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What's Your Diagnosis? Acute Vulvar Erythema, Edema, and Pruritus in a Young Woman
J Pediatr Adolesc Gynecol (2005) 18:275–280
Pedi-Gyn Derm What’s Your Diagnosis? Acute Vulvar Erythema, Edema, and Pruritus in a Young Woman Section Editor and Author: Jonathan D.K. Trager, MD The Mount Sinai Medical School, New York, New York, USA
Introduction
Differential Diagnosis
A 20-year-old woman is seeing you for an extremely pruritic vulvar rash which she has had for several days. Her discomfort is almost unbearable. On examination you note significant vulvar erythema, edema of the right labia minora, and areas of desquamation (Fig. 1). A potassium hydroxide preparation of a vaginal swab is negative for yeast forms. On further questioning, the cause of her rash becomes apparent.
The most common causes of an acute, extremely pruritic vulvitis in girls and young women are vulvovaginal candidiasis and irritant and allergic contact dermatitis. Vulvar atopic dermatitis may periodically flare and cause similar symptoms, although usually not as intense. Psoriasis of the vulva may occur at any age from infancy to adulthood and may be preceded by a streptococcal pharyngitis; well-demarcated vulvar erythema is generally seen accompanied by variable degrees of pruritus. Lichenification (skin thickening, accentuation of skin lines, and hyperpigmentation) would signify a chronic vulvar dermatitis but is non-specific. Vulvar lichenification may be seen in chronic irritant or allergic contact dermatitis, atopic dermatitis, and lichen simplex chronicus. Labial edema may also be seen in a primary herpes simplex virus infection. The fine desquamation seen in this patient is typical of an evolving allergic contact dermatitis.
Questions For The Clinician What’s your diagnosis – and what question will lead you to it? What tests would you perform? What treatment would you prescribe? Diagnosis: Allergic Contact Dermatitis The question that will lead you to the diagnosis is: “What products have you used in the genital area?” In this case the answer was VagisilR, a topical anti-itch cream containing benzocaine (Table 1). The patient had used the topical agent for genital pruritus and developed an acute allergic contact vulvitis. The cause of her original pruritus could not be determined. (A candidal culture was also negative.) The patient was treated with soothing topical compresses and a 14-day course of prednisone (1 mg/kg/ day initially, then tapered). Her signs and symptoms quickly resolved and she was counseled to avoid topical creams containing benzocaine and cross-reacting medications. Address correspondence to: Jonathan D.K. Trager, MD, Adolescent-Young Adult Medicine of Great Neck, LLC, 212 Middle Neck Road, Suite #5, Great Neck, NY 11021; E-mail: [email protected]
쑖 2005 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
Discussion: Contact Vulvitis Contact vulvitis is inflammation of vulvar skin caused by an external agent acting as an irritant (irritant contact vulvitis) or as an allergen (allergic contact vulvitis).1 Either type may be acute, subacute, or chronic. Skin changes may range from minor (irritation or pruritus without visible skin changes) to extreme (erythema, edema, blistering, erosions, exudate). Some agents, such as propylene glycol (a solvent, humectant, and preservative used widely in topical medications, food, and industry) may cause both an irritant and an allergic contact vulvitis.1,2 To make matters worse, some women who become sensitized to propylene 1083-3188/05/$22.00 doi:10.1016/j.jpag.2005.05.015
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Fig. 1. Twenty-year-old woman with severe vulvar dermatitis.
