Contact dermatitis can be either irritant (nonimmunologic) and/or allergic (immunologic). Lesions occur on areas of the vulva that contact environmental irritants or antigens. It is essential to restore the normal skin barrier and protect the skin from additional injury. Treatment begins with identification and withdrawal of the offending substance. To prevent recurrence, careful documentation of possible irritants or allergens is necessary. Women with vulvar dermatoses should be patch tested to define or rule out disease-causing agents (11).
After irritant withdrawal, symptoms of nonimmunologic contact dermatitis should disappear rapidly. However, if the lesions are of allergic etiology, signs and symptoms can persist for days after the discontinuation of the allergen. Though clinical improvement is apparent and supported by clinical trials, there has been no RCT evaluating treatment for contact dermatitis of the vulva.
Common habits can cause mucocutaneous irritation, and behavior modifications are necessary to reduce risk of vulvar irritation and ensure successful management. Modifications include, but are not limited to, use of cotton underwear, lubrication with sexual contact, washing with mild soap, keeping the vulva clean and dry, and avoidance of cosmetics, perfumes, or other caustic substances in this sensitive area. Aluminum acetate in water (e.g., Burow's solution), topical creams (such as Sorbolene or aqueous cream), sitz baths with mild soap, and lubricants (such as petroleum jelly) are helpful in some cases. Secondary bacterial or Candida infections require specific treatment.
Antipruritic medications, such as antihistamines, are not of great therapeutic benefit except as soporific agents. Drugs with antihistamine and sedative properties, such as doxepin (10-20 mg at night), can be helpful in controlling nocturnal scratching (12).
Topical corticosteroids can be helpful in cases of irritant contact dermatitis that are unresponsive to conservative therapy. These agents may reduce inflammation in allergic contact dermatitis, but typically are not used for the long-term treatment. Ointments are preferred to creams or lotions, which can be dry and irritating. Topical corticoids are most effective when applied and covered with a barrier, such as plastic wrap, a gauze dressing, cotton gloves, or petroleum jelly.
Pharmacologic treatment consists of mid- to high-potency topical corticos-teroids, such as triamcinolone, betamethasone, and fluocinolone (2), usually for 14 days or until symptoms have resolved. At this point, a weaker corticosteroid, such as 1% hydrocortisone, can be continued for an additional two to three months. This cycle can be repeated if disease activity flares. In cases of mild disease, low-potency steroids are safer and are preferred, typically. Use low-potency topical steroids, such as hydrocortisone 2.5%, on thinner skin and for patients who prefer to use a topical preparation regularly. Alternatives include intralesional triamclinone injections every three to six months. Brief courses of systemic corticosteroids are reserved for severe or recalcitrant dermatitis. Adequate dosage and an adequate taper length are important points to consider. Treatment with topical corticosteroids should be limited, as long-term use may induce telangiectasias, skin friability, striae formation, and easy bruising. Caution must also be taken to avoid rebound inflammation upon withdrawal from long-term, high-potency corticosteroids. See Chapter 12 for a more thorough discussion of contact dermatitis of the vulva.
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