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Vulval Problems

Vulval Problems

There are many different conditions that can affect your vulva, ranging from mild infections to skin conditions and, very rarely, to cancer. They can all cause very different symptoms, including itching, bleeding, rashes or a lump. It is very important that if you notice any new symptoms or lumps in your vulval region then you see a doctor promptly. Your doctor will be able to examine you and decide which treatment will be appropriate to you. This will depend on the underlying cause of your symptoms.

What is the vulva?

Female Genitals

The outer (external) sex organs of a woman are known as the vulva. The vulva is made up of two pairs of 'lips'. The outer pair, called the labia majora, is covered in pubic hair. The inner pair is called the labia minora, which are thinner and more delicate.

There are two openings between these lips. One is the vagina which leads to the womb (uterus). The other is the urethra, which is the short tube that carries urine from the bladder. At the front of the vulva is the small organ called the clitoris.

When babies develop during pregnancy, problems may very rarely occur in the development of the sexual organs and the genitalia. Developmental problems may lead to a swollen clitoris or the labia being joined together. These are very rare though.

What symptoms may occur?

Obviously the symptoms you experience will depend on the underlying condition. Symptoms may range from pain, itching, and finding a lump to noticing a change in appearance of your vulva.

There are various conditions that can affect your vulva. Some are more common than others; some are more serious than others. If you notice a new lump or swelling on your vulva or have any bleeding from around your vulva then you must see a doctor promptly.

Most conditions that affect your vulva can be diagnosed by examining you. However, it is sometimes necessary for other tests to be undertaken. For example:

  • Internal swabs may be taken. A swab is a small ball of cotton wool on the end of a thin stick. It can be gently rubbed in various places to obtain samples.
  • A biopsy may be carried out. In this procedure, a small sample of tissue is taken from a lump. The sample can then be examined under a microscope in the laboratory.

What infections can affect the vulva?

Infections are caused by germs such as bacteria, viruses and fungi. Infections in the vagina are common and these infections can also affect your vulva.

The following infections may occur:

  • Thrush: around three quarters of women have thrush at some stage in their lives. Thrush infection can lead to a whitish discharge and often leads to your vulval area becoming red and very itchy. This is usually treated with antifungal creams which are available from your doctor or local pharmacy.
  • Genital herpes infection: this is usually a sexually transmitted infection which is passed on by skin-to-skin contact. Many people infected with this virus never have symptoms, but can still pass on the infection to others. If symptoms occur, they can range from a mild soreness to painful blisters on the genitals and surrounding area. Treatment is with antiviral medication.
  • Genital warts: these are caused by a virus that can be passed on by close sexual contact. They usually grow on the vulva but can also grow on the skin around your bottom. They are usually either treated with chemicals or with physical treatments such as freezing to destroy them.
  • Chickenpox can sometimes lead to spots developing on the vulval area. This can sometimes become very itchy and troublesome. Having warm baths and using calamine lotion can often really help.
  • Other infections: these include scabies and pubic lice.

Which skin conditions can affect the vulva?

In babies and toddlers wearing nappies, nappy rash can occur and be very irritating and distressing. Most cases are due to a reaction of the skin to urine and poo (faeces). In addition, the germ that causes thrush can grow in the inflamed skin and make nappy rash worse. Nappy rash can lead to the skin of the vulva and the area round the back passage (anus) becoming bright red and very sore. Frequent nappy changing and having times without wearing a nappy can help. So too can using a barrier cream. Some babies need to have a steroid cream or an antifungal cream. Therefore, if the nappy rash does not improve or it worsens, it is very important to see your doctor.

Any skin condition can affect the vulval area too. For example, eczema, psoriasis, lichen planus and lichen sclerosus. Inflammation of the vulva (vulvitis)  can be caused by many different conditions, including infections and skin conditions. Learn more about vulvitis.

Lichen sclerosus is a condition of your vulva which usually causes itching and soreness. It is more often seen in women with immune conditions such as thyroid disorders or diabetes. It is usually treated with a steroid cream to rub in sparingly on the affected area. Read more about lichen sclerosus.

A condition called vulval intraepithelial neoplasia (VIN) can affect the skin of the vulva in different ways. This is not vulval cancer but it is classed as a pre-cancerous condition, as VIN (after several years) may develop into vulval cancer in some women. VIN also usually causes a change in the appearance to the affected part or parts of the vulva. These include areas of redness, or white areas of skin. Sometimes affected areas of the vulva develop raised areas of skin. A persistent itch in the vulva is the most common symptom of VIN. Other symptoms that may develop include soreness, burning or tingling in the vulva. Treatment to clear VIN is usually advised, which is usually by surgery.