glycol through vulvar skin products may show a “systemic” (widespread) contact dermatitis after ingesting foods containing this agent. The clinician should also keep in mind that a product intended for vulvar use may also be used on clothing, further spreading allergens around and potentially extending the dermatitis to extragenital sites. For example, the manufacturer of FDSR Feminine Deodorant Spray recommends their product be used on “undergarments, pantyhose & tights, yourself, lingerie, workout wear, linens & pajamas, pads & panty liners.”3 Irritant Contact Vulvitis Irritant contact vulvitis is caused by direct skin irritation by an offending agent (Table 2).1,4 Any woman
may potentially develop irritant contact vulvitis if exposed to enough of the irritant over a long enough period of time. This is in contrast to allergic contact dermatitis in which the reaction occurs only in sensitized individuals. Vulvar skin has been shown to be more readily irritated than the vagina and skin on the trunk and the extremities.4,5 There are three basic clinical responses to vulvar irritants:1 • Acute irritant dermatitis: equivalent to a chemical burn caused by a potent caustic agent; cause usually obvious by history • Chronic irritant dermatitis: irritation due to repeated exposure to a weak irritant; agent may not be obvious by history
Table 1. Ingredients in VagisilR Anti-Itch Cre`me, Maximum Strengtha,b Active Ingredients: Contains: Benzocaine (20% - External analgesic), Resorcinol (3% - External analgesic) Inactive Ingredients: Aloe Barbadensis Miller, Carbomer, Cetyl Alcohol, Cholecalciferol (Vitamin D), Corn Oil (Zea Mays), Fragrance, Glyceryl Stearate, Isopropyl Myristate, Isopropyl Palmitate, Isopropyl Stearate, Lanolin Alcohol, Methylparaben, Mineral Oil, PEG-100 Stearate, Propylene Glycol, Retinyl Palmitate (Vitamin A), Sodium Sulfate, Tocopheryl Acetate (Vitamin E), Triethanolamine, Trisodium HEDTA, Water a
www.drugstore.com Underlined items: potential irritants; bolded items: potential allergens; some agents are both potential irritants and allergens; (underlining and bolding added by author) b
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Table 2. Vulvar Irritants1,4 Category/Agent Strong caustic irritants Weak cumulative irritants
Physically abrasive agents Thermal irritants Pubic hair grooming Miscellaneous Douches Feminine deodorant sprays Clothing Cleansers Sanitary napkins, panty-liners
Potential Irritants Bichloroacetic acid and trichloroacetic acid, 5-fluorouracil, lye (in soap), phenol, podofilox, podophyllin, sodium hypochlorite, solvents Alcohol, bubble baths, deodorants, detergents, diapers, feces, perfume, povidone iodine, powders, propylene glycol, semen, soap, sanitary napkins, sweat, urine, vaginal secretions, water, wipes Face cloths, sponges Hair dryers, hot water bottles Depilatory, shaving, and waxing products Acid irritants: alum citric acid, lactic acid Alkali irritants: sodium bicarbonate, sodium borate Due to propellant if held too close to vulva Tight-fitting clothing, wet bathing suits Bubble baths Frictional irritation, fragrance
• Sensory irritation: stinging and burning without detectable skin change; normal vulvar pigmentation may obscure subtle erythema4 The symptoms of irritant contact vulvitis include itching, burning, and irritation.1 Clinical findings vary depending on the acuity of the presentation:1 • Acute: erythema, edema, blistering, scaling • Subacute: erythema, scaling, erosions • Chronic: lichenification, excoriations, pigmentary changes Allergic Contact Vulvitis Allergic contact vulvitis is an inflammatory reaction occurring only in individuals sensitized to a particular allergen and is a classic type IV delayed hypersensitivity reaction. Keep in mind that sensitizing medications or douches well tolerated by the vaginal mucosa may produce an allergic contact vulvitis and dermatitis of the thighs.4 In addition, differentiation of allergic from irritant contact vulvitis may be difficult as signs and symptoms may overlap. Topical anesthetics are a common cause of allergic contact vulvitis.1 Benzocaine, the likely culprit in our patient, is present in hundreds of over-the-counter products and cross-reacts with sulfa drugs, paraaminobenzoic acid, and paraphenylenediamine (an ingredient in hair dye).1 Due to the active or inactive ingredient(s), other topical treatments, such as anti-candidal agents and topical corticosteroids, may cause an allergic dermatitis. Clothing with azo dyes and formaldehyde-treated permanent press fabrics may also be culprits. Allergic reactions from feminine sprays appear to occur particularly on skin that has been previously
injured by some type of nonallergic dermatitis (candidiasis, seborrheic dermatitis).4 Clinical Presentation of Allergic Contact Vulvitis1. • Acute 䊊 Symptoms: severe pruritus, burning 䊊 Signs: vesiculation, oozing, erythema, erosions, edema 䊊 Time course: reaction occurs 7–14 days following exposure to a new sensitizer and 1–2 days after exposure if the patient is already sensitized (classic example: poison ivy). • Subacute 䊊 Symptoms: pruritus and burning, to a lesser extent than an acute reaction 䊊 Signs: vulvar erythema, scaling, pigmentary changes 䊊 Time course: over weeks or months • Chronic 䊊 Symptoms: mild to moderate pruritus 䊊 Signs: lichenification, pigmentary changes 䊊 Time course: over weeks or months to years Secondary infection with bacteria and Candida may cause pustules, fissures, oozing and crusting. Evaluation and treatment of allergic contact vulvitis is discussed below. Product Categories. The number of products which are “designed” to come into contact with vulvar skin is bewildering. A young woman may be exposed to dozens if not hundreds of potential vulvar irritants and allergens on a daily basis depending on the number and types of products she uses. The main categories of these products are: • Feminine products: cleansers, deodorants, douches, lubricants, powders, pleasure-enhancing creams • Medicated products: anesthetics, anti-fungal creams, hormones
