8.06 Contact vulvovaginitis
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agk's Library of Common Simple Emergencies

Presentation
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Patients complain of vulvar itching and 
swelling. Occationally there will be tender- 
ness, pain, burning and dysuria severe enough 
at times to cause urinary retention. The 
vulvovaginal area is inflammed, erythematous 
and edematous. In more severe cases there may 
be vesiculation and ulceration and in cases 
where there is a chronic contact dermatitis 
there may be lichenification, scaling and skin 
thickening.

What to do:
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- Try to identify an offending agent and have 
    the patient stop using it. Most reactions 
    are caused by agents that the patient 
    unknowingly applies or uses for hygenic or 
    therapeutic purposes. Chemically scented 
    douches, soaps. bubble baths, deodorants 
    and perfumes as well as dyed or scented 
    toilet paper, dyed underwear, scented 
    tampons or pads and feminine hygene 
    products are the most common causative 
    agents. Less commonly, plant allergens such 
    as poison oak or poison ivy may be the 
    inadvertently-applied substances that 
    trigger the reaction.
- Rule out an alternate cause of vulvar puritis 
    such as [pinworms] or [trichomonas]. 
    Candida albicans may also be the cause of 
    pruritis but it may present as an over- 
    growth when contact vulvovaginitis is the 
    primary problem.
- Instruct the patient in the use of cool baths 
    and wet compresses using boric acid or 
    Burow's solution (Domboro).
- Prescribe liberal amounts of topical cortico- 
    steroids like fluocinolone (Synalar cream 
    0.025%) or triamcinolone (Stistocort 0.025% 
    cream) bid to qid (dispense 15-60 grams).
- In more severe cases, also prescribe oral 
    steroids in a tapering dose-pack schedule 
    like prednisone (Sterapred DS or Sterapred 
    DS 12 day), methylprednisolone (Medrol 
    Dosepack) or triamcinolone (Aristo-Pak) for 
    six days of systemic therapy.

What not to do:
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- Do not have the patient use hot baths or 
    compresses. This will usually exacerbate 
    the burning and pruritis.
- Do not prescribe antihistamines. They are 
    relatively ineffective in treating contact 
    vulvitis and may increase discomfort by 
    drying the vaginal mucosa.

Discussion
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The major problem with managing contact 
vulvovaginitis is identifying the primary 
irritant or allergen. In many cases, more than 
one substance is involved or potentially 
involved and may be totally unsuspected by the 
patient (such as the use of scented toilet 
paper). For this reason, a thorough 
investigative history is very important.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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