Note: VIN is a very uncommon cause of itching of the vulva. Itching of the vulva (pruritus vulvae) is common in women and can be caused by many different conditions. If a woman has VIN, she is likely to have an itchy vulva but an itchy vulva doesn't mean she has VIN. Read more about pruritus vulvae.

What can cause lumps in the vulva?

There are many different conditions that can cause lumps on your vulva.

Infections

Some infections such as herpes and syphilis can cause lumps. Genital herpes is an infection of your vulva and vagina and surrounding area of skin. Genital herpes is usually passed on by skin-to-skin contact with someone who is already infected with the virus. Treatment is usually with painkillers and antifungal medication which stops the herpes infection from multiplying. Syphilis is a sexually transmitted infection which usually starts with a painless ulcer on your vulva. Although it is an uncommon infection, the number of cases in the UK has increased over recent years.

Bartholin's cyst or abscess

The two Bartholin's glands lie next to the entrance to the vagina. Find out more about Bartholin's cysts and abscesses.

Cancer of the vulva

Cancer of the vulva is a rare cancer that usually affects women aged over 60 years. Most vulval cancers are squamous cell cancers. This means they have developed from the skin cells in the outer layer of the vulva. Rarely, vulval cancers are due to a melanoma which develops from cells in the skin that cause pigmentation. The most common symptoms of vulval cancer are a persistent itch or pain in the vulval area. Some vulval cancers start as a sore or lump in the vulva. Vulval cancer is usually treated by an operation to remove the cancer. Most vulval cancers can be cured. The outlook is good in women who have small cancers that have not spread.

The two Bartholin's glands lie next to the entrance to the vagina. They make a small amount of mucus-like fluid. This fluid passes down a duct to keep the vagina moist. If this duct becomes blocked, a fluid-filled swelling (a cyst) sometimes develops. This is known as a Bartholin's cyst. Sometimes a gland or cyst becomes infected, which may then develop into a collection of pus (an abscess). Antibiotic medicines may cure an infection or abscess. A small operation is a common treatment for a Bartholin's cyst or abscess.

What are Bartholin's glands and what do they do?

Bartholin's glands are a pair of small glands that are just next to the lower part of the entrance to the vagina. Each gland is about the size of a pea. Unless swollen or infected, you cannot normally see or feel these glands. They are within the soft tissues (labia) next to the entrance to the vagina.

Each gland makes a small amount of mucus-like fluid. The fluid from each gland drains down a short tube (duct) called the Bartholin's gland duct. Each duct is about 2 cm long and comes out towards the lower part of the entrance to the vagina. The fluid helps to keep the entrance to the vagina moist.

What problems can arise from Bartholin's glands?

Bartholin's cyst

If the tube (duct) that drains the fluid becomes blocked then a fluid-filled swelling (cyst) develops. The size of a cyst can vary from small and pea-like to the size of a golf ball, or even bigger in some cases. The cyst may remain the same size or may slowly become bigger. The reason why a Bartholin's duct may become blocked and lead to a cyst is not clear.

Bartholin's abscess

An abscess is a collection of pus that can occur with an infection. An abscess can occur in any part of the body and sometimes occurs in a Bartholin's gland. Sometimes an abscess develops from a Bartholin's cyst that becomes infected. Sometimes the gland itself becomes infected and forms into an abscess. Within a few days, the abscess can become the size of a hen's egg, sometimes larger, and is usually very painful.

Many types of germs (bacteria) can infect a Bartholin's cyst or gland to cause an abscess. Most are the common germs that cause skin or urine infections, such as Staphylococcus spp. and Escherichia coli. So, any woman can develop a Bartholin's abscess. Some cases are due to sexually transmitted germs such as gonorrhoea or chlamydia.

Bartholin's gland cancer

This is a very rare cancer and is very unlikely in women aged under 40. However, if there is any doubt about the cause of the swelling, a small sample of tissue (biopsy) can be checked.

Who develops Bartholin's cysts and abscesses?

About 3 in 100 women will develop a fluid-filled swelling (Bartholin's cyst) or a collection of pus (Bartholin's abscess) at some point in their lives. So, they are a common problem. Most cases occur 'out of the blue' in women aged between 20 and 30. However, they can also occur in older or younger women.

What are the symptoms of Bartholin's cysts and abscesses?