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• Moisture protection and menstrual products: pantiliners, tampons, and sanitary napkins6 (scented and unscented) • Contraceptive products: latex condoms, spermicides Each product, in turn, may contain a number of potential irritants and allergens (see Table 1 for list of irritants and allergens in VagisilR). In addition, a number of allergen-containing products not designed specifically for vulvar use may nonetheless be used on vulvar skin. These agents include topical antibiotics (e.g., neomycin, bacitracin, polymyxin, clindamycin, mupirocin) and topical steroids. Environmental allergens, such as poison ivy, may come in contact with vulvar skin and cause a severe dermatitis. Cosmetics used on other body areas such as perfumes and nail polish may be transferred by touch to the vulva resulting in an allergic dermatitis. Scented toilet paper may also be a culprit. Seminal fluid is a rare cause of vulvar allergic contact dermatitis.1,7 A sex partner’s cologne, perfume, or saliva may likewise be an offending allergen.1 Finally, metals such as nickel-containing alloys used for genital piercing, and pigments (especially red) in vulvar tattoos may cause allergic contact vulvitis.8 The clinician should become familiar with the common and not-so-common irritants and allergens involved in contact vulvitis (Tables 2 and 3). Evaluation of Contact Vulvitis The cause of acute vulvar erythema and pruritus may be obvious or may be a diagnostic challenge. For the girl with multiple linear vesicular plaques of poison ivy on her trunk and extremities, the cause of similar plaques on her vulva would be obvious. For the girl with lichen sclerosus who is using a topical steroid, a topical antibiotic, and an emollient and who also spends hours in a wet bathing on summer days, sorting out the causes of vulvar erythema may be more difficult. Is the lichen sclerosus flaring? Is there a candidal infection? An allergic reaction to the topical steroid? An irritant or allergic reaction to the emollient? An irritant reaction from the wet bathing suit? The clinical challenge is to determine if a vulvar infection, a contact dermatitis, or another dermatosis is occurring in isolation or in combination. More than one visit may be necessary to accomplish this. Start by taking a comprehensive history of all possible vulvar contactants including products used by sex partners. Patients are often perplexed as to how they could have developed an irritant or allergic reaction when they “haven’t used anything new.” Clinicians must tell patients that the reaction may be caused by “something old”—such as a product they have been
using for weeks or months that contains a weak, cumulative vulvar irritant or a product with an allergen to which they have become sensitized over time. Examine the rest of the skin for other clues. For example, eyelid dermatitis is commonly caused by nail polish, which can also be transferred to vulvar skin causing allergic contact vulvitis. If contact vulvitis is suspected, initiate treatment as describe below. If the cause is not readily apparent, obtain appropriate cultures for infectious causes of vulvovaginitis and treat empirically using the treatment guidelines below while cultures are pending. See the patient in 2 to 3 days for a follow-up. Close followup will help ensure that you and the patient are on the right therapeutic track. A biopsy may be needed to identify an underlying vulvar dermatosis such as lichen sclerosus, lichen planus, or psoriasis. When allergic contact vulvitis has cleared, patch testing to identify specific allergens is vital.1 Allergen testing may be done with the North American Contact Dermatitis Group series of 50 allergens. Additional testing with a corticosteroid series and medication series may be indicated as well as patch testing for specific medicines, perfumes, preservatives, and emulsifiers.1,9 Consultation with a dermatologist specializing in contact dermatitis may be necessary. Another strategy is to simply have the patient avoid the offending allergen and common cross reactants. If the dermatitis recurs, patch testing would then be essential. Treatment The goal of treating irritant or allergic contact vulvitis is to very quickly alleviate pruritus and restore vulvar skin to normal. Treatment encompasses:1 ■
■
■
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Identifying and removing the possible/suspected offending irritant or allergen Restoring the barrier function of vulvar skin 䊊 Sitz baths with plain tepid water 䊊 Pat skin dry 䊊 Apply thin film of plain petrolatum Relieving pruritus 䊊 Topical cool packs, cool milk compresses 䊊 Sedating antihistamines, especially at bedtime Relieving inflammation 䊊 Aluminum acetate (Burrow’s solution, Domeboro’s solution) compresses, especially for weeping, exudative areas 䊊 Topical corticosteroid – mild, moderate, or super-potent, depending on the degree of inflammation 䊊 Apply twice a day for 1 to 2 weeks 䊊 Use a cream or gel formulation for weeping, exudative dermatitis and an emollient cream or ointment formulation for a dry dermatitis
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Table 3. Vulvar Allergens1,4 Product/Agent Feminine Products Cleansers
