Vulval itch, pain and skin change

Gynaecology

Family practice or gynaecology clinic, at any age

The first question

Is this an infection, a skin disease, or a lesion that needs a biopsy?

01
Itch, pain or a lump
The dominant symptom sorts the causes: itch to infection and dermatoses, pain to vulvodynia and fissures, a lump or ulcer to the biopsy question.
02
Look properly
Good light, the whole vulva and perianal skin, the architecture (labia minora, clitoral hood, introitus) and any change in colour, texture or symmetry; a mirror for the patient.
03
Test what can be tested
Swabs for candida, trichomonas and bacterial vaginosis; a viral swab of an ulcer; a skin scraping; a biopsy of any thickened, ulcerated, pigmented or persistent lesion.
04
Treat by cause and stop the cycle
Emollients and avoiding soaps for everyone; a potent topical steroid for lichen sclerosus and lichen planus; antifungals only for proven candida; review the response.
05
Follow up
Lichen sclerosus needs long-term follow-up for control and for the small risk of squamous cell carcinoma; a lesion that does not respond in a few weeks is biopsied.

Where it is

Each opens the structure on the 3D pelvis.

Itch, soreness, burning or pain; provoked (touch, intercourse, tampons) or spontaneous
Discharge, its colour and smell, and the timing with the cycle
A lump, ulcer, bleeding or a change in the skin's colour
Duration and the treatments tried, including over-the-counter antifungals and steroid creams
Washing habits, soaps, wipes, pads, tight clothing, hair removal
Skin disease elsewhere: psoriasis, eczema, lichen planus in the mouth
Diabetes, immunosuppression, antibiotics, incontinence
Sexual history and contraception; menopausal status; the effect on intimacy and mood

The vulva in good light: erythema, fissures, excoriation, white plaques, atrophy, loss of the labia minora, fusion of the hood, narrowing of the introitus
The perianal skin, a figure-of-eight distribution in lichen sclerosus
Ulcers: number, base, tenderness; inguinal nodes
The vagina and cervix with a speculum when discharge is part of the picture
Cotton swab mapping of tenderness at the vestibule in vulvodynia
Skin, nails and mouth for the dermatosis that explains the vulva

High vaginal and vulval swabs for candida species, trichomonas and bacterial vaginosis
Sexually transmitted infection testing and a viral swab from an ulcer
Glucose or HbA1c in recurrent candida
Skin scraping for dermatophyte where the pattern suggests it
Vulval biopsy of any thickened, ulcerated, pigmented or treatment-resistant lesion

Diagnosis	Favours	Against	Urgency
Vulvovaginal candidiasis	Itch with a thick white discharge, fissures, erythema with satellite lesions; antibiotics, diabetes or pregnancy	Repeated negative swabs, a white atrophic plaque	routine
Lichen sclerosus	White, wrinkled or thickened skin in a figure of eight, loss of architecture, fissures, older or prepubertal patient, itch worse at night	Discharge, normal architecture, positive swabs	routine
Lichen planus	Erosive red areas at the introitus with a lacy white edge, pain more than itch, mouth involvement	No erosion, no oral disease	routine
Contact or irritant dermatitis	A new product, wipes or pads; ill-defined erythema and lichenification; improves with avoidance and emollients	Architectural change, ulceration	routine
Vulvodynia	Burning pain with a normal-looking vulva, provoked at the vestibule by a cotton swab, months of duration	Visible skin change or infection	routine
Vulval intraepithelial neoplasia or squamous cell carcinoma	A persistent plaque, ulcer, lump or pigmented area, bleeding, non-response to treatment, long-standing lichen sclerosus, smoking, HPV	A short history that resolves with treatment	urgent
Genital herpes or other ulcer	Painful grouped vesicles and erosions, dysuria, systemic symptoms in the first episode	A painless indurated ulcer, which is syphilis until proven otherwise	urgent

Pitfalls this pathway refuses

Repeated antifungal courses without a positive swab
Prescribing a weak steroid for lichen sclerosus and calling it treatment failure
Missing the biopsy in a lesion that has been 'thrush' for six months
Not looking at the whole vulva and the perianal skin in good light
Forgetting the mouth and the skin elsewhere when the vulva looks like a dermatosis