As mentioned earlier, a fluid-filled swelling is a cyst. A collection of pus is an abscess. A Bartholin's cyst or abscess typically only develops on one of the two glands. If a cyst remains small and does not become infected then you may have no symptoms. You may just feel a small lump to one side at the lower end of the entrance to the vagina, which may cause no problems. However, a larger cyst may cause some discomfort - in particular, when walking, sitting, or having sex. Very large cysts can become quite painful.

With an abscess, a lump develops and quickly becomes bigger, typically over a few hours or days. It is likely to become very painful. You may feel unwell and have a high temperature; the skin over the abscess tends to become red, hot and very tender. The tender swelling makes it painful to sit down, to walk or to have sex.

Some women may also have some vaginal discharge also.

How is it diagnosed?

An examination by a doctor can usually diagnose the problem. A Bartholin's fluid-filled swelling (cyst) and collection of pus (abscess) have a typical appearance. No test is usually needed to make the diagnosis.

Sometimes a sample of the pus inside an abscess may be taken (a swab). This is sent to the laboratory to find out which germs are causing the infection. This helps the doctors choose the right antibiotics if these are needed.

What is the treatment for Bartholin's cysts and abscesses?

Treatment is not always needed

If you have a small fluid-filled swelling (cyst) that causes no symptoms and does not become infected, it may be best simply to leave it alone. However, you should always report a 'lump' in the area around your vagina (your vulva) to your doctor. Do not just assume a small lump is a Bartholin's cyst. It is best for a doctor to examine you to confirm the diagnosis and to rule out other causes of lumps in the vulva. If a cyst causes symptoms then it can be treated.

A collection of pus, confirmed as a Bartholin's abscess, will almost always need treatment, as it can be very painful. However, if an abscess is left for long enough it is likely to burst and then may resolve without treatment. This is not recommended though, as it will be very painful and you could become quite ill.

Antibiotic medicines for an infection or abscess

A course of antibiotics may cure an infected gland or abscess. However, the more pus that forms, the larger the abscess, and the less chance that antibiotics alone will be sufficient to clear the abscess. In large abscesses, usually it is necessary to drain the pus. Where this is done, antibiotics may or may not also be needed.

A small operation is needed in many cases

The main aim of the operation is to drain any fluid or pus. This relieves symptoms. In addition, another aim is to minimise the chance of the problem happening again (recurring).

Marsupialisation
A small operation called marsupialisation is the traditional treatment used to treat a Bartholin's cyst or abscess. It may be done under general anaesthetic. It can also be done under local anaesthetic when the overlying skin is numbed with an injection of local anaesthetic. A small cut (incision) is made into the cyst or abscess just inside the entrance to the vagina. Any fluid or pus drains out. The cut is widened to about 1 cm. A few stitches are then used to stitch the inside lining of the cyst to the overlying skin. This then creates a small new permanent opening for fluid to drain out of the gland.

Initially, the opening that is left is like a pouch - hence the name of the operation. However, the opening gradually becomes smaller and soon the opening becomes tiny and not noticeable. This new opening becomes a new tube (duct) which allows any fluid that is made by the gland to drain.

A course of antibiotics may be prescribed if pus is drained from an abscess. However, antibiotics are not always needed once the pus has been drained.
Marsupialisation is usually successful. In only a few cases the problem comes back if this procedure is done. If a simple cut is made to drain the fluid or pus without then doing a marsupialisation, there is a high chance that the problem will come back at some point.

As with all operations there is a small chance of problems. For example, infection of the wound occurs in a small number of cases following marsupialisation.

Other types of operation
In recent years, various other procedures have been introduced which are sometimes used instead of marsupialisation. For example:

  • Insertion of a Word catheter. This is a small, thin rubber tube. The head of the catheter is inserted through a small cut made into the cyst or abscess. The tip of the catheter has a tiny balloon which is blown up to keep the catheter in place for 2-6 weeks. Whilst the catheter is in place you can go about your normal activities. The aim is to keep the opening from closing up. As the tissues heal, it allows the cells to form a new tube (duct) over the catheter.
  • Insertion of a Jacobi ring. This too is a thin catheter that is passed into the cyst or abscess through one small cut and out from a separate cut. The two ends of the catheter are tied together with a silk thread that goes through the middle of the catheter. As with a Word catheter, this is left in place for a few weeks to allow a new duct to form.

The operation chosen depends on factors such as the size of the cyst or abscess and the preference and expertise of the surgeon. They all usually work well with a low rate of recurrence.

