Synonyms
- Vulvar Dermatoses
- Vulvar Dermatitis
Subdivisions
General Discussion
Just like any other area of our bodies, the vulva and vagina can experience dermatological (skin) disorders that can cause discomfort and pain. Many of these skin disorders are common, chronic conditions that can affect all aspects of the patient's life ranging from the ability to perform daily activities, ability to have sex, relationships and feelings of self-worth. [1] Patients may experience many emotions such as shame, fear, and embarrassment in addition to the physical discomfort of the disorder.
This article will primarily discuss general information related to vulva and vagainal skin conditions because symptoms, causes and treatments will vary based on the specific skin disorder. For more information about individual disorders see our condition specific information pages in the Related Disorders section of this article.
The skin of the vulva and vagina is primarily mucous membranes. The clitoral hood and labia minora are modified mucous membranes that transition to the vaginal mucous membrane at the vestibule (the opening to the vagina). This transition zone in the skin is called Hart’s line.[3] The variation in skin type means that some conditions are more likely to affect some areas of the genitals versus others. Mucous membranes are found on other parts of the body; the inside of the mouth is an area of mucous tissue that can also be affected in some patients with vulvovaginal skin disorders.
Although it is not discussed or represented often enough in our culture, there are many variations of normal vulva color, size and shape of the anatomy. For some people Hart’s line is easily distinguishable by a change in color and/or texture. However, it is also common for there to be no significant marking at this transition. Some people have a more prominent presentation of sebaceous glands which visually present as a yellowish texture on the labia minora [3]. Throughout our lives natural changes to the structure and color of the vulva through major life transitions such as puberty, pregnancy and menopause. The health of vulva mucous tissues is dependent on many factors including (but not limited to) hormones, the microbiome, and the way we treat our bodies. Pain, loss or fusion of portions of the vulva anatomy or any of the symptoms noted below are not normal. If you are experiencing any of these symptoms you should consult your gynecologist or dermatologist.
Signs & Symptoms
Symptoms of vulva skin disorders may include:
- Change in vulva and/or vaginal skin color or texture
- Changes in vulva anatomy
- Lesions - refers to places where the skin structure has changed. Lesions are any type of abnormal bump, rash, blister, ulcer, or plaque.
- Vulva and/or vaginal pain such as burning, rawness, stinging, or stabbing sensations
- Itching (pruritus)
- Fissures - splits, cracks or tears in the skin
- Pain with sex (dyspareunia)
Sometimes there are very obvious skin or anatomy changes; however often the symptoms can be vague, continuous, come and go, be localized to a specific area or general all over the vulva [1] Exact signs and symptoms vary based on the disorder. See our individual pages for a more in depth discussion of each disorder.
Along your path to diagnosis you may encounter additional medical terminology used to describe symptoms of skin disorders. The following is a list of terms that may aid in communication of symptoms to your doctor.
- Papules - Is a type of skin lesion. Papules are a solid raised spot on the skin that is less than 1cm (approx. 3/8 inch) wide.
- Ulcers - An open sore where the skin is broken and one or more layer of tissue is lost
- Plaque - Is a type of lesion. It is a distinct thickened patch on the skin that is usually raised.
- Pigmentation - This term refers to a color change of the skin.
- Vulvovaginal Atrophy - A state where the vulvovaginal tissues are weak and brittle due to lack of hormone signals
- Erosive - Refers to a superficial sore or area where the outer layers of the skin break down
- Keratinized - When the skin is thickened and hardened by cells filled with keratin proteins
Causes
Contact dermatitis can result from an exposure to an allergen that initiates an immune response or an irritant may directly damage the vulvo-vaginal tissue. Responses to irritants can be immediate or delayed. The vulva is more susceptible to irritants when the protective barriers of the skin have been compromised by factors such as estrogen deficiency, moisture from urine or vaginal discharge, friction, heat, or stool residual enzymes. [1]
Over aggressive washing, use of douches, and cleansing products can damage or undermine the skin’s natural defenses leaving you more susceptible to irritants. Common examples of irritants are urine, sweat, topical medications, feminine hygiene products, soaps and cleansers. Common examples of allergens are topical antibiotics, corticosteroids, thiuram used in condoms, chemicals used in clothing dye, preservatives, and ingredients in wet wipes. [1]
For all other skin disorders the causes vary and in many cases are unknown. It can be difficult to determine the cause because of the varying presentations. Origin theories include triggering factors such as trauma, viruses, hormones, and autoimmune disorders.
Affected Populations
Vulvar skin conditions can affect people of any age. Individual skin disorders have varying levels of occurrence. Contact dermatitis accounts for up to 50% of vulvovaginal skin symptoms. [1] Whereas, vulvar psoriasis accounts for an estimated 5% of all female patients who present with persistent vulvar discomfort. [1]
Some patients that experience inflammatory skin conditions on other areas of their body will also have the condition present in the genitals. If we continue with psoriasis as an example, psoriasis affects approximately 2% of the general population and 29-46% of psoriasis patients will have genital psoriasis. Although less common, it is possible to experience psoriasis only in the genital area. 2-5% of psoriasis patients only have skin in the genital area affected. [2]
Diagnosis
There is often a delay in diagnosis of vulvo-vaginal dermatiological disorders until skin changes have progressed to match clear diagnostic criteria of a disorder. The skin disorders are challenging for doctors to diagnosis because symptoms such as itching or pain with sex often overlap with those of other vulvo-vaginal disorders and skin disorders may occur at the same time as other vulvodynia conditions. For example, one may experience pelvic floor muscle dysfunction and lichen planus at the same time. Both conditions can cause pain with sex.
