Dermatitis of the vulva N76.3

Vulvar dermatitis, often referred to as "vulvar eczema", is defined as an acute, subacute or chronic inflammatory intolerance reaction of the female genital skin due to damage of the epidermis by external noxious agents. It can be triggered by both irritative and immune mechanisms. Initially self-limited, it may become chronic if the cause or underlying disposition persists.

Vulvar dermatitis affects a topical "special region", namely a skin region with a particular texture and special functional properties that enable it to adapt to physiological regional features. The anatomy of the skin of the labia majora is characterized by a keratinizing squamous epithelium with abundant hair (pubic hair) and sebaceous, eccrine and apocrine sweat glands. The labia majora enclose the nonkeratinizing areas of the labia minora, orificium urethrae, clitoris, and introitus vaginae.

Vulvar dermatitides not infrequently have a chronic course with significant morbidity, usually characterized by multiple pretreatments of all types. Thus, diagnosis and therapy also represent a challenge for the treating physician. They often require interdisciplinary collaboration involving family physicians, gynecologists, and dermatologists. Frequently, it is the symptom "non-suppressible itching" that leads to physician consultations. Thus, 5-10% of all pruritus cases are related to the female genital area, which illustrates the general importance of these diseases.

Vulvar dermatitis can be classified as follows:

• Non-allergic acute or chronic contact dermatitis (most common dermatosis of the vulva).
• Allergic acute or chronic contact dermatitis
• Atopic vulvar dermatitis
• Lichen simplex chronicus Vidal

It is often triggered by cumulative toxic irritations, less frequently by contact allergies. Vulvar dermatitis can also be a manifestation of atopic dermatitis. A special clinical feature is lichen simplex chronicus, which many classify as a chronicized, localized variant of atopic dermatitis.

A broad area in triggering vulvar dermatitis is provided by cosmetic procedures such as shaving of pubic hair. Some women formally apologize even before the examination that they "were not freshly shaved just now".

Allergic acute or chronic contact dermatitis

The prerequisite is sensitization (type IV reaction) to topically applied substances. The following substances play a role here:

• Fragrances
• Disinfectants
• Antibiotics
• Local anesthetics
• lubricants
• Components of other therapeutics

Non-allergic acute or chronic contact dermatitis

• Substances of skin cleansing agents
• Disinfectants
• Irritation caused by urine or stool products (women with incontinence are particularly affected)

Atopic dermatitis (in the context of generalized atopic dermatitis or (more rarely) as a localized minus variant). Clinically usually severe lichenification of the skin, other evidence of atopic diathesis.

Lichen simplex chronicus Vidal (usually localized variant of atopic dermatitis; often no evidence of atopic diathesis).

Inflammatory vulvar dermatoses often have an altered clinical appearance due to the intertriginous regional situation compared to the corresponding diseases in other parts of the body. The reason for this is the "intertriginous environment of the genital region", which is caused by occlusion of tight-fitting clothing, by panty liners, by mechanical influences, by chemically irritating intimate cosmetics, by shaving, heat, moisture and sweat, by urine and vaginal secretions, and by unsuitable topicals.

Chronic pruritic dermatitis is predominant. The itching is often described as excruciating. In addition, there is a feeling of soreness and sometimes pain. The itching manifests or intensifies especially when sitting for a long time with uncomfortable tight-fitting clothing (tight-fitting jeans pants). This is also true when riding a bicycle. Psychological stress can have a reinforcing effect. Thus, itching in observed civilized surroundings can build up to an agonizing itch scenario.

Regardless of the exact etiologic provenance, the clinical picture of vulvar dermatitis is characterized by indistinct, faint erythema, mild swelling, scaling of varying degrees, even scaly crusts or incrustations, and scratch excoriations. Chronic persistence is usually accompanied by varying degrees of lichenification (a secondary phenomenon caused by severe pruritus and the unsuppressible scratch-friction reflex).

In addition to the clinical-morphological examination of the vulva, both groins, the perineal and anal regions and, if necessary, the entire integument should be examined (e.g. in atopic diseases and in suspected psoriasis). If the vulva is to be assessed in more detail, vulvoscopy is recommended, which allows examination at 7-30x magnification. If necessary, epicutaneous testing should be performed after careful history taking (intimate cosmetics, disinfectants, cleansers, contraceptives, condom components). In addition, RAST diagnostics can be performed if an atopic component is suspected. In the case of prolonged symptoms (>4 weeks) and suspicious clinical local findings, histological clarification by means of a 4-mm punch biopsy is recommended.

The differential diagnosis of vulvar dermatitis includes several, usually uncomfortably itchy, acute or chronic, infectious or noninfectious dermatitides of the vulva.

Infections of the vulva (about 25% of cases).

