Most chronic vulvar irritation is not candida: history is key

OB/GYN News, Sept 15, 2003 by Sharon Worcester

ASHEVILLE, N.C.--All that itches is not candida.

In fact, most patients with vulvar itching and irritation do not have candida infections. Allergic, contact, or irritant dermatitis is more likely to blame, Dr. Linn Parsons said at the annual Southern Obstetric and Gynecologic Seminar.

The vulva responds similarly to most irritants--with itching, burning, and inflammation. These signs and symptoms alone can't help in making the diagnosis, which is why phone diagnoses should be avoided in patients with chronic complaints, said Dr. Parsons, who is with a group practice in Winston-Salem, N.C.

A recent study revealed that a high percentage of presumptive diagnoses based on a phone call were incorrect. Of 123 women with vulvar symptoms, only half proved to have a microbiologic diagnosis, and the symptoms did not differ between those who did and did not have an infection.

In a study of 1,000 women, chronic itching and burning were associated with fungal infections in only 4% of cases. And in another study of 111 women who were surveyed regarding their symptoms during an office visit, 43 insisted they had yeast, but only a third of them actually did; 23 said they weren't sure if they had yeast, and 87% of them actually did have yeast; and 45 said they were absolutely sure they did not have yeast, but half of them actually did have it.

Even at an office visit, it can be difficult to distinguish between candida infection and various types of dermatitis, including neurodermatitis. That's why a careful history is necessary.

If a patient says symptoms occur just following her period, consider the possibility of a reaction to products, such as pads, that she may have used. Certain pads contain formaldehyde, which can be an irritant.

If the problem occurs after exercise, consider contact dermatitis associated with wearing tight spandex clothing. Sweat can also be an irritant. And vulvar irritation following intercourse may be related to lubricants that contain preservatives.

In patients who have failed to respond to over-the-counter products, it may be that they replaced one problem (yeast) with another (allergic dermatitis); the treatment may have caused a reaction. Diflucan is warranted in these patients.

Consider asking patients with complaints of chronic irritation to stop using all products, including soap, for 2 weeks. If they insist on using soap, recommend a mild cleanser such as fragrance-free Dove. Cornstarch or an ice pack (such as a bag of frozen peas, or a frozen bottle of Ivory dishwashing liquid, which has an hour-glass shape that will fit comfortably between the thighs when wrapped in a towel) can help relieve irritation during this time.

Patients are often better by the time they come to your office. Patch testing to determine the cause of the irritation may be useful. A low- to mid-potency steroid ointment can be used to treat future irritation.

For those patients who do prove to have recurrent fungal infections, consider a culture to determine what type. Intermittent therapy can be helpful; consider weekly Diflucan, especially in those with Candida albicans. Eventually this can be tapered to once-monthly treatment.

Intermittent boric acid treatments can help as well, particularly with non-albicans infections, and are an inexpensive alternative. After 12 months, these intermittent treatments can be stopped to determine whether the patient's immune status has changed.

Fungal infections that fail to respond to treatment may not originate from fungus after all. An example is an underlying neurodermatitis that is superinfected with fungus. If the underlying problem goes untreated, the patient will appear as if she is having recurrent infections.