Other techniques

Some people recommend that sitting in a warm bath for 10-20 minutes, three or four times a day, may encourage a Bartholin's cyst to burst naturally. It is not clear how well this may work. However, it is always best to see a doctor if you think an abscess is developing.

Other less commonly used procedures include application of silver nitrate to an abscess cavity and use of a carbon dioxide laser.

Sometimes the entire gland is removed by a surgical operation. This is considered a 'last resort' but may be advised if you have several recurrences of a Bartholin's cyst or abscess.

Will it happen again?

In most cases, a Bartholin's fluid-filled swelling (cyst) or collection of pus (abscess) does not happen again after treatment with one of the operations described above. If antibiotics alone cured the problem, or if the abscess is simply drained, there is more chance of it happening again at some point. Treatment may need to be repeated, or another type of treatment used.

Cases due to sexually transmitted infections

If you have a Bartholin's gland infection or abscess, a swab (a small ball of cotton wool on the end of a thin stick, used to take a sample) of the area or a sample of pus is usually sent to the laboratory. This is to identify which germ (bacterium) caused the infection. If a sexually transmitted germ is the cause of the infection then further screening for other sexually transmitted infections for yourself and your partner will usually be advised.

Can Bartholin's cysts or abscesses be prevented?

Not usually. Most occur 'out of the blue' for no apparent reason. Some Bartholin's abscesses are due to sexually transmitted infections and so using a condom when having sex may prevent some cases.

Itchy vulva (pruritus vulvae) is itching of the skin of the vulva. The vulva is the skin outside the vagina, including the lips of the vagina and the skin between the vagina and the anus. Itchy vulva is also called pruritus vulvae. Pruritus is the medical word for itch.

What is an itchy vulva?

'Pruritus vulvae' simply means itching of the vulva. The vulva is the area of skin just outside the vagina. Most women experience a slight vulval itch now and again. However, pruritus vulvae means the itch is persistent and causes distress. The itch may be particularly bad at night and may disturb your sleep. About 1 woman in 10 sees a doctor about a persistent 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.

What causes an itchy vulva?

An itchy vulva (pruritus vulvae) is a symptom, not a condition in itself. It can be caused by many different conditions. Therefore, if you have a persistent itchy vulva, you should see your doctor to find out the cause.

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

Infections

For example:

Sensitisation 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.

Skin conditions that may affect vulval skin

For example:

  • Atopic eczema.
  • Psoriasis.
  • Lichen simplex can affect the vulva. It is caused by scratching, usually initially triggered by the itch of eczema.
  • Lichen planus affects the vulval skin and the entrance to the vagina.
  • Lichen sclerosus affects the vulval skin and the skin around the anus. It may cause the skin to look like it is bruised or, more often, it turns the skin white. Read more about lichen sclerosus.

Urinary or faecal incontinence

  • This can make the skin of the vulva moist and irritated.
  • In little 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 prone to itch.
  • The low oestrogen levels can also cause vaginal dryness.
  • Low oestrogen levels can start before the actual menopause, ie when you are still having periods.
  • Local oestrogen can be helpful, either used as a cream, tablet 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 any other symptoms of the menopause too.

Pregnancy

  • This can cause itch 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.

Breast-feeding

Can cause itch due to low oestrogen levels.

Generalised body itch

Any cause of generalised body itch may also cause itching of the 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.

Diabetes

Can cause itch in the vulval area, 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 small lump or warty bit of skin as well as itch.

Stress

Stress can cause an itchy vulva. It may also make an itchy vulva which is due to some other cause last long after the original cause has settled.

Unknown causes

In some cases, including some severe cases, no cause can be found.

When should I see a doctor?

If you have an itchy vulva (pruritus vulvae) that is persisting, don't be embarrassed. Go to see your doctor or go to your nearest genitourinary medicine (GUM) clinic. If you think you have thrush and have been using cream that you have bought from a pharmacy but it isn't getting better after a week, stop using the cream and go to see a doctor.

Do I need any investigations?

Often, your doctor will be able to find the cause of your itchy vulva (pruritus vulvae) after talking to you and examining you. Examination will probably involve your doctor looking at the skin of your vulva and may also involve an internal (vaginal) examination. They may need to ask you quite personal questions about your sex life and may then suggest that sample swabs should be taken from your vulva and/or vagina to look for infection.

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

Skin patch testing may be suggested in some cases to determine if there is something that may be sensitising and causing irritation of the vulval skin.

