Understanding and addressing vulval skin problems

Genital skin problems in women can cause discomfort, pain, and distress. They can also interfere with daily activities, sexual intimacy, and self-esteem. Additionally, untreated infections can lead to complications.

Leading consultant in sexual and reproductive health Dr Emily Lord provides a guide to the various types of vulval skin problems, including an explanation of what happens during a clinical examination, and how they can be managed.

What are genital skin problems?

Genital skin problems are prevalent, encompass a wide range of conditions and can affect women of any age. These conditions are often misdiagnosed and can have significant impacts on both physical and emotional well-being. Many women experience these symptoms for years, experimenting with various creams and treatment plans, without finding effective relief. These women often describe itch, soreness, dryness, and pain, and occasionally also have a change in discharge or irregular bleeding.

What are the various types of skin problems?

Inflammation of the vuvla: vulvitis

Vulvitis can be caused by various infections:

• Fungal: candida (more commonly known as thrush).
• Bacterial: streptococcal vulvitis or bacterial vaginosis.
• STIs: Trichomonas vaginalis.
• Viral: Herpes simplex or Human Papilloma Virus (HPV).
• Allergic reactions to soaps, detergents, lubricants, or sanitary wear.

Underlying skin disorders

Lichen sclerosus is a chronic skin condition, that mainly affects the vulva and perianal region. Women suffering from the condition may describe itch, soreness or burning and pain, particularly when attempting to have sex or sexual contact or when passing urine.

Additionally, they may notice a whitening of the affected skin (in the non-hairy areas), or may describe a change in the appearance of their vagina, with the labia minora becoming smaller or fused and a ‘burying’ of the clitoral hood.

Moreover, they might observe a lightening of the impacted skin in areas without hair or describe alterations in the appearance of their vagina, such as a reduction in the size of the labia minora or their fusion, along with a 'covering up' of the clitoral hood.

Lichen Planus

Lichen planus is an inflammatory disorder that can impact various parts of the body, including the skin, genital area, and oral mucous membranes. In the vulval area, the most common form is ‘erosive lichen planus.’ It usually affects the labia minora and entrance to the vagina. Women describe genital pain and burning and often severe itch.

The vulvar can appear bright red, and raw. If left untreated it can cause chronic changes in the vulval skin, such as reabsorption of the clitoral hood, shrinkage/fusions of the labia minora and scarring at the entrance of the vagina, which can, in some cases, cause significant narrowing.

Lichen simplex

Vulvar lichen simplex is a form of dermatitis where excessive scratching leads to thickened plaques (known as lichenification) on one or both sides of the vulva, and may be provoked by an underlying skin condition. The itch often intensifies at night, leading to an ‘itch-scratch cycle’ that proves challenging to break. During examination, the specialist may find be erythema, a thickened skin, that may appear white, as well as a reduction in public hair in the affected area.

Psoriasis

Genital psoriasis affects the genital skin, including the pubic area, labia majora, skin folds (such as the natal cleft), and buttocks. It typically manifests as well-demarcated, bright red plaques without the same scaling seen in psoriasis elsewhere. Notably, it does not affect the inner vagina or mucosal surfaces. Typical signs and symptoms of psoriasis include itching, discomfort, and soreness.

Eczema

Vulval eczema can cause redness, soreness, and an itch, and can often affect people with ‘atopy,’ e.g. those who also suffer from hay fever or asthma. Furthermore, it may also be triggered by contact with an allergen, or an irritant. Patients suffering from vulval eczema may describe soreness/redness and itch, and the skin around the vulval area may be thickened or cracked.

Vulval pain syndrome

Generalised vulvodynia refers to widespread pain throughout the vulvar region, where there is no physical explanation for it. It should be noted that women with the condition may experience symptoms which closely resemble those of women with infectious or dermatological problems, despite visual examinations yielding normal results. Pain or irritation may be persistent, or triggered by touch or pressure on the vulva.

What happens during a clinical assessment?

Assessing genital skin problems requires a thorough approach, beginning with a comprehensive medical history to understand the context of symptoms. An examination of the affected areas will identify any visible signs or anomalies. Depending on the presentation, swabs for pathogens such as candida or sexually transmitted infections (STIs) may be taken to rule out other potential causes of the symptoms. If required, a skin biopsy may be needed.

How can genital skin problems be managed?

Managing genital skin problems involves a tailored approach to address the underlying cause and alleviate symptoms effectively. Depending on the diagnosis, treatment may include steps such as careful washing, and using emollients/soap substitutes.  Additionally, topical medications such as corticosteroids or antifungals may be prescribed, while in some situations, systemic medications may also be prescribed by a specialist. Additionally, regular follow-ups are essential to monitor progress and adjust treatment as necessary.

If you are suffering from vulval problems and would like to book a consultation with Dr Lord, simply visit her Top Doctors profile today