Vulvitis: Factors of Development, Clinical Manifestations, Diagnosis, Treatment

Vulvitis is an inflammatory process of vulvar tissues, which is a manifestation of various diseases. In the process, the labia minora and labia majora, clitoris, pubis and vaginal vestibule may be affected.

Vulvitis most often affects pre-menarcheal girls and menopausal women. This is due to low estrogen levels, which can cause the vulva to become thin and dry. Thin vulvar tissue is at a higher risk of injury and infection.

It is worth noting that often the inflammatory process is not limited to the vulva and spreads to the vagina, in such a case is diagnosed as vulvovaginitis.

In addition to infectious causes, there are idiopathic forms, such as granulomatous vulvitis, which presents with chronic painless genital edema with histologic features of granulomatous inflammation.

A separate category of vulvar diseases is vulvar dermatoses:

• Scleroatrophic lichen vulvae;
• Squamous lichen vulvae;
• Simple chronic lichen planus;
• Eczema of the vulva;
• Vulvar psoriasis;
• Intraepithelial neoplasia of the vulva;
• Vulvar ulcer;
• Lipschutz’s acute vulvar ulcer.

Infectious agents of vulvitis are representatives of opportunistic microflora. In 90% of cases, vulvitis is caused by Candida albicans, in other cases E. coli, Staphylococcus epidermidis, Streptococcus group B, Enterobacterales species, etc. are found. Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis can also be pathogens.

Among viral infections, herpes simplex virus is the main etiologic agent.

Less often the cause of vulvitis is caused by pathogens of tuberculosis and diphtheria.

Conditions for infection are created as a result of damage to the vulvar tissues by various factors.

Predisposing factors for vulvitis

Factors that lead to violation of the integrity of the skin and mucosa of the external genitalia.

• Vulvovaginal atrophy;
• Urinary incontinence, which can be an independent trigger or can occur in conjunction with prolonged use of urological pads;
• Endocrine diseases and metabolic disorders (diabetes mellitus, obesity);
• Synthetic or tight underwear, which leads to trauma to the mucosa;
• Allergic reactions to colored or scented toilet paper, scented pads or tampons, soaps, vaginal sprays and shower products containing harsh ingredients, and laundry detergents and rinses;
• Prolonged use of a wet swimsuit or wet underwear, resulting in maceration of the skin;
• Injuries from activities such as bicycling or horseback riding;
• Spermicides that cause an allergic reaction;
• Vulvar abscesses with scabies or pubic lice;
• Radiation therapy.

Clinical manifestations of vulvitis

Patient complaints are nonspecific and may include:

• Itching;
• Burning;
• Hyperemia and edema;
• Cracks and Excoriation;
• Rash in the form of macules, spots, papules, plaques, nodules, vesicles, blisters, or pustules.

Skin masses may not be different in color from the norm, or they may be red, white, brown, or black.

In the case of vulvovaginitis, patients pay attention to abnormal discharge with an unpleasant odor.

Chronic inflammation in the vulvar area can lead to:

• Swelling, thickening and deformity of the external genitalia;
• In girls, to the formation of synechiae.

In such cases, patients report persistent dyspareunia and dysuria.

Differential diagnosis

Scleroatrophic lichen

In scleroatrophic lichen planus, the main areas affected are the labia majora and labia minora, the hood of the clitoris and the perianal area. As a rule, the vagina is not involved in the pathologic process. Extragenital lesions occur in 10% of patients.

On examination, pallor is visualized, often atrophic but may be hyperkeratotic in atypical variants.

Purpura (ecchymosis) is common and pathognomonic for this dermatosis. Loss of external genital architecture may result in resorption of the labia minora and/or midline. The clitoral hood may be fused to the clitoris, but the clitoris itself is unaffected. Erosions are often visualized, and lichenification and hyperkeratosis may be present, but these are atypical features that may be signs of vulvar intraepithelial neoplasia.

The changes may be localized (the hood of the clitoris is a typical site) or be in the shape of the number 8, including the perianal area.