Deodorant Sprays Douches Lubricants Powders Pleasure Enhancing Creams Medicated Productsa Anesthetics Anti-candidal creams Antibitoics Antiseptics Topical Steroids Topical hormones Vaginal spermacides Miscellaneous Body fluids Clothing Metal products Nail polish Poison ivy Rubber products Sanitary napkins Scented panty-liners and tampons Tattoos Toilet tissue
Potential Allergens
Aloe, carbomer, cocamidopropyl betaine, dye, fragrance, glycerin, lanolin oil, methylchloroisothiazolinone, methylparaben, methylisothiazolinone, nonoxynol-9, PEG-7, polysorbate, propylene glycol, quaternium-15, triclosan, vitamin A, D, and E Bacteriostats (benzethonium chloride, chlorhexidine, triclosan), emollients (fatty alcohols and derivatives, isopropyl myristate and palmitate,) fragrance, lanolin, propylene glycol, vitamin A Benzethonium chloride, cetyl pyridinium chloride, diazolidinyl urea, fragrance, methyl salicylate, oil of eucalyptus, oxyquinoline, phenylmercuric acetate, povidone-iodine, thymol Aloe, chlorhexidine, glycerin, isopropyl palmitate, methylparaben, phenoxyethanol, polysorbate 60, propylene glycol, propylparaben, vitamin E Aloe, benzethonium chloride, fragrance Camphor, carbomer, dye, ethyl aminobenzoate, flavor/fragrance, glycerin, menthol, propylparaben, triethanolamine Benzocaine, crotamiton, dibucaine, diphenhydramine, lidocaine, tetracaine Imidazoles, Nystatin Bacitracin, clindamycin, mupirocin, neomycin, polymyxin, sulfonamides Gentian violet, hexachlorophene, povidone iodine, phenylmercuric salts, mercuric chloride, thimerisol All Estrogen, progesterone Hexylresorcinol, nonoxyl, oxyquinoline sulfate, pheylmercuric acetate and borate, quinine hydrochloride Saliva, seminal fluid Dye, formaldehyde, synthetic resin Nickel Formaldehyde resin, toluene, sulfonamide Urushiol Latex, mercaptobenzothiazole, thiurams (condoms, diaphragms, gloves, pessaries) Acetyl acetone, colophony, formaldehyde, fragrance, methacrylates Fragrance Pigment, especially red Fragrance
a
Medicated products also contain a number of inactive ingredients which themselves are allergens, including: benzyl alcohol, carbomer, cetyl alcohol, glycerin, glyceryl monostearate, methylparaben, mineral oil, propylene glycol, sodium lauryl sulfate 䊊
䊊
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■
If contact vulvitis does not resolve with a topical steroid as expected, consider evaluating for topical steroid allergy Systemic steroid for severe inflammation 䊊 Prednisone 0.5 to 1 mg/kg/day, tapered over 14 days 䊊 Intramuscular tramcinolone acetonide
Treating secondary infection 䊊 Oral treatment is optimal as it avoids any further potential skin irritation; on the other hand, topical agents may sometimes help soothe inflamed skin—be careful not to give another product with the suspected irritant or allergen 䊊 Oral antibiotic for bacterial infection 䊊 Oral fluconazole for candidiasis Educating patients/parents about irritants/ allergens 䊊 Discourage overzealous cleansing 䊊 Provide patients with a written list of their irritants and/or allergens, common products
■
which contain these agents, and cross-reacting agents; encourage patients to read product labels carefully in order to avoid future exposure. The Contact Allergen Replacement Database of the American Contact Dermatitis Society can help you find products for your patients that do not contain their particular allergens10 䊊 Discuss with young women the true need— or rather lack thereof—to use certain vulvar products, the incorrect beliefs that product advertisers may foster regarding vulvar “hygiene,” the potential health risks of some of these agents (such as douches), while at the same time remaining sensitive to a young woman’s personal and cultural beliefs surrounding vulvar skin and vaginal care Providing psychosocial support as contact vulvitis may be extremely uncomfortable, frustrating and even debilitating
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References 1. Margesson LJ: Contact dermatitis of the vulva. Dermatol Therapy 2004; 17:20 2. Rietschel RL, Fowler JF: Fisher’s Contact Dermatitis, (5th ed.). Philadelphia: Lippincott Williams & Wilkins, 2001 3. Product labeling from FDSR Feminine Deodorant Spray from www.drugstore.com. 4. Rietschel RL, Fowler JF: Fisher’s Contact Dermatitis, (5th ed.). Philadelphia: Lippincott Williams & Wilkins, 2001, pp 60–62, 486–488 5. Britz MB, Maibach HI: Human cutaneous vulvar reactivity to irritants. Contact Dermatitis 1979; 5:375
6. Rademaker M: Allergic contact dermatitis to a sanitary pad. Australas J Dermatol 2004; 45:234 7. Guillet G, Dagregorio G: Seminal fluid as a missed allergen in vulvar allergic contact dermatitis. Contact Dermatitis 2004; 50:318 8. Tanzi EL, Michael E: Tattoo reactions. E-medicine, December 7, 2004, http://www.emedicine.com/derm/topic512.htm 9. Virgil A, Bacillieri S, Corazza M: Evaluation of contact sensitization in vulvar lichen simplex chronicus. A proposal for a battery of selected allergens. J Reprod Med 2003; 48:33 10. American Contact Dermatitis Society: www.contactderm.org
Pedi-Gyn Derm What’s Your Diagnosis? Acute Vulvar Erythema, Edema, and Pruritus in a Young Woman Section Editor and Author: Jonathan D.K. Trager, MD The Mount Sinai Medical School, New York, New York, USA
Introduction
Differential Diagnosis
A 20-year-old woman is seeing you for an extremely pruritic vulvar rash which she has had for several days. Her discomfort is almost unbearable. On examination you note significant vulvar erythema, edema of the right labia minora, and areas of desquamation (Fig. 1). A potassium hydroxide preparation of a vaginal swab is negative for yeast forms. On further questioning, the cause of her rash becomes apparent.
