Itchy Vulva Pruritus Vulvae

'Pruritus vulvae' simply means itching of the vulva. The vulva consists of the external female sex organs, including the labia, clitoris, Bartholin's glands and the area of skin just outside the vagina.

Most women experience a slight vulval itch now and again. 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 woman in 10 sees a doctor about a persistently itchy vulva at some stage in her life. Vulval itching can affect any woman, at any age. It can lead to scratching and rubbing which can break the skin and can lead to soreness, bleeding and skin infections.

What causes an itchy vulva?

An itchy vulva (pruritus vulvae) is a symptom, not a condition in itself. It can be caused by many different conditions. Therefore, if you have a persistently itchy vulva, you should see your doctor to find out the cause.

Causes of an itchy vulva tend to differ slightly between adults and children. However, they can include the following:

Infections

For example:

• Thrush.
• Threadworms.
• Scabies.
• Some sexually transmitted infections, such as trichomoniasis and genital warts.

Sensitivity of the vulval skin

Sensitivity of the vulval skin is the most common cause of persistent vulval itch. The vulval skin can become sensitive to anything that comes into contact with it, such as:

• Creams, including treatments for, for example, thrush.
• Soaps.
• Perfumes.
• Deodorants.
• Excessive sweat.
• Condoms.
• Wet wipes.
• Textile dyes - for example, in coloured underwear.
• Detergents.
• Fabric conditioners - may cause an itchy vulva or just irritate a vulva that is already itchy.
• Panty liners.
• Sanitary pads and tampons.

Skin conditions that may affect vulval skin

For example:

• Atopic eczema.
• Psoriasis.
• Lichen simplex.
• Lichen planus.
• Lichen sclerosus.

Urinary or faecal incontinence

• This can make the skin of the vulva moist and irritated.
• In little girls a particularly common cause is careless or inadequate washing or drying of the area, and wiping the bottom in the 'wrong' direction (towards the front).
• Scrubbing too vigorously with toilet tissue can also contribute.

Menopause

• Because of lower oestrogen levels, the vulval skin tends to become thinner and drier during and after the menopause. This can make it prone to itch.
• The low oestrogen levels can also cause vaginal dryness.
• Low oestrogen levels can start before the actual menopause, ie when you are still having periods.
• Local oestrogen can be helpful, either used as a cream, tablet or plastic ring inserted into the vagina, where it will help just these symptoms. Hormone replacement therapy (HRT) is also available as tablets or patches that will help any other symptoms of the menopause too.

Pregnancy

• This can cause an itchy vulva due to swelling of the veins in the vulva (vulval engorgement).
• There is also an increased risk of vaginal discharge and thrush during pregnancy, which may also cause itch.

Breastfeeding

Can cause an itchy vulva due to low oestrogen levels.

Generalised body itch

Any cause of generalised body itch may also cause an itchy 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 an itchy vulva, particularly if the diabetes is not well controlled and sugar levels are tending to run high.

Cancer of the vulval skin

• This is an uncommon cause.
• Usually there is a small lump or warty bit of skin as well as itch.

Stress

Stress can cause an itchy vulva. It may also make an itchy vulva which is due to some other cause last long after the original cause has settled.

Unknown causes

In some cases, including some severe cases, no cause can be found for an itchy vulva.

When should I see a doctor for an itchy vulva?

If you have an itchy vulva (pruritus vulvae) that is persisting, don't be embarrassed. Go to see your doctor or go to your nearest genitourinary medicine (GUM) clinic. If you think you have thrush and have been using cream that you have bought from a pharmacy but it isn't getting better after a week, stop using the cream and go to see a doctor.

Do I need to be examined for an itchy vulva?

Often, your doctor will be able to find the cause of your itchy vulva (pruritus vulvae) after talking to you and examining you. Examination will probably involve your doctor looking at the skin of your vulva and may also involve an internal (vaginal) examination. They may need to ask you quite personal questions about your sex life and may then suggest that sample swabs should be taken from your vulva and/or vagina to look for infection.

Sometimes, other tests may be suggested, including blood tests - for example, to look for diabetes, or 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.

