Clinical Care of Vulvar Pruritus – Lichen Simplex Chronicus

Source: Vulvovaginal Dermatology – Dermatologic Clinic
Clinical Care of Vulvar Pruritus, with Emphasis on One Common Cause, Lichen Simplex Chronicus

Causes of Vulvar Pruritus

• The most common causes of vulvar pruritus are candidiasis, contact dermatitis, lichen simplex chronicus (LSC), and lichen sclerosus.
• Vulvovaginal candidiasis is the most common cause of acute-onset vulvar pruritus, and it is the most common cause of vulvar pruritus diagnosed by gynecologists.

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LICHEN SIMPLEX CHRONICUS (LSC)

The key to successfully treating LSC is concomitant, combination therapy including a potent topical corticosteroid, nighttime sedation as needed, symptomatic antipruritic treatment with topical anesthetics, appropriate treatment of secondary bacterial and fungal infections, avoidance of all irritants, and identification and treatment of underlying conditions.

Topical corticosteroids

• The modified mucous membranes are relatively corticosteroid resistant, requiring potent corticosteroids.
• Superpotent corticosteroid (e.g. clobetsol diporpionate 0.05% ointment) applied sparingly twice daily for 4 weeks
• Hair-bearing skin, medial thighs, and perianal skin easily become atrophic and at risk for steroid dermatitis. These areas should be followed very carefully. Patients should be examined monthly initially when on daily clobetasol.

Topical calcineurin inhibitors

• Topical tacrolimus ointment and pimecrolimus 1% cream approved as second-line treatments for eczema.
• Used for patients who are intolerant or resistant to topical corticosteroids, due to lack of side effects (atrophy, striae, and steroid-related dermatitis)
• Risk for squamous cell carcinoma and lymphoma.

Sedation for nighttime itching

• Hydroxyzine and diphenhydramine: sedating but producing REM sleep (when patients still rub)
• Tricyclic medications: inducing deep sleep, longer period (about 10 hours), and more effective. Also beneficial for depressed and anxious patients (for chronic itching)
• Amitriptyline and doxepin at a dose of 10 to 100 mg 2 hours before bedtime. Start low dow and warn pts with side effects dry mucosa, constipation, increased appetite)

Antipruritic with topical anesthetics

• For initial time when topical steroid pending effect
• Lidocaine (Xylocaine) jelly 2% applied as often as needed as a cooling, nonirritating, and nonallergenic anesthetic
• Avoid sensitizers (Vagisil, topical containing  benzocaine and resourcinol, and topical diphenhydramine)

Treat possible etiology

• Cutaneous candidasis (glazed texture, crural crease erythema, satellite collarettes or pustules, or skin-fold fissures): Empiric oral fluconazole, 150 mg once weekly, or nystatin ointment twice daily for 1 to 2 weeks. Imidazole creams effective against most Candida species, but cream vehicles may irritate vulvar skin
• Bacterial superinfection: Cepalexin, 500 mg twice a day for a week effective and inexpensive. When treating topical corticosteroids and oral antibiotics, add fluconazole 150 mg once a week, to prevent secondary yeast infection

Patient Education

• To wash with water only, using soft fingertips
• To avoid inadvertent rubbing that commonly accompanies the use of washcloths
• To hydrate skin by soaking in a tub of water at a comfortable temperature followed by applying bland emollient (Vaseline)
• To discontinue other treatments
• To avoid soap, bubble baths; douches; lubricants; and exacerbating factors, such as excessive washing, heat, and friction
• To cut her nails and possibly wear gloves at nighttime
• To include her partner in discussions regarding diagnosis and treatment
• To understand that LSC can be controlled but not cured
• To have written instructions listing the diagnosis, treatment instructions, reliable Internet resources
• To follow up in 4 weeks go a long way in securing a good patient-physician relationship
• To be treated for likely depressed feeling, with a trial of amitriptyline or gabapentin (neuropathy) in recalcitrant cases