The most common causes of an acute, extremely pruritic vulvitis in girls and young women are vulvovaginal candidiasis and irritant and allergic contact dermatitis. Vulvar atopic dermatitis may periodically flare and cause similar symptoms, although usually not as intense. Psoriasis of the vulva may occur at any age from infancy to adulthood and may be preceded by a streptococcal pharyngitis; well-demarcated vulvar erythema is generally seen accompanied by variable degrees of pruritus. Lichenification (skin thickening, accentuation of skin lines, and hyperpigmentation) would signify a chronic vulvar dermatitis but is non-specific. Vulvar lichenification may be seen in chronic irritant or allergic contact dermatitis, atopic dermatitis, and lichen simplex chronicus. Labial edema may also be seen in a primary herpes simplex virus infection. The fine desquamation seen in this patient is typical of an evolving allergic contact dermatitis.
Questions For The Clinician What’s your diagnosis – and what question will lead you to it? What tests would you perform? What treatment would you prescribe? Diagnosis: Allergic Contact Dermatitis The question that will lead you to the diagnosis is: “What products have you used in the genital area?” In this case the answer was VagisilR, a topical anti-itch cream containing benzocaine (Table 1). The patient had used the topical agent for genital pruritus and developed an acute allergic contact vulvitis. The cause of her original pruritus could not be determined. (A candidal culture was also negative.) The patient was treated with soothing topical compresses and a 14-day course of prednisone (1 mg/kg/ day initially, then tapered). Her signs and symptoms quickly resolved and she was counseled to avoid topical creams containing benzocaine and cross-reacting medications. Address correspondence to: Jonathan D.K. Trager, MD, Adolescent-Young Adult Medicine of Great Neck, LLC, 212 Middle Neck Road, Suite #5, Great Neck, NY 11021; E-mail: [email protected]
쑖 2005 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
Discussion: Contact Vulvitis Contact vulvitis is inflammation of vulvar skin caused by an external agent acting as an irritant (irritant contact vulvitis) or as an allergen (allergic contact vulvitis).1 Either type may be acute, subacute, or chronic. Skin changes may range from minor (irritation or pruritus without visible skin changes) to extreme (erythema, edema, blistering, erosions, exudate). Some agents, such as propylene glycol (a solvent, humectant, and preservative used widely in topical medications, food, and industry) may cause both an irritant and an allergic contact vulvitis.1,2 To make matters worse, some women who become sensitized to propylene 1083-3188/05/$22.00 doi:10.1016/j.jpag.2005.05.015
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Fig. 1. Twenty-year-old woman with severe vulvar dermatitis.
glycol through vulvar skin products may show a “systemic” (widespread) contact dermatitis after ingesting foods containing this agent. The clinician should also keep in mind that a product intended for vulvar use may also be used on clothing, further spreading allergens around and potentially extending the dermatitis to extragenital sites. For example, the manufacturer of FDSR Feminine Deodorant Spray recommends their product be used on “undergarments, pantyhose & tights, yourself, lingerie, workout wear, linens & pajamas, pads & panty liners.”3 Irritant Contact Vulvitis Irritant contact vulvitis is caused by direct skin irritation by an offending agent (Table 2).1,4 Any woman
may potentially develop irritant contact vulvitis if exposed to enough of the irritant over a long enough period of time. This is in contrast to allergic contact dermatitis in which the reaction occurs only in sensitized individuals. Vulvar skin has been shown to be more readily irritated than the vagina and skin on the trunk and the extremities.4,5 There are three basic clinical responses to vulvar irritants:1 • Acute irritant dermatitis: equivalent to a chemical burn caused by a potent caustic agent; cause usually obvious by history • Chronic irritant dermatitis: irritation due to repeated exposure to a weak irritant; agent may not be obvious by history
Table 1. Ingredients in VagisilR Anti-Itch Cre`me, Maximum Strengtha,b Active Ingredients: Contains: Benzocaine (20% - External analgesic), Resorcinol (3% - External analgesic) Inactive Ingredients: Aloe Barbadensis Miller, Carbomer, Cetyl Alcohol, Cholecalciferol (Vitamin D), Corn Oil (Zea Mays), Fragrance, Glyceryl Stearate, Isopropyl Myristate, Isopropyl Palmitate, Isopropyl Stearate, Lanolin Alcohol, Methylparaben, Mineral Oil, PEG-100 Stearate, Propylene Glycol, Retinyl Palmitate (Vitamin A), Sodium Sulfate, Tocopheryl Acetate (Vitamin E), Triethanolamine, Trisodium HEDTA, Water a