In additon to the inherant chanlleges associated with identify accurately diagnosing the disorder, dermatologists are often unfamiliar with vulvar exams and female sexual concerns and general gynecologists are often unfamiliar with the management of dermatological disorders. This gap between specialties can leave patients undiagnosed. [1]
If you suspect you have a vulvo-vaginal skin disorder look for a sexual medicine specialist with training in skin disorders. Sexual medicine specialists may be gynecologists, urologists, or genital dermatologists who have additional experience in treating these disorders. Your primary care provider or general gynecologist should be able to help you with a referral to a specialist.
It is important to rule out other conditions in the process of diagnosing skin disorders. After your doctor has taken a detailed medical history, he or she should perform a detailed vulva exam, take vaginal cultures to rule out infections and STIs. If contact dermatitis is suspected, a detailed review of daily product use and hygiene practices will likely be reviewed. Your doctor may provide a referral to a dermatologist for patch testing to try to identify any irritants that could be causing a delayed allergic response if the irritant or allergen is not easily found. Your doctor may recommend a biopsy to further aid the diagnosis.
Standard Therapies
The treatments for most vulvovaginal skin disorders involve treatment with topical corticosteroids. The strength of the corticosteroids, dose and length of treatment varies based on the level of symptoms and the disorder being treated.
Irritant (atopic) dermatitis:
Treatments for irritant dermatitis include: anti-inflammatory, anti-proliferative, immunosuppressive and vasoconstrictive actions. The overall goal of these therapies is to decrease acute and chronic inflammations as well as associated itching. In some cases, long term daily use can result in unwanted side effects and HPA axis suppression; therefore, using high potency treatments is recommended until dermatitis is completely clear and then transitioning to a twice weekly dosing (with a mid-potency agent) thereafter can significantly reduce the risk of relapse.
Moisturizers are non-pharmacological therapies for irritant (atopic) dermatitis. There is strong evidence encouraging the use of moisturizers on the skin and that they reduce disease severity and the need for pharmacologic interventions. Moisturizers should be applied soon after bathing to improve skin hydrations. Moisturizers can be the main primary treatment for mild disease and should be part of the regimen for moderate and severe disease. Emollients (i.e. glycol and glyceryl stearate, soy sterols) lubricate and soften the skin, occlusive agents (i.e. petrolatum, simethicone, mineral oil) form a layer to retard evaporation of water, whereas humectants (i.e.glycerol, lactic acid, urea) attract and hold water. It is imperative that a moisturizer approved for vulvovaginal use is selected. If you suspect, or have been diagnosed with, a skin disorder consult your doctor before self-treating with a vulvovaginal moisturizer.
High-potency steroids are best for lichenified plaques, nummular or prurigo-like lesions.
In extreme cases surgery may be required for labia fusion, vaginal scarring, or clitoral phimosis in order to restore urinary and sexual function.
Investigational Therapies
Support Available
References
- Kellogg-Spadt S, Kusturiss, E. Vulvar Dermatoses: A Primer for the Sexual Medicine Clinician, ISSM Sex Med Rev 2015;3:126-136
- Simonetta C, Burns E, Guo M. Vulvar Dermatoses A Review and Update, Missouri Medicine 2015;7-8:301-307
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170060/ - Schlosser B, Mirowski G. Approach to the patient with vulvovaginal complaints Dermatologic Therapy, Vol. 23, 2010, 438-448
https://pubmed.ncbi.nlm.nih.gov/20868399/ - https://rarediseases.org/rare-diseases/lichen-sclerosus/
- https://rarediseases.org/rare-diseases/lichen-planus/
- Mauskar M, et. al. Vulvar Diseases, American Academy of Dermatology, Inc. Vol 82 No. 6, 2020, 1287-1298
- https://www.issvd.org/application/files/1016/3298/4948/19EN_-_ExtraMammaryPagetHH_-_v2.pdf
- https://www.issvd.org/application/files/8016/3298/3506/13EN_-_VULVAR-LICHEN-PLANUS2021_LSHH_-_V2.pdf
- Ringel, N. Iglesia, C. Common Benign Chronic Vulvar Disorders, American Family Physician, 2020
https://www.aafp.org/dam/AAFP/documents/journals/afp/Ringel.pdf - Beck, K. et. al Treatment of Genital Psoriasis: A Systematic Review, Dermatol Ther (Heidelb) 2018 8:509-525
- Portman, D. et. al, Genitourinary syndrome of menopause: New Terminology for Vulvovaginal Atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society, Menopause: The Journal of The North American Menopause Society, Vol. 21, No. 10, 2014 1063-1068
