Itchy vulva

What is 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. Pruritus vulvae is also often associated with vaginal itchiness.

Most women experience a slightly itchy vulva from time to time. However, pruritus vulvae means the itch is persistent and causes distress. The itch may be particularly bad at night and may disturb 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. It can also affect a woman's sex life, making sex uncomfortable.

What causes an itchy vulva?

An itchy vulva (pruritus vulvae) can be caused by many different conditions.

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

Infections

• Thrush. This is a common cause of vulval and vaginal itching in women from the age of puberty to the menopause. It is very uncommon in younger girls and also less common in older women. It is often caused by antibiotic use. It can be associated with a thick white discharge, typically described as appearing like cottage cheese.

• Threadworms. This very commonly causes itchiness of the vulva and vagina, particularly at night. It can also cause a sensation of needing to pass urine. This is very common in children but also occurs in adults.

• Scabies. This tends to cause widespread itchiness over much of the body but can also cause itching of the vulva and vagina.

• 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.

• Bath products such as bubble baths.

Skin conditions that may affect vulval skin

• 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 young 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 very itchy.

• The low oestrogen levels can also cause vaginal dryness.

• These symptoms are now known as "genitourinary syndrome of the menopause" and can be very distressing.

• Low oestrogen levels can start during the perimenopause whilst women are still having periods.

• Local oestrogen can be helpful, either used as a cream, pessary 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 many 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

Women who are breastfeeding have lower oestrogen levels than normal (similar levels to women in the peri-menopause and menopause) and this can cause an itchy vulva and vaginal itching. Local oestrogen can be prescribed if needed (as described above). The oestrogen levels return to normal by about 6 months or sooner if breastfeeding is stopped earlier than this. Symptoms resolve once the oestrogen levels have returned to normal.

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. Some people describe a generalised body itch for which no cause can be found.

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 lump or growth that can be seen alongside the symptoms of itchiness.

Stress

Stress can cause an itchy vulva. An itchy vulva or vaginal itching which is due to another cause can also persist longer (even when the other cause has been treated) due to stress.

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?

Medical advice should be sought for an itchy vulva or vaginal itching that is persisting and not settling.

Thrush is easily treated with medication bought over the counter (tablets, pessaries or cream) but, if the symptoms are not settling within a week, medical advice should be sought.

Do I need to be examined for an itchy vulva?

Usually an examination will be needed after a description of the symptoms. Examination will probably involve a medical professional looking at the skin of the vulva and may also involve an internal (vaginal) examination.

They may need to ask you quite personal questions about sexual practices and will usually suggest that sample swabs should be taken from the vulva and/or vagina to look for infection.

Sometimes symptoms will suggest a particular condition which can be treated without an examination, with advice to come back if the symptoms do not resolve. This is typical of threadworms and can also be the case with thrush.

Pre-pubertal girls will often not need to be examined and will never need an internal examination. If they do need to be examined the healthcare professional will usually just look at the area and not need to touch it. Vulvovaginitis is a very common cause of an itchy vulva or vaginal itching in young girls and the vulval skin can look red and sore. The advice will usually be to avoid any products (including soap or bubble bath) and to avoid washing hair in the bath so that the vulva does not come into contact with shampoo in the water. It is best to avoid using wet wipes and to use toilet paper gently but ensuring that the area is dry and clean.

Other tests

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

Referral to a dermatologist or gynaecologist with a special interest in dermatology may be suggested in order to arrange skin patch testing to determine if there is something that may be sensitising and causing irritation of the vulval skin.

Rarely, a doctor may need to examine the vulval skin in detail using a type of microscope called a vulvoscope. Taking a sample (biopsy) of the vulval skin may be suggested. This would usually be done by a gynaecologist.

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.

What treatments are there for an itchy vulva?

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

• Identifying and stopping the use of anything that may be sensitising the vulval skin.

• Using antifungal medications for thrush.

• Using antibiotic medicines for sexually transmitted infections.

• Using steroid cream for various skin conditions.

• Using hormone cream or hormone replacement therapy (HRT) if the itch is related to the menopause.

Young girls should be encouraged 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).

Moisturisers

• Bland moisturisers such as emulsifying ointment can help to ease itching.

• Moisturisers can be used in addition to most other treatments.

• Moisturisers should be used very liberally. Emollients can also be used as a soap substitute.

• Applying some cool emollient from the refrigerator on to the skin may be soothing if the area is particularly itchy.

• Emollients can be bought over the counter from pharmacies. They are available on prescription but there may be limitations as to which brand is prescribable.

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

Occasionally, some people become sensitised to various ingredients that are in some emollients. This can make an itch worse. However this is unusual and, in most people, bland moisturisers without added perfumes do help to reduce symptoms.

Aqueous cream is best used simply as a soap substitute and not as a moisturiser. Other emollients can be used for both.

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.

• Scratching may make the itch worse.

• Excessive scratching can also cause thickening of the skin, known as "lichenification" - which then becomes even itchier.

• Try not to scratch if at all possible.

• Keep nails cut short to reduce the risks of damaging the skin.

• Consider wearing cotton gloves at night to stop scratching during sleep.

Scratching may also damage the vulval skin and increase the risk of the skin becoming infected with bacteria.

General vulval skin care and other advice

The following may also help ease an itchy vulva, whatever the cause.

Clothes

• Wearing loose 100% cotton underwear. Avoiding nylon or synthetic underwear material which tends to block fresh air and causes increased sweating.

• Changing underwear daily.

• Avoiding 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.

• Wearing no underwear when possible - for example, at night.

Washing

• The vulva should be washed gently, once a day. It is best to avoid using a sponge or flannel to wash with. Over-cleaning often makes symptoms worse. Using a bland, unscented moisturiser as a soap substitute can help as 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 it is important to wash off any soap, shower gel or shampoo.

• It is best to avoid putting on underwear until the vulva is fully dry. The skin can be dried gently by dabbing it with a soft towel but a hairdryer - on a cool setting and held well away from the skin - may be useful to dry properly.

Other general advice

• Sometimes soaps, perfumes, bubble baths, deodorants, scented creams, the dye in toilet tissue, etc can irritate (sensitise) the delicate vulval skin - these should not be used in bathwater or the shower. Plain, non-coloured toilet tissue. Non-perfumed sanitary towels and panty liners should be used when necessary but it is best to avoid using them on a regular basis. Plasticised 'one-way' top sheets on sanitary products can cause sweating and reduce air circulation and therefore may make an itchy vulva worse.

• Antiseptics or special vaginal washes or douches should be avoided.

• 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.

• Condoms that are lubricated with spermicide can be sensitising. Similarly, perfumed lubricants should be avoided.

• Shaving pubic hair can cause itching as the skin is very sensitive. This is best avoided.

Is there anything that can help me sleep?

An antihistamine medicine at bedtime may help if sleep is affected by vulval or vaginal itching.

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 the cause, treatment is sometimes prolonged or may need to be repeated.

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 dealing with the underlying cause. However, in some cases no cause can be found. The general advice on clothes, washing, etc will usually help.

Topical oestrogen may help and is usually safe to try.

A mild steroid ointment such as hydrocortisone may be advised for a week or so. This often settles the itch within a few days and may also help to break any itch-scratch cycle that has developed.

However, steroid ointment should not be used regularly on the vulva, unless medically advised for a condition such as lichen sclerosus, as it can have a thinning effect on the skin with long-term use.