Skin conditions of the vulva

The vulva is the area surrounding the opening of the vagina. It includes the labia (the inner and outer vaginal lips) and the clitoris.

Many women have symptoms, which can occur at any age. The most common are itching, pain, soreness or a change in the skin colour and texture. These symptoms may be caused by a condition that only affects the vulva, but they can sometimes be a sign of a more general medical problem or other skin disease. Your symptoms may be made worse by moisture, heat or rubbing and by the use of scented products/deodorants.

Yes. It is important that you visit your doctor to see what may be causing the problem. He or she should also be able to advise on how to help your symptoms.

Your doctor will ask you questions about the symptoms affecting your vulva and also about any symptoms in other parts of your body. You will also be asked about what medication you are taking and about your personal and family medical history. This is because conditions such as thyroid disease, diabetes, anaemia or a history of hay fever, asthma or eczema can be linked to some vulval skin conditions.

Women can often have an allergic reaction in their vulval skin, so it may be useful to list any treatments such as creams and ointments that you have been using on your skin in that area. Sometimes irritation can also be caused by chemicals in washing powders and bath or sanitary products.

The skin of your vulva will be examined for signs of a skin condition that might affect other parts of your body. Your doctor may look at your mouth, scalp, elbows, knees and nails, the inside of your vagina and the skin around your anus.

Vulval skin conditions may sometimes make sex difficult. This can be very distressing. You may be asked some intimate questions to help reach a diagnosis and to decide which treatment is the most suitable for you.

If your doctor thinks you may have a more general health problem, you may need to have blood tests and swabs to check for infection.

Often your doctor may be able to decide what is wrong from the appearance of your skin. You will be offered treatment that is most likely to work for your condition. If your skin does not get better or if the diagnosis is unclear, you may be advised to have a biopsy (a tiny sample of skin taken for testing).

Biopsies are often performed in the outpatient clinic, using local anaesthetic to numb the area so you will feel no pain when the biopsy is taken.

Itching of the vulva may be caused by an allergy. You can develop sensitivity after you have been using a product for some time. Your doctor may suggest having further tests to find out what you are sensitive to.

There are several skin conditions that may affect the vulva, including:

• Lichen sclerosus
  • This can affect women of any age but is most often found in women after the menopause. It is thought to be caused by a problem with the immune system. It is not related to the use of hormonal contraceptives or hormone replacement therapy (HRT).
• Lichen planus
  • This condition tends to cause pain rather than itching. It can affect the skin anywhere on the body, particularly the mouth.
• Vulval dermatitis (lichen simplex)
  • This can happen if you have sensitive skin, dermatitis or eczema. It may also extend to your inner thighs or pubic area. Stress and chemical irritants may make your symptoms worse.
• Vulval atrophy
  • This can happen when the female hormone estrogen falls, usually after the menopause. It causes the skin to be pale and can cause itching or soreness.
• VIN (vulval intraepithelial neoplasia)
  • VIN is found in the vulva and can only be diagnosed by taking a biopsy. In this condition there are changes in the skin that may become cancerous over time. It is similar to the pre-cancerous changes that are looked for in cervical smears. Your doctor may advise you to have your cervix and vagina examined in detail with a microscopic camera (colposcopy) to check those areas as well. Women who have lichen sclerosus may sometimes have VIN.
• Candida infection (thrush)
  • This tends to cause irritation and soreness of the vulva rather than the discharge that most women are aware of when it affects the vagina. Sometimes candida can be passed to a sexual partner so it is important that they are checked and treated if necessary, if your symptoms don’t improve.
• Psoriasis
  • This may affect the vulva and cause dryness and thickening of the skin. Other parts of your body such as the nails and scalp may also be affected.

Apart from candida, the above conditions are not infectious and will not be passed to a sexual partner.

Most symptoms respond to simple measures, such as avoiding irritants, using a soap substitute for cleansing and making sure the skin is moisturised, but sometimes treatment is needed. The type of treatment will depend on which skin condition you have.

Medication such as antihistamines or anti-itching drugs may help, especially if you are having difficulty sleeping.

