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, and the clinical task is always to identify the specific underlying cause rather than to treat the itch blindly.
Causes span infection, inflammatory dermatoses, hormonal change, neoplasia, and systemic disease. The single most common cause is vulvovaginal candidiasis (thrush), followed by the chronic dermatoses – particularly lichen sclerosus, eczema/contact dermatitis, and psoriasis. Two skills matter most: examine the vulva in every persistent case, and 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 / 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. |
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🧠 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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