www.drugstore.com Underlined items: potential irritants; bolded items: potential allergens; some agents are both potential irritants and allergens; (underlining and bolding added by author) b
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Table 2. Vulvar Irritants1,4 Category/Agent Strong caustic irritants Weak cumulative irritants
Physically abrasive agents Thermal irritants Pubic hair grooming Miscellaneous Douches Feminine deodorant sprays Clothing Cleansers Sanitary napkins, panty-liners
Potential Irritants Bichloroacetic acid and trichloroacetic acid, 5-fluorouracil, lye (in soap), phenol, podofilox, podophyllin, sodium hypochlorite, solvents Alcohol, bubble baths, deodorants, detergents, diapers, feces, perfume, povidone iodine, powders, propylene glycol, semen, soap, sanitary napkins, sweat, urine, vaginal secretions, water, wipes Face cloths, sponges Hair dryers, hot water bottles Depilatory, shaving, and waxing products Acid irritants: alum citric acid, lactic acid Alkali irritants: sodium bicarbonate, sodium borate Due to propellant if held too close to vulva Tight-fitting clothing, wet bathing suits Bubble baths Frictional irritation, fragrance
• Sensory irritation: stinging and burning without detectable skin change; normal vulvar pigmentation may obscure subtle erythema4 The symptoms of irritant contact vulvitis include itching, burning, and irritation.1 Clinical findings vary depending on the acuity of the presentation:1 • Acute: erythema, edema, blistering, scaling • Subacute: erythema, scaling, erosions • Chronic: lichenification, excoriations, pigmentary changes Allergic Contact Vulvitis Allergic contact vulvitis is an inflammatory reaction occurring only in individuals sensitized to a particular allergen and is a classic type IV delayed hypersensitivity reaction. Keep in mind that sensitizing medications or douches well tolerated by the vaginal mucosa may produce an allergic contact vulvitis and dermatitis of the thighs.4 In addition, differentiation of allergic from irritant contact vulvitis may be difficult as signs and symptoms may overlap. Topical anesthetics are a common cause of allergic contact vulvitis.1 Benzocaine, the likely culprit in our patient, is present in hundreds of over-the-counter products and cross-reacts with sulfa drugs, paraaminobenzoic acid, and paraphenylenediamine (an ingredient in hair dye).1 Due to the active or inactive ingredient(s), other topical treatments, such as anti-candidal agents and topical corticosteroids, may cause an allergic dermatitis. Clothing with azo dyes and formaldehyde-treated permanent press fabrics may also be culprits. Allergic reactions from feminine sprays appear to occur particularly on skin that has been previously
injured by some type of nonallergic dermatitis (candidiasis, seborrheic dermatitis).4 Clinical Presentation of Allergic Contact Vulvitis1. • Acute 䊊 Symptoms: severe pruritus, burning 䊊 Signs: vesiculation, oozing, erythema, erosions, edema 䊊 Time course: reaction occurs 7–14 days following exposure to a new sensitizer and 1–2 days after exposure if the patient is already sensitized (classic example: poison ivy). • Subacute 䊊 Symptoms: pruritus and burning, to a lesser extent than an acute reaction 䊊 Signs: vulvar erythema, scaling, pigmentary changes 䊊 Time course: over weeks or months • Chronic 䊊 Symptoms: mild to moderate pruritus 䊊 Signs: lichenification, pigmentary changes 䊊 Time course: over weeks or months to years Secondary infection with bacteria and Candida may cause pustules, fissures, oozing and crusting. Evaluation and treatment of allergic contact vulvitis is discussed below. Product Categories. The number of products which are “designed” to come into contact with vulvar skin is bewildering. A young woman may be exposed to dozens if not hundreds of potential vulvar irritants and allergens on a daily basis depending on the number and types of products she uses. The main categories of these products are: • Feminine products: cleansers, deodorants, douches, lubricants, powders, pleasure-enhancing creams • Medicated products: anesthetics, anti-fungal creams, hormones
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Trager: Vulvar Erythema, Edema, and Pruritus