Rarely, a doctor may need to examine your vulval skin in detail using a type of microscope called a vulvoscope. Taking a sample (biopsy) of the vulval skin may be suggested. 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.

How do you treat an itchy vulva?

By treating the cause if possible.

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

  • Identifying and stopping the use of anything that may be sensitising the vulval skin.
  • Using antifungal cream for thrush.
  • Using antibiotic medicines for certain infections,
  • Using steroid cream for various skin conditions.
  • Using hormone cream or hormone replacement therapy (HRT) if the itch is related to the menopause.

In young girls, learning 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).

What general treatments are there for an itchy vulva?

These are treatments which are likely to help with an itchy vulva (pruritus vulvae) whatever the cause.

Moisturisers
Bland moisturisers (emollients) such as emulsifying ointment can help to ease the itch. You can use emulsifying ointment in addition to most other treatments. Use it very liberally. Emollients can also be used as a soap substitute. Some of the creamier emollients can be stored in the refrigerator to keep them cool. If you are feeling particular itchy, applying some cool emollient from the refrigerator on to the skin may be soothing.

You can buy emollients at pharmacies, or obtain them on prescription. However, there is a slight word of caution. Occasionally, some people become sensitised to various ingredients that are in some emollients. This can make itch worse. Aqueous cream is a commonly available unbranded emollient but the ingredients can vary between manufacturers, including the addition of perfume, so it is best used simply as a soap substitute and not as a moisturiser. Sensitivity to emollients is unusual, however; bland moisturisers without added perfumes do help symptoms in most cases.

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

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. So, if you scratch, it may make the itch worse. Excessive scratching can also cause thickening of the skin - which then becomes even itchier. Therefore, apart from any other treatment, try not to scratch if at all possible.

Keep your nails cut short and don't wear nail varnish. Consider wearing cotton gloves at night to stop scratching in your sleep. Scratching may also damage the vulval skin and increase the risk of the skin becoming infected with germs (bacteria).

General vulval skin care and other advice

The following may also help ease an itchy vulva (pruritus vulvae), whatever the cause.

Clothes

  • Wear loose 100% cotton underwear. Avoid nylon or synthetic underwear material which tends to block fresh air and causes you to sweat more.
  • Change your underwear daily.
  • Avoid 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.
  • Consider wearing no underwear - for example, when you are at home, and at night.

Washing

  • Wash your vulva gently, once a day. Do not scrub or wash vigorously and avoid using a sponge or flannel to wash with. Over-cleaning may make symptoms worse. Use a bland, unscented moisturiser as a soap substitute. (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 take care to wash off any soap.
  • Don't put on your underwear until your vulva is fully dry. Dry the skin gently by dabbing it with a soft towel. A hairdryer may be useful to dry properly. Make sure it is on cool and held well away from the skin.
  • Try to avoid getting shampoo (which runs down your body in a shower) on to the vulva, where it may irritate.

Other general advice

  • Sometimes soaps, perfumes, bubble baths, deodorants, scented creams, the dye in toilet tissue, etc, can irritate (sensitise) the delicate vulval skin. Don't use any of these on your vulva or in your bath water or shower. Use plain, non-coloured toilet tissue. Use non-perfumed sanitary towels and panty liners and try to avoid using them on a regular basis. Consider avoiding plasticised 'one-way' top sheets which can cause sweating and reduce air circulation.
  • Avoid antiseptics or special vaginal washes.
  • 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.
  • Avoid condoms that are lubricated with spermicide, as they can be sensitising. Similarly, avoid perfumed lubricants.
  • Do not shave pubic hair.

Is there anything that can help me sleep?

An antihistamine medicine at bedtime may help if sleep is affected. Antihistamines do not have a great effect on the itch but some cause drowsiness (for example, hydroxyzine). This may help you to sleep. A doctor or pharmacist can advise on which antihistamines are sedating.

What is the outlook?

Most of the time, when a cause can be found, the cause is treated and the itch improves. However, depending on what the cause is, treatment is sometimes prolonged or may need to be repeated. Your doctor will advise on the best approach depending in your particular situation.

What if no cause is found?

In most cases, a cause can be found for an itchy vulva (pruritus vulvae). Treatment is then aimed at the underlying cause. However, in some cases no cause can be found. The general advice on clothes, washing, etc, will usually help. In addition, your doctor may advise that you use a mild steroid ointment such as hydrocortisone for a week or so. This often settles the itch within a few days. It may also help to break any itch-scratch cycle that has developed. However, you should not use steroid ointment regularly on the vulva, unless you have been advised to do so by your doctor, as it can have a thinning effect on the skin with long-term use.

