Chronic pruritic vulva lesion
The patient was not sexually active and denied any vaginal discharge. So what was causing the intense itching on her labia?
Focus Tx on interrupting the itch-scratch cycle
Tell patients with lichen simplex chronicus that a permanent cure may not be possible. Intermittent therapy may be necessary for years.1 The key to long-term success is disruption of the itch-scratch cycle. Often, the scratching occurs during sleep without the patient even being aware. So it’s helpful to educate patients about the itch-scratch cycle and to advise them to keep their nails trimmed, wear gloves at nighttime, and if needed, apply an occlusive dressing.1,2 It’s also helpful to avoid irritants such as harsh soaps and washcloths, panty liners, tight clothing, perfumes, and deodorants.2
Help the patient break the nighttime itch-scratch cycle by prescribing sedating H1 antihistamines such as hydroxyzine (10-25 mg taken within 2 hours of bed time); increase the dose every 7 days until scratching ceases or adverse effects develop.2 Another option is a tricyclic antidepressant—doxepin 25 to 75 mg or amitriptyline 25 to 75 mg— taken within 2 hours of bed time.1
Recommend that patients use lubricants and petroleum-based ointments to restore the damaged skin barrier and its natural function. Using these products after bathing may be especially helpful.1
Class I and II topical steroids can be used as first-line treatment to reduce inflammation and pruritus. Be sure to advise patients of potential adverse effects of potent topical steroids, such as atrophy, discoloration, and striae.1,2,5
Second-line topical treatments include tacrolimus ointment 0.1%, pimecrolimus cream 1%, topical lidocaine 2%, and capsaicin 0.025% to 0.075% cream applied 3 times a day.2 Depending on the size and shape of the lesion, intralesional steroids such as triamcinolone acetate in varying concentrations may be beneficial.
Selective serotonin reuptake inhibitors have been shown to benefit patients during the day, and to address other psychological comorbidities that may be present (eg, anxiety, depression, or obsessive-compulsive disorder).1
Be sure to screen for secondary super-infections (bacterial and fungal) and treat accordingly. Follow-up should be scheduled for 4 weeks after treatment has begun.2
Steroids provided relief for my patient
I prescribed clobetasol 0.05% ointment without occlusion twice a day for 4 weeks. I also prescribed hydroxyzine 25 mg to be taken at bedtime and fluoxetine 20 mg daily for underlying depression.
At follow-up 4 weeks later, my patient reported excellent relief from her pruritus. Her labia’s erythema had greatly decreased, but chronic skin changes were still present. I advised her to apply the clobetasol every 2 weeks as needed, with follow-up in 3 months.
CORRESPONDENCE
Stephen Colden Cahill, DO, Assistant Clinical Professor, Michigan State University, 8300 Westpark Way, Zeeland, MI 49464; cahillst@msu.edu