If you have lichen sclerosus or lichen planus, you may need to use steroid ointment. This will improve symptoms for most women. Once treatment is completed, the colour and texture of your skin may not return to normal. Women under the age of 50 tend to respond best to these treatments. Unfortunately, symptoms often come back and long-term treatment may be needed.

About 1 in 10 women with lichen sclerosus have symptoms that do not improve with steroids. If this happens, you should be referred to a specialist clinic.

If your skin is pale, which suggests a lack of estrogen, you may be offered a short course of estrogen cream.

Candida is treated with antifungal tablets and creams. If you have candida that keeps coming back, you may need treatment for a longer period, often up to 6 months.

Most conditions of the vulva will be helped by these simple measures. If your symptoms persist despite treatment, it is important to tell your GP, who should refer you to a specialist.

You will usually have the affected piece of skin removed by surgery. If you don’t have this done, the doctor will take several tiny skin samples to make sure there is no cancer present.

Most small areas of VIN can be removed without any problems. If a large area of skin needs to be removed, you may need to have reconstructive (plastic) surgery to prevent excessive scarring, skin tension or problems with sex.

You may be offered other treatments such as laser or creams but these are not suitable for everyone. Your doctor will discuss the best option for you in your situation.

You should check your vulva regularly. You can ask your GP or practice nurse to do this for you but you can also do it yourself. If you examine yourself regularly, you become aware of what is normal for you, and can quickly detect any changes.

If you have lichen sclerosus or lichen planus, you will usually be followed up by your GP rather than at the hospital. It is particularly important with these conditions that you watch out carefully for any change in your symptoms and go back to your doctor if you have any concerns. This is because there is a small risk that skin cancer may develop.

If you have VIN, you will have regular check-ups, usually once a year, at a specialist clinic. This is because there is a higher risk of developing cancer of the vulva. You will also be given advice to look out for ulcers or blisters on the skin. If you develop these or have any concerns, you should tell your doctor so that you can be seen earlier if necessary.

Vulval skin is very sensitive so it is important to avoid irritants that may make symptoms worse.

Washing

• Washing with water and soap may cause dry skin and make itching worse. Using soap substitutes can be soothing and protective, and will stop the skin from becoming as dry and irritated. Aqueous cream (a special type of moisturiser available without prescription from your pharmacy or on prescription from your doctor) can be used instead of soap. It can be kept in the fridge and also be dabbed on to cool and soothe the skin.
• Too much washing can make the symptoms worse so you should clean the vulval area only once a day. If possible, have a shower rather than a bath, but if you do have a bath it is helpful to add an emollient (see below). Don’t use antiseptics. Avoid using sponges or flannels to wash the vulva as these can irritate the skin. To dry, pat the area with a soft towel or use a hairdryer on a cool setting held well away from the skin.
• Avoid wearing panty liners or sanitary towels on a regular basis. Avoid coloured toilet paper.

Clothing

• Wear loose-fitting cotton or silk underwear (rather than synthetic, dyed underwear). White or light-coloured underwear is preferable as dark textile dyes may cause allergies.
• Avoid clothes such as tights, leggings, tight jeans and cycling shorts. At home, you may find it more comfortable to wear loose-fitting clothes without underwear. Sleep without underwear.
• Avoid using fabric conditioners and biological washing powders.

Irritants

• Avoid using soaps, shower gels, scrubs, bubble baths, deodorants, baby wipes and douches as all of these may contain skin irritants.
• Be careful when using over-the-counter preparations as some of those available may aggravate allergies and prolong symptoms, e.g. baby or nappy creams, herbal creams (tea tree oil, aloe vera) and thrush treatments.
• If you tend to scratch your skin, keep your nails trimmed if possible and avoid wearing nail polish.

Emollients

Emollients (moisturising creams and ointments) help protect the skin. They are available over the counter or on prescription. Using a moisturiser even when you do not have symptoms can prevent flare-ups. It is important to find the one that suits you best – if the first one you try does not relieve your symptoms, it is worth trying a different one.