Note: steroid ointments can make some conditions of the vulva worse. Some steroid creams are available 'over the counter'; however, you should see a doctor about a persistent itchy vulva before using any treatment, particularly steroid treatments.

Some women find an itchy vulva embarrassing, particularly if it becomes a persistent (chronic) problem. It can make them feel distressed and depressed and may interfere with their sex life. If you feel like this, go to see your doctor. They will be able to help and it is more likely than not that a simple treatment will solve the problem.

Lichen sclerosus (pronounced 'lie-ken scler-roe-suss') is a skin condition that mainly affects the genital skin (vulva) in women and the penis in men. It most commonly occurs in middle-aged women. Symptoms include itch, soreness and changes in the appearance of affected skin. Treatment with a steroid cream or ointment often eases the symptoms.

What is lichen sclerosus and who does it affect?

Lichen sclerosus is an uncommon skin condition. It used to be called lichen sclerosus et atrophicus, but it is often now just called lichen sclerosus. It most commonly affects the genital skin (vulva) of women. Less commonly it affects other areas of the skin. It can occur at any age but most commonly develops in young girls and also in women who have gone through their menopause. It is estimated that lichen sclerosus affects about 1 in 1,000 women. However, it may be more common than this, as some mild cases may go undiagnosed.

In men, lichen sclerosus affects the foreskin and end of the penis. It is very rare, affecting only around 1 in 100,000 men. It is more common in young boys and also adult men. Lichen sclerosus in males is sometimes also called balanitis xerotica obliterans.

This photo shows the typical appearance of lichen sclerosus in a woman in her 60s:

Lichen sclerosus open access image from Open-I: vulva.

This photo shows the condition balanitis xerotica obliterans in a man aged 65:

Balanitis xerotica obliterans in a 65 year old.

What are the symptoms of lichen sclerosus?

Women and girls - vulval and anal area

In a typical case, small pearly white spots develop on the genital skin (vulva). The spots are usually itchy. However, in some people there is no itch or other discomfort and lichen sclerosus is sometimes diagnosed by chance when the genitals are examined by a doctor for another reason. In about 3 in 10 cases, the skin around the back passage (anus) is also affected. Sometimes only the skin around the anus is affected. Typically, the itch and irritation become persistent and distressing. The itch tends to be worse at night which can disturb sleep. Sometimes soreness rather than itch is the main symptom. Lichen sclerosus is a skin condition only and does not extend into the vagina or inside the anus.

Over time, the white spots may become larger and join together. The whole vulva and/or anal skin may then become white and be more fragile than normal. The fragile skin may become damaged, inflamed, raw and prone to painful splitting and cracking. It may become painful to have sex. If the anal skin is affected, passing poo (faeces) may cause pain.

If left untreated, over months or years the vulva may shrink (doctors call this 'atrophy'). In some cases the changes of the vulval skin may make the entrance to the vagina narrower. This can make it difficult or painful to have sex. Also, thrush and other infections tend to be more common if the vulva is sore or cracked.

Symptoms may slowly get worse but not all the above symptoms may occur. It can take months or years from the first small spots to progress to more severe symptoms. At first the symptoms may be mistaken for thrush or other problems: often women have tried lots of creams from the chemist before being examined and having lichen sclerosus diagnosed.

Men and boys - penis

White spots develop on the foreskin and end of the penis. These can be sore. In time, the changes to the affected skin may cause difficulty in retracting the foreskin and in passing urine. Erections may become painful. The anal skin is rarely affected in men.

Other areas of skin

Sometimes small patches of lichen sclerosus occur on other parts of the body. These look like small pearly white areas on the skin. Sometimes they occur in people who also have genital lichen sclerosus. Sometimes they occur without genital problems. Away from the genital area, patches of lichen sclerosus usually do not cause itch or other symptoms.

What causes lichen sclerosus?

The cause is not known. There is a type of inflammation within affected skin which causes changes to the structure of the affected skin. It is not clear why this happens.

The cause is possibly an autoimmune disease. When this occurs, the body's immune system accidentally attacks your own body. This causes inflammation and damage to the affected part of the body. In people with lichen sclerosus the genital area of skin may be attacked by some parts of the immune system which then causes inflammation. However, this has not been proved and it is not really known what triggers lichen sclerosus to develop.

