GPAtlas🧭 When to suspect
Pruritus vulvae – persistent, distressing itching of the vulva – is a symptom, not a diagnosis. It is one of the commonest reasons women present with vulval complaints: always identify the specific underlying cause rather than treat the itch blindly.
Causes span infection, inflammatory dermatoses, hormonal change, neoplasia, and systemic disease.
• The most common cause is vulvovaginal candidiasis (thrush).
• It is followed by the chronic dermatoses – particularly lichen sclerosus, eczema/contact dermatitis, and psoriasis.
Two skills matter most:
• Examine the vulva in every persistent case.
• Never miss the dermatosis or malignancy hiding behind a label of "recurrent thrush".
| Category | Causes to consider |
|---|---|
| Infective | • Vulvovaginal candidiasis (commonest) • Bacterial vaginosis • Trichomoniasis • Threadworm (especially nocturnal itch, common in children) • Scabies and pubic lice • Genital herpes and warts |
| Inflammatory dermatoses | • Irritant or allergic contact dermatitis (soaps, wipes, "feminine hygiene" products) • Atopic eczema • Psoriasis (often flexural/inverse) • Lichen simplex chronicus • Lichen sclerosus • Lichen planus |
| Hormonal | Atrophic vaginitis or genitourinary syndrome of the menopause (GSM) – oestrogen deficiency causing a thin, dry, fragile vulva. |
| Neoplastic | • Vulval intraepithelial neoplasia (VIN) • Vulval squamous cell carcinoma (SCC) • Extramammary Paget disease (an eczema-like, intractable itch that will not settle) |
| Systemic | • Diabetes mellitus (recurrent candidiasis) • Iron deficiency • Thyroid disease • Chronic kidney or liver disease – usually with generalised, not isolated, itch |
|
🧠 Clinical pearl • Let age steer the differential. • Before puberty, think threadworm and irritant/hygiene factors – candidiasis is uncommon. • In the reproductive years, candidiasis and contact dermatitis dominate. • After the menopause, recurrent "thrush" in a woman not on hormone replacement is atypical, because candidiasis is oestrogen-dependent – reach instead for atrophy, lichen sclerosus, or neoplasia. |
Source: BAD · BASHH · NICE NG12
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