Bacterial infections

• Folliculitides
• Furuncles
• Acne inversa (hidradenitis suppurative
• a)
• Streptococcal vulvitis in childhood

Mycological infections

• Candidiasis (smear examination with culture)
• Tinea genitalis (not infrequently the anal and inguinal areas are also affected; mycological diagnosis)
• Condylomata lata

Other infections

• Infections caused by scabies mites (light microscopic diagnostics, duct structures)
• Infestations by crabs (light microscopic diagnosis)
• Condylomata acuminata
• Lymphogranuloma venereum
• Ulcus molle
• Herpes simplex

Other inflammatory (pruritic) diseases of the vulva

• Intertrigo
• Pruritus sine materia
• Vulvodynia
• Fixed drug reaction
• Fox-Fordyce's disease
• Skin changes in the context of psoriasis vulgaris (to be cured is psoriasis on other parts of the skin); rarer is a localized minus variant of psoriasis
• Lichen sclerosus et atrophicus
• lichen planus
• Hailey-Hailey disease
• Pemphigus of the vulva
• Graft versus host disease in organ transplant recipients
• Langerhans cell histiocytosis (very rare)
• Rhagades of the vulva
• Urticaria of the vulva (mastocytoma) Arik Yilmaz E et al (2017).
• Dermatographism with vulvar symptoms (Riviera S et al 2021).
• Vulvodynia

Therapy

• No shaving of pubic hair
• Avoidance of soaps, shower gels, intimate sprays, avoidance of triggering noxae
• Change of pad brand, untreated eco-pads are recommended
• daily care with Deumavan®, Linola Schutzbalsam®, Dexeryl® or pomegranate oil (Weleda)
• in case of strong inflammatory reactions Clobetasol- cream or fat ointment 3-5 days 2x/d, followed by Prednicarbat (Dermatop®) or Methylprednisolon (Advantan®) 2x/d for one week; in case of chronic problems also maintenance dose 1-2x/week possible
• Sitz baths with Tannolact ® or Töpfer Kleiebad® (clover bath)
• In postmenopausal atrophic vulvitis, vaginal estrogenization with estriol suppositories or cream, if necessary also preparations containing estradiol (Linoladiol®, Estring®)
• Elidel® (pimecrolimus) is an option in atopic vulvar dermatitis

1. Admani S et al (2021) Localized systemic contact dermatitis: The vulva as a clue to identify allergen ingestion. Int J Womens Dermatol 7:843-844
2. Arik Yilmaz E et al (2017) Rare cause of recurrent urticaria in childhood and its unusual presentation: Solitary mastocytoma on vulva. J Dermatol 44:213-214.
3. Ball SB et al (19989 Vulvar dermatoses: lichen sclerosus, lichen planus, and vulval dermatitis/lichen simplex chronicus. Semin Cutan Med Surg 17:182 -186
4. Black RJ (2005) Vulval eczema associated with propolis sensitization from topical therapies treated successfully with pimecrolimus cream. Clin Exp Dermatol 30:91-95.
5. Caminati M et al (2019) Allergy and sexual behaviors: an update. Clin Rev Allergy Immunol56:269- 274.
6. Crone AM et al (2000) Aetiological factors in vulvar dermatitis. J Eur Acad Dermatol Venereol 14:181-186.
7. Gilissen L et al (2021) Iatrogenic allergic contact dermatitis in the (peri)anal and genital area. Contact Dermatitis 84:431-438.
8. Guerrero A et al (2015) Inflammatory vulvar dermatoses. Clin Obstet Gynecol 58:464 -475.
9. Guillet G et al (2004) Seminal fluid as a missed allergen in vulvar allergic contact dermatitis. Contact Dermatitis 50:318-326.
10. Hoang MP et al (2014) Vulvar inflammatory dermatoses: an update and review. Am J Dermatopathol 36:689-694.
11. Krishnan A et al (2013) Scrotal dermatitis - Can we Consider it as a Separate Entity? Oman Med J 28:302-305.
12. Nardelli A et al (2004) Contact allergic reactions of the vulva: a 14-year review. Dermatitis 15:131 -135
13. Preston A et al (2019) Textile-induced vulvar and perianal dermatitis. Contact Dermatitis 81:66-68
14. Prieto MA et al (2004) Vestibular papillae of the vulva. Int J Dermatol 43:143-144
15. Rivera S, Mirowski GW. Dermatographism with vulvar symptoms. Int J Womens Dermatol. 2021 May 5;7(4):454-457.
16. Stand S et al (2003) Antipruritic effects of pimecrolimus and tacrolimus. Dermatologist 54: 413-417
17. Trivedi MK et al (2018) Testing in vulvar allergic contact dermatitis. Dermatitis 29:95-98
18. Utaş S et al (2008) Patients with vulval pruritus: patch test results. Contact Dermatitis 58:296-298
19. Woodruff CM et al (2018) Allergic contact dermatitis of the vulva. Dermatitis 29:233-237