About 1 in 4 people with lichen sclerosus have another autoimmune disease such as thyroid disease, vitiligo, or pernicious anaemia. This is why it is thought that lichen sclerosus might be an autoimmune disease.

Are there any complications from lichen sclerosus?

The itch and discomfort may cause a lot of distress. The changes to the genital skin may cause sexual difficulties or problems in passing urine. There is also a small increased risk of developing cancer of the vulva. The exact risk is not known but it is thought that about 4 in 100 women with lichen sclerosus develop this cancer. In men there is a small increased risk of developing cancer of the penis. Again, the exact risk is unknown but it is thought that around 8 in 100 men with lichen sclerosus develop this cancer.

How is lichen sclerosus diagnosed?

The appearance is often fairly typical, in which case no further tests are needed. If the diagnosis is in doubt, a small sample (biopsy) of affected skin may be taken under local anaesthetic. The sample of skin is put under a microscope to look at the structure of the skin cells and tissues. This can confirm the diagnosis and rule out other disorders which can sometimes copy (mimic) this condition.

If lichen sclerosus is diagnosed it is usual also to do a routine blood test to check for an underactive thyroid gland. This is because of the association between lichen sclerosus and autoimmune diseases and, in particular, autoimmune thyroid disease. Up to 3 in 10 people with lichen sclerosus also have an underactive thyroid gland.

What is the treatment for lichen sclerosus?

Topical steroid

A strong steroid ointment or cream (topical steroid) is the main treatment (clobetasol or mometasone). Steroids reduce inflammation. It is usual to use the ointment or cream regularly for three months. A common plan is to use a single application at night for four weeks, followed by alternate nights for four weeks and then twice a week for four weeks. You must use the steroid as directed by your doctor. Keep on with treatment for as long as advised. Irritation tends to ease after two weeks or so, but the skin may take about three months of treatment to look and feel better.

The skin may return to normal if lichen sclerosus is diagnosed and treated with a topical steroid at an early stage. If the appearance of the skin has already changed a lot, the changes may not reverse much with topical steroid treatment even though symptoms of itch and soreness are often relieved.

After the initial regular treatment for about three months, you may then only need to use the ointment or cream once or twice every 1-2 weeks to keep symptoms away.

Some general measures

Use a moisturising (emollient) cream or ointment instead of soap to clean the genital area. Avoid bubble baths, scented soap, detergents, perfumes, etc, to the genital skin (vulva) of women. These may irritate the skin and make symptoms worse. Lubricants are useful during sex if having sex is painful.

Other treatments that are sometimes used

  • Other medicines. In the small number of cases where topical steroids do not help, a skin specialist may advise other medicines to reduce inflammation.
  • A vaginal dilator may be advised if you have any narrowing of the vaginal opening. A vaginal dilator is a cylinder-shaped piece of plastic that you insert into the vagina to gently stretch the opening and the inside. You use it each day for a time as directed by your doctor.
  • Surgery. An operation to widen the opening of the vagina is occasionally needed in women with severe lichen sclerosus which has caused narrowing of the vaginal entrance. (But note: regular use of a dilator as described above may prevent the need for surgery.)
  • Foreskin removal (circumcision) may be needed in some affected men or boys.
  • Some men may need other operations to improve the narrowing and scarring of the water pipe (urethra) caused by this condition.

Will it go away?

There is no permanent cure for lichen sclerosus. However, treatment with a topical steroid usually controls the symptoms of itch and soreness, and often prevents the condition from getting worse. Occasionally the condition clears away for good for no apparent reason. This is more common in young girls when the condition often goes during puberty.

What is vulvitis?

Vulvitis is an inflammation of your vulva. It is not a disease or an actual condition. It has many different causes which will be discussed in this leaflet.

How common is vulvitis?

Inflammation of the vulva (vulvitis) is very common and can occur in women of all ages.

What causes vulvitis?

Inflammation of the vulva (vulvitis) has many different causes, as listed below. It is sometimes difficult to determine the cause of the vulvitis.

Infections

Infections are caused by germs such as bacteria, viruses and fungi. Infections in the vagina are common and these infections can also affect your vulva. The following infections may occur causing vulvitis:

  • Thrush: around three quarters of women have thrush at some stage in their lives. Thrush infection can lead to a whitish discharge and often leads to your vulval area becoming red and very itchy. This is usually treated with antifungal creams which are available from your doctor or local pharmacy.
  • Genital herpes infection: this is usually a sexually transmitted infection which is passed on by skin-to-skin contact. Many people infected with this germ (virus) never have symptoms but can still pass on the infection to others. If symptoms occur, they can range from a mild soreness to painful blisters on the genitals and surrounding area. Treatment is with antiviral medication.
  • Genital warts: these are caused by a virus that can be passed on by close sexual contact. They usually grow on the vulva but can also grow on the skin around your bottom. They are usually either treated with chemicals or with physical treatments such as freezing to destroy them.
  • Other infections: these include scabies and pubic lice.

