The vulva comprises the external genital organ in women, with the surface covered by skin. Itching, which is an unpleasant sensation, of the vulval skin is a very common symptom in women. The sensation of itch leads to a desire to scratch the area, however, prolonged scratching will damage the skin and lead to a vicious ‘itch-scratch-itch’ cycle which further increases the itching.

Itching, which may vary in intensity, can be intermittent or constant. If present for more than 6 weeks it is termed chronic and can sometimes become very severe and difficult to treat. Environmental factors such as heat, dryness and stress contribute to the intensity and persistence of itch. Complications of chronic itch include ; difficulty in sleeping, difficulty in concentrating, decreased sexual desire and sexual function, agitation, depression and secondary infection.

Vulval itch FAQs

What causes vulval itch?
There are numerous causes of vulval itch which include a wide range of pathologies and conditions. Sometimes there is more than one cause present.

Infections
Thrush (a fungal infection) is a very common cause of itch. Other infections include genital warts (a viral infection) and scabies (a mite infection).

Skin dermatoses
Skin dermatoses (inflammations) are amongst the most common causes of vulval itch. Conditions include eczema, lichen simplex, lichen sclerosus and psoriasis. Vulval skin is most susceptible to irritants and allergens which can trigger an immune response causing a contact dermatitis. Frequent offenders consist of body fluids, hygiene products and topical medications.

Vulval intraepithelial neoplasia
Vulval intraepithelial neoplasia (VIN) is a skin condition where the cells become overactive, and increase in size and become larger. It is a precancerous condition and in a proportion (about 15%) of women will progress to cancer. This is an increasingly common problem, particularly among women in their 40s. VIN is commonly associated with certain types of human papillomavirus, cigarette smoking and conditions where the immune system may be low. In some women it is associated with a pre-existing dermatosis such as lichen sclerosus. The commonest symptom is itching but about 1/3 of women will have no symptoms. The diagnosis can be difficult as the appearance of VIN varies but most women have visible lesions that are elevated. Biopsy is essential to get an accurate early diagnosis. Treatment is indicated for all cases of VIN and afterwards, women should be closely monitored.

Systemic disease Infrequently, vulval itch may occur because of a disease elsewhere in the body. These include; thyroid problems, liver and kidney disease, postmenopausal atrophy and Sjorgen’s disease.

Others Skin lesions such as fissures and skin tags may be found occasionally and very occasionally a reaction to a drug may be responsible. Other rare causes include nerve damage and psychological problems.
How can the cause of my itch be identified?
The most important thing is to take a proper history including a full allergy and drug history. A detailed, careful examination is vital. Investigations for patients with itch on the skin with a rash include a skin biopsy and laboratory investigation. Patients with itch normal, non-inflamed skin may need laboratory and radiological tests adapted to the patient's history and pre-existing diseases.
How can my itch be treated?
First of all an accurate diagnosis is crucial as treating itch depends on identifying and removing the cause. The aims of treatment are to control or stop the symptom of itch, disease activity and reduce inflammation. It should be noted that many conditions are chronic and expectation of cure should be realistic.

Whatever the cause, these general guidelines should be followed to minimise/prevent the symptoms:

  • Avoid irritants and aggravating factors -- many topical agents can be irritating
  • Avoid over washing and pay attention to hygiene

The sensation of itching is heightened if the skin is warm. Patients should therefore take measures to cool the skin, including having tepid showers, wearing light clothes that absorb sweat and avoiding over heated rooms where appropriate

  • Restrict time in the shower or bath
  • Apply moisturisers immediately after bathing
  • Avoid wearing wool or tight clothing
  • Avoid cleansers containing alcohol
  • Use a barrier cream or ointments e.g. zinc if there is incontinence or sweating, they help the skin to retain water
  • Avoid rapid changes in environmental humidity
  • Avoid hot or spicy foods
  • Avoid alcohol

Emollients and Moisturisers
Specific treatment will be determined according to the cause. However, Emollients and Moisturisers are a must. These act on the top layers of skin to soften, soothe, smooth and hydrate it. Dryness is an important remediable cause. Most common ones consist of soft paraffin or a combination of soft, liquid and hard paraffin. They should be used both as a soap substitute and to moisturise the skin to help restore and preserve the barrier function of skin. The effects are short lived so use frequently and liberally on a maintenance basis; 15-25gm a week with x 2 daily application to groins and vulva. You may try different ones but try and avoid those with dyes and fragrances even if the skin is clear. Smooth on, don’t rub in, and always apply in the direction of hair growth. Ointments are particularly suitable for dry, chronic lesions but may exacerbate acne and folliculitis.

If itching continues to be a problem despite treatment, there are a number of drugs available to use - however, these should always be discussed with a doctor before using.

Read further about the common causes of vulval itch

Infections

See section on abnormal vaginal discharge.

Vulval dermatoses

Generalized skin disease can affect the vulva as part of the process but there are a number of conditions which are more specifically localized to vulval skin. These are grouped together under the term vulval dermatoses. They share some characteristics and yet have their own distinct features. Treatment of all these conditions relies on a precise diagnosis.