• Moisture protection and menstrual products: pantiliners, tampons, and sanitary napkins6 (scented and unscented) • Contraceptive products: latex condoms, spermicides Each product, in turn, may contain a number of potential irritants and allergens (see Table 1 for list of irritants and allergens in VagisilR). In addition, a number of allergen-containing products not designed specifically for vulvar use may nonetheless be used on vulvar skin. These agents include topical antibiotics (e.g., neomycin, bacitracin, polymyxin, clindamycin, mupirocin) and topical steroids. Environmental allergens, such as poison ivy, may come in contact with vulvar skin and cause a severe dermatitis. Cosmetics used on other body areas such as perfumes and nail polish may be transferred by touch to the vulva resulting in an allergic dermatitis. Scented toilet paper may also be a culprit. Seminal fluid is a rare cause of vulvar allergic contact dermatitis.1,7 A sex partner’s cologne, perfume, or saliva may likewise be an offending allergen.1 Finally, metals such as nickel-containing alloys used for genital piercing, and pigments (especially red) in vulvar tattoos may cause allergic contact vulvitis.8 The clinician should become familiar with the common and not-so-common irritants and allergens involved in contact vulvitis (Tables 2 and 3). Evaluation of Contact Vulvitis The cause of acute vulvar erythema and pruritus may be obvious or may be a diagnostic challenge. For the girl with multiple linear vesicular plaques of poison ivy on her trunk and extremities, the cause of similar plaques on her vulva would be obvious. For the girl with lichen sclerosus who is using a topical steroid, a topical antibiotic, and an emollient and who also spends hours in a wet bathing on summer days, sorting out the causes of vulvar erythema may be more difficult. Is the lichen sclerosus flaring? Is there a candidal infection? An allergic reaction to the topical steroid? An irritant or allergic reaction to the emollient? An irritant reaction from the wet bathing suit? The clinical challenge is to determine if a vulvar infection, a contact dermatitis, or another dermatosis is occurring in isolation or in combination. More than one visit may be necessary to accomplish this. Start by taking a comprehensive history of all possible vulvar contactants including products used by sex partners. Patients are often perplexed as to how they could have developed an irritant or allergic reaction when they “haven’t used anything new.” Clinicians must tell patients that the reaction may be caused by “something old”—such as a product they have been
using for weeks or months that contains a weak, cumulative vulvar irritant or a product with an allergen to which they have become sensitized over time. Examine the rest of the skin for other clues. For example, eyelid dermatitis is commonly caused by nail polish, which can also be transferred to vulvar skin causing allergic contact vulvitis. If contact vulvitis is suspected, initiate treatment as describe below. If the cause is not readily apparent, obtain appropriate cultures for infectious causes of vulvovaginitis and treat empirically using the treatment guidelines below while cultures are pending. See the patient in 2 to 3 days for a follow-up. Close followup will help ensure that you and the patient are on the right therapeutic track. A biopsy may be needed to identify an underlying vulvar dermatosis such as lichen sclerosus, lichen planus, or psoriasis. When allergic contact vulvitis has cleared, patch testing to identify specific allergens is vital.1 Allergen testing may be done with the North American Contact Dermatitis Group series of 50 allergens. Additional testing with a corticosteroid series and medication series may be indicated as well as patch testing for specific medicines, perfumes, preservatives, and emulsifiers.1,9 Consultation with a dermatologist specializing in contact dermatitis may be necessary. Another strategy is to simply have the patient avoid the offending allergen and common cross reactants. If the dermatitis recurs, patch testing would then be essential. Treatment The goal of treating irritant or allergic contact vulvitis is to very quickly alleviate pruritus and restore vulvar skin to normal. Treatment encompasses:1 ■
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Identifying and removing the possible/suspected offending irritant or allergen Restoring the barrier function of vulvar skin 䊊 Sitz baths with plain tepid water 䊊 Pat skin dry 䊊 Apply thin film of plain petrolatum Relieving pruritus 䊊 Topical cool packs, cool milk compresses 䊊 Sedating antihistamines, especially at bedtime Relieving inflammation 䊊 Aluminum acetate (Burrow’s solution, Domeboro’s solution) compresses, especially for weeping, exudative areas 䊊 Topical corticosteroid – mild, moderate, or super-potent, depending on the degree of inflammation 䊊 Apply twice a day for 1 to 2 weeks 䊊 Use a cream or gel formulation for weeping, exudative dermatitis and an emollient cream or ointment formulation for a dry dermatitis
Trager: Vulvar Erythema, Edema, and Pruritus
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Table 3. Vulvar Allergens1,4 Product/Agent Feminine Products Cleansers
Deodorant Sprays Douches Lubricants Powders Pleasure Enhancing Creams Medicated Productsa Anesthetics Anti-candidal creams Antibitoics Antiseptics Topical Steroids Topical hormones Vaginal spermacides Miscellaneous Body fluids Clothing Metal products Nail polish Poison ivy Rubber products Sanitary napkins Scented panty-liners and tampons Tattoos Toilet tissue