Skin conditions

Inflammation of the skin of the vulva can be due to an allergy, similar to an allergy affecting other areas of your skin. This is called an allergic or contact dermatitis. Any skin conditions that affect the skin can also affect the skin of your vulva - for example, psoriasis, lichen sclerosus or lichen planus.

Irritation

There are many different products that can cause irritation to the vulval area which then leads to vulvitis. Examples of these include:

  • Scented toilet paper.
  • Perfumed soaps or bubble baths.
  • Spermicides.
  • Swimming pool water or hot tub water.
  • Horse riding or cycling.
  • Synthetic underwear.

Low oestrogen levels

Levels of the female chemical (hormone) called oestrogen are reduced during the menopause. Some women develop vulvitis as a result of their low oestrogen levels. This is usually associated with atrophic vaginitis which causes your vagina to become quite dry and sore.

Vulval cancer

Vulval cancer is an uncommon cancer and usually affects women aged over 60 years. Vulval cancer can start as a sore or lump in the vulva.

Note: if you have noticed any new changes (however minor) in your vulval area then you should see your doctor.

Vulvodynia

Vulvodynia is a burning, stinging but often unexplained pain affecting the skin around your vagina or vulva. The skin of your vulva is usually normal but some women have some swelling or inflammation.

What symptoms may occur?

Symptoms vary greatly between women and the symptoms often depend upon what is causing the inflammation of your vulva (vulvitis). The most common symptoms are itching (this can often be worse at night) and soreness.

It is really important to try not to scratch, as this can lead to further irritation and sometimes an infection developing.

What changes may occur to my vulva?

It can be common to develop redness and/or swelling of your vulval area. You may notice thickened or whitish patches around your vulval area. Some women develop clear, fluid-filled blisters.

What is the treatment of vulvitis?

The treatment of inflammation of the vulva (vulvitis) depends on the underlying cause.

It is usually recommended that you do not use soap or fragranced products to wash your vulva. In addition, you should avoid contact of your vulval skin with bubble bath, shampoo, personal deodorants, wet wipes, detergents, textile dyes, fabric conditioners and sanitary wear. These can all worsen the irritation.

You should just wash this area once a day with warm water. Ideally you should wear cotton underwear that is not too tight. Your doctor may recommend an emollient which you can use instead of soap and this can be very soothing for many women. Emollient creams can also be very soothing to use, as they work to moisturise the skin. If the itching is particularly bad then your doctor may recommend you take an antihistamine tablet which will reduce the itching.

If you are using contraception, it is recommended that your partner should avoid using spermicidally lubricated condoms. Some women find using lubricating gels useful during sex (intercourse).

Steroid creams are often given which are usually used for short periods of time. These work by reducing the inflammation and also the irritation and can be really effective for many women. There are different strengths of steroid cream and usually the weakest strength is given first. However, if this does not work effectively then stronger steroid creams are usually given.

If the underlying cause is an infection then an antifungal or antibiotic treatment may be given.

Sometimes a cream, pessary or vaginal tablet containing the female chemical (hormone) called oestrogen is prescribed if the cause of your vulvitis is low oestrogen levels.

Local anaesthetic creams, some medications and surgery are some treatments for women with burning, stinging but often unexplained pain affecting the skin around the vagina or vulva (vulvodynia).

Further reading & references

  • Lawton S; Nappy rash: diagnosis and treatment. J Fam Health Care. 2014 Jul-Aug;24(5):36-40.
  • The Management of Vulval Skin Disorders; Royal College of Obstetricians and Gynaecologists (February 2011)
  • Reyes MC, Cooper K; An update on vulvar intraepithelial neoplasia: terminology and a practical approach to diagnosis. J Clin Pathol. 2014 Apr;67(4):290-4. doi: 10.1136/jclinpath-2013-202117. Epub 2014 Jan 7.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.

Author:
Dr Colin Tidy
Peer Reviewer:
Dr Helen Huins
Document ID:
28996 (v2)
Last Checked:
18/10/2017
Next Review:
17/10/2020