Eczema: vulval eczema may occur on its own or be part of a more widespread disease. It frequently affects the vulva and is a common cause of itch which has often been mistakenly ascribed to a thrush infection. There are a number of subtypes with different underlying causes. Atopic eczema occurs in people with a strong family history and in those with asthma and hay fever. Medicaments and perfumes are major causes of contact irritant dermatitis (eczema), which is very common on the vulva and may cause an acute eczema. Contact allergic dermatitis may be caused by an underlying allergy to e.g. lanolin or latex and may need to be excluded. Although it is a lifelong chronic condition with proper treatment, good control can be achieved.

Lichen simplex: lichen simplex is a very common cause of vulval itch and can be very severe. The skin thickens as a result of scratching and the skin barrier is not working properly. Like eczema, the itch is often mistakenly ascribed to a thrush infection. Of course both may occur together and need the appropriate treatment. Strong steroids may be required. It can be chronic with flares and recurrences.

Lichen sclerosus: In lichen sclerosus, the skin becomes thin, brittle and often appears white and wrinkled. Although the cause is unknown, the skin is damaged by the immune system. About ¼ of women will have another immune condition such as thyroid disease. It can affect women of any age but is often not diagnosed early. It is important to get an accurate early diagnosis because if the disease is not controlled, noticeable scarring and damage can occur. There is also a small (5-10%) increased risk of developing a skin cancer, so long term follow up is recommended.

Psoriasis: vulval psoriasis may occur on its own or be part of more widespread disease. The classic appearance of psoriasis is lost on the vulva making diagnosis more difficult. When only the vulva is affected, accurate and early diagnosis is important so that if disease develops elsewhere it can all be managed correctly. Many of the standard treatments used are too irritating on vulval skin. It is a lifelong chronic condition.

Vulval intraepithelial neoplasia

What is vulval intra-epithelial neoplasia?
Vulval intra-epithelial neoplasia (VIN) is a skin disorder that affects the vulva. Some of the skin cells in one or more areas of the vulva become abnormal, and change in their appearance. It is called VIN as:

  • Vulval means affecting the vulva.
  • Intra-epithelial means that the condition is limited to within the skin cells (epithelium is a medical word for the top layer of skin).
  • Neoplasia means abnormal growth or multiplication of cells.

Note: VIN is not a cancer. The word neoplasia is sometimes used when talking of various cancers but its strict definition is an abnormal multiplication of cells.

VIN is classed as a precancerous condition because over time, the cells of VIN in some affected women become cancerous. VIN can develop anywhere on the vulva. It may affect only one patch, or develop in a number of different parts of the vulva.

(It is similar to the abnormal cells that are found in some women following cervical screening - previously called the cervical smear test. The abnormal cells that may be found in this situation are also precancerous and not actually cancer.

VIN is subdivided (classified) into three groups:

  • VIN, usual type. This type is associated with the human papillomavirus (HPV).
  • VIN, differentiated type. This is much less common than VIN, usual type. This type is not usually associated with HPV but may develop in conjunction with another skin disease such as lichen sclerosus.
  • VIN, unclassified type. This is rare.

Note: before 2004, VIN was classified into VIN 1, 2 and 3 which roughly meant mild, moderate and severe. The new classification was introduced in 2004 as recommended by the International Society for the Study of Vulvovaginal Diseases (ISSVD). However, there is some dispute among specialists as to whether to go along with the new classification. Some specialists retain the VIN 1, 2, 3 classification. This can be confusing! But, for the sake of simplicity, the rest of this leaflet will go along with the ISSVD classification.
What causes vulval intra-epithelial neoplasia?
The exact cause of VIN is not known.

VIN, usual type, is strongly linked to HPV. There are over 100 different types (strains) of HPV. Two types, 16 and 18, are particularly associated with the development of most cases of VIN. Type 31, and possibly some other types, may also be associated with VIN.

Note: some other types of HPV cause common warts and verrucas. These types of HPV are not associated with VIN.

The types of HPV associated with VIN are nearly always passed on by having sex with a person carrying the virus. An infection with one of these types of HPV does not usually cause symptoms. You cannot tell if you or the person you have sex with are infected with one of these types of HPV. In some women, the types of HPV that are associated with VIN affect the cells of the vulva. This makes them more likely to become abnormal which may later (usually years later) turn into VIN.

Note: HPV infection is very common but within two years, 9 out of 10 infections with HPV will clear completely from the body. And, even if it remains in the body, most people with HPV do not go on to develop VIN. So, although most cases of VIN are associated with HPV, most women who are infected with HPV do not develop VIN.

Other factors may also play a role in causing VIN, these include; smoking and anything that depresses the immune system.

VIN, differentiated type develops more commonly in women who have another vulval skin disease such as lichen sclerosus or lichen planus.

