and malathion will use to eliminate[8]. Here second treatment is needed after 7 days to kill lice come out of the surviving eggs.
Valval dermatitis lichen sclerosus- Strong topical steroid creams/ ointments (eg; clobetasol propionate) should be applied as a thin layer for a few weeks or months[3] . vulval dermatitis- If there is any identifiablr irritant is present, remove the irritant to avoid future contact. Application of topical steroid creams/ ointments is the medical treatment. Lichen planus- Antihistamines Pills will be helpful for itchiness. Topical corticosteroid cream/ointment, corticosteroid pills (eg; prednisone), PUVA therapy, retinoic acid use to treat this condition. vulval psoriasis- Tar creams, calcipotriol (Vitamin D), salacylic acid should apply in the morning and cortisone should be applied at night[4] .
Chronic liver failure, thyroid disease, haematological malignancy Symptomatic management of pruritus will be useful and specific managment of the medical condition should be consider[6].
Renal failure with uraemia Haemodialysis[6] will helpful in uraemia.
Vulval carcinoma Surgery is the main way of treatment[9] both in curative and palliative intentions. Surgery will depend on the stage at presentation[1] . Radiotherapy[2] and chemotherapy also play a role in reducing morbidity.
Idiopathic vulval itching After excluding other causes this condition should be consider. General vulval skin care, Topical local anaesthetic gel, amitriptyline ( start with low dose at night and increase as required, then gradually reduce dose over 3 months) and antiepileptics like gabapentin( rarely use with specialist referral for chronic pain) can be used.
Psychotherapy Aromatherapy, autogenic training, brief dynamic psychotherapy, cognitive–behavioral therapy, habit-reversal behavioral therapy, stress management and structured education are identified as effective in this condition[6].
Urinary incontinence Pelvic floor exercises[11] and anticholinergic drug[10] (eg; oxybutynin) are helpful.
References
  1. HERR D, JUHASZ-BOESS I, SOLOMAYER EF. Therapy for Primary Vulvar Carcinoma Geburtshilfe Frauenheilkd [online] 2014 Mar, 74(3):271-275 [viewed 24 July 2014] Available from: doi:10.1055/s-0033-1360145
  2. DE HULLU JA, VAN DER ZEE AG. Surgery and radiotherapy in vulvar cancer. Crit Rev Oncol Hematol [online] 2006 Oct, 60(1):38-58 [viewed 24 July 2014] Available from: doi:10.1016/j.critrevonc.2006.02.008
  3. FISTAROL SK, ITIN PH. Diagnosis and treatment of lichen sclerosus: an update. Am J Clin Dermatol [online] 2013 Feb, 14(1):27-47 [viewed 24 July 2014] Available from: doi:10.1007/s40257-012-0006-4
  4. PARDASANI AG, FELDMAN SR, CLARK AR. Treatment of psoriasis: an algorithm-based approach for primary care physicians. Am Fam Physician [online] 2000 Feb 1, 61(3):725-33, 736 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10695585
  5. YOUNG GL, JEWELL D. Topical treatment for vaginal candidiasis (thrush) in pregnancy. Cochrane Database Syst Rev [online] 2001:CD000225 [viewed 24 July 2014] Available from: doi:10.1002/14651858.CD000225
  6. COHEN KR, FRANK J, SALBU RL, ISRAEL I. Pruritus in the Elderly: Clinical Approaches to the Improvement of Quality of Life P T [online] 2012 Apr, 37(4):227-239 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351862
  7. KARTHIKEYAN K. Crusted scabies. Indian J Dermatol Venereol Leprol [online] 2009 Jul-Aug, 75(4):340-7 [viewed 24 July 2014] Available from: doi:10.4103/0378-6323.53128
  8. ANDERSON AL, CHANEY E. Pubic lice (Pthirus pubis): history, biology and treatment vs. knowledge and beliefs of US college students. Int J Environ Res Public Health [online] 2009 Feb, 6(2):592-600 [viewed 24 July 2014] Available from: doi:10.3390/ijerph6020592
  9. HEROD JJ, SHAFI MI, ROLLASON TP, JORDAN JA, LUESLEY DM. Vulvar intraepithelial neoplasia with superficially invasive carcinoma of the vulva. Br J Obstet Gynaecol [online] 1996 May, 103(5):453-6 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8624319
  10. MADHUVRATA P, SINGH M, HASAFA Z, ABDEL-FATTAH M. Anticholinergic drugs for adult neurogenic detrusor overactivity: a systematic review and meta-analysis. Eur Urol [online] 2012 Nov, 62(5):816-30 [viewed 24 July 2014] Available from: doi:10.1016/j.eururo.2012.02.036
  11. TIBAEK S, GARD G, JENSEN R. Pelvic floor muscle training is effective in women with urinary incontinence after stroke: a randomised, controlled and blinded study. Neurourol Urodyn [online] 2005, 24(4):348-57 [viewed 24 July 2014] Available from: doi:10.1002/nau.20134