Vulvar squamous lichen planus

Vulvar squamous lichen planus is categorized into three main types based on clinical presentation:

• Classic – keratinized anogenital skin shows typical papules with or without strictures on the inner side of the vulva. Hyperpigmentation occurs after the papules heal, especially in people with a darker skin type. It is worth noting that this type of squamous lichen planus can be completely asymptomatic.
• Hypertrophic – this type is relatively rare and difficult to diagnose. As a rule, the perineum and perianal area is involved in the pathological process in the form of thickened wart-like rashes or plaques that can ulcerate, become infected and painful, without spreading to the vagina. Such manifestations may mimic malignant neoplasms.
• Erosive is the most common type. Erosions are visualized on the mucosa of the vulva. At the edges of the erosions there is a pale purple lacy mesh (Wickham’s striae). In the absence of timely treatment, the healing of erosions leads to scarring, formation of synechiae and complete stenosis of the vagina. The masses may present as friable telangiectasias with focal erythema, which cause common symptoms of postcoital bleeding, dyspareunia and variable serous hemorrhagic discharge.

Simple chronic vulvar lichen planus

Simple chronic vulvar lichen planus is most often associated with atopic eczema or psoriasis. Chronic scratching results in lichenification, i.e. thickened, slightly flaky skin that takes on a pale or earthy hue. Clinically, the disease manifests as an erythematous inflammation with poorly defined edges. Cracks may be present. The skin appears very dry (xerosis), slightly scaly, and in chronic course may be thickened and lichenized from scabbing.

Irritant contact dermatitis

Irritant contact dermatitis is usually draining and limited to the area directly affected by the irritating product.

Allergic contact dermatitis

Unlike the irritant form, in allergic contact dermatitis, the affected skin may be blotchy and the edges are usually more indistinct and extend beyond the area of direct contact with the suspected allergen. Symptoms and signs of allergic contact dermatitis usually appear 48 to 72 hours after exposure of previously sensitized skin to the allergen. In severe allergy, the genital skin becomes extremely inflamed and swollen, sometimes also with the formation of sores, blisters and erosions.

Seborrheic eczema

Seborrheic eczema usually appears as slightly pink, shiny, poorly defined patches with a light plaque. Skin changes may affect the pubic area, inguinal folds and anal area, and vulva. Lichenification, often with excoriations, is characteristic. There may also be loss of pubic hair in the affected area.

Vulvar psoriasis

Characterized by well circumscribed, brightly erythematous plaques, usually symmetrical on the labia majora, with possible extension to the inguinal folds and perianal skin. Fissures may be observed, but desquamation is rare. Involvement of other areas of the body such as the scalp, navel and nails is also characteristic.

Squamous cell intraepithelial lesion

The clinical presentation of squamous cell intraepithelial lesions (formerly vulvar intraepithelial neoplasia) is highly variable. The lesions may be white or erythematous or pigmented plaques, often warty in appearance. Typically, multifocal lesions show resistance to treatment. They may be hyperkeratotic, erosive, or ulcerated. Typically, these lesions occur around the clitoris, the labia minora and vaginal entrance, and the inner part of the labia majora. Less frequently, they form in the perianal area and perineum.

Diagnosis of vulvitis

1. Detailed history taking and gynecologic examination;
2. Swabbing the affected area and testing with DNA technology is a highly sensitive diagnostic method. It can be used to detect:

• Candida;
• Trichomonas vaginalis;
• Chlamydia;
• Neisseria gonorrhoeae;
• as well as species of E. coli, Streptococcus spp;
• Staphylococcus spp. et al.

3. Vulvoscopy;
4. A biopsy is necessary in the following cases:

• Failure to make a diagnosis;
• Atypical course of the disease;
• Any suspicion of an intraepithelial lesion or malignant process;
• Lack of response to first-line treatment;
• Development of atypical pigmented areas.

5. Patch test – if secondary allergy or contact dermatitis is suspected.

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Treatment of vulvitis

1. Antibiotic therapy. In vulvitis, which is complicated by bacterial infection, local forms of broad-spectrum antibiotics are used. If Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae are detected, specific antibiotic therapy is carried out.
2. Antifungal agents are used to treat candidal vulvitis. Treatment with azoles results in symptomatic relief in 80%-90% of patients, use:

• Clotrimazole;
• Miconazole;
• Thioconazole;
• Butoconazole;
• Terconazole.

3. Antiviral therapy is aimed at treating herpetic infection, recommended drugs:

• Acyclovir;
• Famciclovir;
• Valacyclovir.

Treatment of vulvar dermatoses: local therapy with glucocorticosteroids is used.