Potential Allergens
Aloe, carbomer, cocamidopropyl betaine, dye, fragrance, glycerin, lanolin oil, methylchloroisothiazolinone, methylparaben, methylisothiazolinone, nonoxynol-9, PEG-7, polysorbate, propylene glycol, quaternium-15, triclosan, vitamin A, D, and E Bacteriostats (benzethonium chloride, chlorhexidine, triclosan), emollients (fatty alcohols and derivatives, isopropyl myristate and palmitate,) fragrance, lanolin, propylene glycol, vitamin A Benzethonium chloride, cetyl pyridinium chloride, diazolidinyl urea, fragrance, methyl salicylate, oil of eucalyptus, oxyquinoline, phenylmercuric acetate, povidone-iodine, thymol Aloe, chlorhexidine, glycerin, isopropyl palmitate, methylparaben, phenoxyethanol, polysorbate 60, propylene glycol, propylparaben, vitamin E Aloe, benzethonium chloride, fragrance Camphor, carbomer, dye, ethyl aminobenzoate, flavor/fragrance, glycerin, menthol, propylparaben, triethanolamine Benzocaine, crotamiton, dibucaine, diphenhydramine, lidocaine, tetracaine Imidazoles, Nystatin Bacitracin, clindamycin, mupirocin, neomycin, polymyxin, sulfonamides Gentian violet, hexachlorophene, povidone iodine, phenylmercuric salts, mercuric chloride, thimerisol All Estrogen, progesterone Hexylresorcinol, nonoxyl, oxyquinoline sulfate, pheylmercuric acetate and borate, quinine hydrochloride Saliva, seminal fluid Dye, formaldehyde, synthetic resin Nickel Formaldehyde resin, toluene, sulfonamide Urushiol Latex, mercaptobenzothiazole, thiurams (condoms, diaphragms, gloves, pessaries) Acetyl acetone, colophony, formaldehyde, fragrance, methacrylates Fragrance Pigment, especially red Fragrance
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Medicated products also contain a number of inactive ingredients which themselves are allergens, including: benzyl alcohol, carbomer, cetyl alcohol, glycerin, glyceryl monostearate, methylparaben, mineral oil, propylene glycol, sodium lauryl sulfate 䊊
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If contact vulvitis does not resolve with a topical steroid as expected, consider evaluating for topical steroid allergy Systemic steroid for severe inflammation 䊊 Prednisone 0.5 to 1 mg/kg/day, tapered over 14 days 䊊 Intramuscular tramcinolone acetonide
Treating secondary infection 䊊 Oral treatment is optimal as it avoids any further potential skin irritation; on the other hand, topical agents may sometimes help soothe inflamed skin—be careful not to give another product with the suspected irritant or allergen 䊊 Oral antibiotic for bacterial infection 䊊 Oral fluconazole for candidiasis Educating patients/parents about irritants/ allergens 䊊 Discourage overzealous cleansing 䊊 Provide patients with a written list of their irritants and/or allergens, common products
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which contain these agents, and cross-reacting agents; encourage patients to read product labels carefully in order to avoid future exposure. The Contact Allergen Replacement Database of the American Contact Dermatitis Society can help you find products for your patients that do not contain their particular allergens10 䊊 Discuss with young women the true need— or rather lack thereof—to use certain vulvar products, the incorrect beliefs that product advertisers may foster regarding vulvar “hygiene,” the potential health risks of some of these agents (such as douches), while at the same time remaining sensitive to a young woman’s personal and cultural beliefs surrounding vulvar skin and vaginal care Providing psychosocial support as contact vulvitis may be extremely uncomfortable, frustrating and even debilitating
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Trager: Vulvar Erythema, Edema, and Pruritus
References 1. Margesson LJ: Contact dermatitis of the vulva. Dermatol Therapy 2004; 17:20 2. Rietschel RL, Fowler JF: Fisher’s Contact Dermatitis, (5th ed.). Philadelphia: Lippincott Williams & Wilkins, 2001 3. Product labeling from FDSR Feminine Deodorant Spray from www.drugstore.com. 4. Rietschel RL, Fowler JF: Fisher’s Contact Dermatitis, (5th ed.). Philadelphia: Lippincott Williams & Wilkins, 2001, pp 60–62, 486–488 5. Britz MB, Maibach HI: Human cutaneous vulvar reactivity to irritants. Contact Dermatitis 1979; 5:375
6. Rademaker M: Allergic contact dermatitis to a sanitary pad. Australas J Dermatol 2004; 45:234 7. Guillet G, Dagregorio G: Seminal fluid as a missed allergen in vulvar allergic contact dermatitis. Contact Dermatitis 2004; 50:318 8. Tanzi EL, Michael E: Tattoo reactions. E-medicine, December 7, 2004, http://www.emedicine.com/derm/topic512.htm 9. Virgil A, Bacillieri S, Corazza M: Evaluation of contact sensitization in vulvar lichen simplex chronicus. A proposal for a battery of selected allergens. J Reprod Med 2003; 48:33 10. American Contact Dermatitis Society: www.contactderm.org