Rarely, a doctor may need to examine your vulval skin in detail using a type of microscope called a vulvoscope. Taking a sample (biopsy) of the vulval skin may be suggested. This is usually done by punching a small hole in the skin of the vulva and removing a small piece of skin. Local anaesthetic cream or injection is used to numb the skin first so that it doesn't hurt. The sample of skin is then examined in a laboratory.

Itchy vulva treatment

This involves treating the cause if possible.

Treatments for itchy vulva (pruritus vulvae) vary, depending on the cause. For example:

• Identifying and stopping the use of anything that may be sensitising the vulval skin.
• Using antifungal cream for thrush.
• Using antibiotic medicines for certain infections,
• Using steroid cream for various skin conditions.
• Using hormone cream or hormone replacement therapy (HRT) if the itch is related to the menopause.

In young girls, learning to wipe gently from front to back, and to wash and rinse well and dry even when showering (when the vulva can be missed or left soapy).

What general treatments are there for an itchy vulva?

These are treatments which are likely to help with an itchy vulva whatever the cause.

Moisturisers
Bland moisturisers (emollients) such as emulsifying ointment can help to ease itching. You can use emulsifying ointment in addition to most other treatments. Use it very liberally. Emollients can also be used as a soap substitute. Some of the creamier emollients can be stored in the refrigerator to keep them cool. If you are feeling particularly itchy, applying some cool emollient from the refrigerator on to the skin may be soothing.

You can buy emollients at pharmacies, or obtain them on prescription. However, there is a slight word of caution. Occasionally, some people become sensitised to various ingredients that are in some emollients. This can make itch worse. Aqueous cream is a commonly available unbranded emollient but the ingredients can vary between manufacturers, including the addition of perfume. Because of this, it is best used simply as a soap substitute and not as a moisturiser. Sensitivity to emollients is unusual, however; bland moisturisers without added perfumes do help symptoms in most cases.

Vaginal moisturisers and lubricants can also be very helpful, especially if the itch is on the inside as well as the outside.

Try to avoid the itch-scratch cycle
The itch-scratch cycle occurs when scratching causes more itching - which causes more scratching - which causes more itching - etc. So, if you scratch, it may make the itch worse. Excessive scratching can also cause thickening of the skin - which then becomes even itchier. 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 germs (bacteria).

General vulval skin care and other advice

The following may also help ease an itchy vulva, 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, and 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 generally better than having a bath, as it's easier to wash the vulva - but take care to wash off any soap.
• Don't put on your underwear until your vulva is fully dry. Dry the skin gently by dabbing it 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.
• Try to avoid getting shampoo (which runs down your body in a shower) on to the vulva, where it may irritate.

Other general advice

• Sometimes soaps, perfumes, bubble baths, deodorants, scented creams, the dye in toilet tissue, etc can irritate (sensitise) 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. Consider avoiding plasticised 'one-way' top sheets which can cause sweating and reduce air circulation.
• 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 for underwear.
• Avoid condoms that are lubricated with spermicide, as they can be sensitising. Similarly, avoid perfumed lubricants.
• Do not shave pubic hair.

Is there anything that can help me 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 is the outlook for an itchy vulva?

Most of the time, when a cause can be found, the cause is treated and the itch improves. However, depending on what the cause is, treatment is sometimes prolonged or may need to be repeated. Your doctor will advise on the best approach depending in your particular situation.

What if no cause for my itchy vulva is found?

In most cases, a cause can be found for an itchy vulva (pruritus vulvae). Treatment is then aimed at the underlying cause. However, in some cases no cause can be found. The general advice 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, unless you have been advised to do so by your doctor, 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. Some steroid creams are available 'over the counter'; however, you should see a doctor about a persistently itchy vulva before using any treatment, particularly steroid treatments.

Some women find an itchy vulva embarrassing, particularly if it becomes a persistent (chronic) problem. It can make them feel distressed and depressed and may interfere with their sex life. If you feel like this, go to see your doctor. They will be able to help and it is more likely than not that a simple treatment will solve the problem.

Dr Mary Lowth is an author or the original author of this leaflet.