A similar condition to VIN can occur on other nearby parts of the body. When it affects the cervix it is called cervical intra-epithelial neoplasia (CIN) and this is much more common than VIN. The cervical screening test is designed to pick up the abnormal cells. Vaginal intraepithelial neoplasia (VAIN) and anal intra-epithelial neoplasia (AIN) are uncommon. The cause of most cases of CIN, VAIN and AIN are also thought to be associated with infection by the HPV. If you have VIN, you have a higher than average risk of also developing one of these other related conditions.
How common is vulval intra-epithelial neoplasia?
VIN is uncommon (it is difficult to give exact figures). However, in recent years the number of cases seems to be rising gradually. Most women affected are over the age of 40. The average age of diagnosis is about 45-50 years. But, it can sometimes affect younger women and, rarely, can even affect teenagers.
What are the symptoms of vulval intra-epithelial neoplasia?
About 1/3 of women have no symptoms and the abnormal changes will only be seen if the skin is examined. These changes include areas of red or white skin which can be thickened. Otherwise itch is the most common symptom and it may become severe. Other symptoms that may develop include soreness, burning or tingling in the vulva. Having sex may be painful. These symptoms are also caused by other conditions so it is important to see a doctor.
How is vulval intra-epithelial neoplasia diagnosed?
The diagnosis is confirmed by a biopsy of the affected area. A biopsy means a small sample of vulval skin is taken to be examined in the laboratory. The biopsy is usually done after numbing the area to be sampled using local anaesthetic. The tissue in the biopsy is examined under a microscope to look for the typical cells of VIN.
Do I need treatment?
If left untreated, in a small number of cases VIN may go away by itself. However, most cases of VIN do not and because of the risk that it may turn into cancer -- treatment is usually advised. It is also important to remember that many cases of VIN do not develop into cancer. However, it is not possible to predict which cases will and which ones won't. On average, it usually takes a long time -- years even, to develop into cancer.
What are the treatment options?
The aim of treatment is to remove or destroy all affected tissue. There are various treatment options. Your specialist will advise on the pros and cons of the different options. For example, the treatment advised may depend on factors such as the extent of the VIN - whether it is just in one small area or in two or more places in the vulva, and the exact subtype of VIN that you have.

Surgery
The traditional treatment is to have the affected area or areas removed by an operation done under general anaesthetic.
There are a number of other treatments available but not commonly performed in this country. These include:

Laser ablation
A laser can destroy the affected areas of the vulva, but it is painful, and there is a high rate of recurrence following this treatment.

Photodynamic therapy (PDT)
For this treatment, a drug is either applied topically (rubbed on to the vulva), or given as an injection into the bloodstream. The drug is taken up by the abnormal cells and is light sensitive. A few hours later, a cold laser light is shone at the abnormal cells. This activates the light-sensitive drug, which has an effect of destroying the abnormal cells.

Imiquimod and similar drugs
New drug treatments that act on the immune system are becoming available and are being investigated for use in VIN so as to avoid the need for surgery. The advantages of PDT and imiquimod (and similar drugs) is that, if they work, there is no alteration in the appearance of the vulva as you would get with surgery.

Imiquimod comes as a cream. It is applied topically (you rub it on to affected areas) each day for a number of weeks. Side-effect include inflammation and some women stop the treatment as a result of discomfort.

Another similar drug currently being researched in a trial is called cidofovir.
What is the prognosis (outlook)?
All of the above treatments have a good chance of clearing VIN. However, with any treatment, even when successful, there is a chance that the VIN will return at some point in the future. This is why if you have VIN you should have regular follow-up assessments with a doctor, even when treatment has been successful. This is typically a review appointment every 6-12 months. But, if you notice any symptoms or changes in your vulva between follow-up appointments, see your doctor promptly. Don't wait for the next routine appointment.

Research continues to determine which treatment is likely to give the best chance of cure and least chance of a recurrence. Also, to look for newer, better treatments. For example, small research trials that looked at combining treatments (imiquimod followed by three doses of HPV vaccine, and imiquimod combined with PDT) showed promising results
Can vulval intra-epithelial neoplasia be prevented?
The HPV vaccine has recently been introduced for girls from the age of 12 in the UK. Studies have shown that the HPV vaccine usually works very well to prevent HPV infection. As discussed earlier, HPV infection is a major factor in the development of VIN. The vaccine has been shown to work better for people who are given the vaccine when they are younger, before they are sexually active, compared with when it is given to adults. It is likely that the number of cases of VIN will greatly reduce by the time the girls being vaccinated today reach adulthood - the age when VIN usually develops.
Smoking and VIN
It is thought that damaging chemicals from cigarette smoking may concentrate in the skin of the vulva and cervix, which can increase the risk of developing VIN and related disorders. If you smoke, giving up reduces your chance of developing VIN. If you have been treated for VIN and you smoke, giving up smoking can reduce your risk of VIN recurring in the future. For example, one research study concluded that women who continued to smoke after treatment for VIN were much more likely to have persistent or recurrent vulval disease compared with non-smokers.