Common Inflammatory Conditions of the Vulva

The vulva, often incorrectly referred to as the vagina (which is the birth canal), is the external female genitalia. The vulva is made from skin that transitions from hair-bearing skin to a modified mucous membrane. The vulvar skin has a distinct environment, influenced by ongoing exposure to moisture, friction, and occlusion, as well as changes in the local microbiome and hormonal fluctuations throughout life. What is often forgotten is that vulvar skin is still skin, and as such the vulva can develop inflammatory skin conditions just as conditions can arise elsewhere.

Why Are Vulvar Skin Conditions So Often Misdiagnosed?

Due to the complexity of vulvar skin, it is unsurprising that patients commonly experience a variety of symptoms, but unfortunately, symptoms often persist for too long before an accurate diagnosis is made. Many of my patients experience symptoms for even decades before accurate diagnosis. Because the vulva is both dermatologic and gynecologic anatomy, patients may bounce between specialties, but most patients present initially to primary or urgent care. A surprisingly common misstep made by clinicians when patients present with vulvar symptoms is failing to perform a careful, systematic exam of the vulvar skin. Patients are often treated empirically without ever being examined. Vulvar symptoms are frequently misdiagnosed as recurrent yeast infections, bacterial vaginosis, or sexually transmitted diseases. For clinicians, the goal isn’t to diagnose every complex condition, but to recognize common patterns, treat straightforward disease, avoid irritants and unnecessary therapies, and know when to refer. Appropriately examining the vulvar skin for unique findings is the first step toward making a diagnosis and choosing the correct treatment.

What Are the Most Common Inflammatory Conditions Affecting the Vulva?

Contact Dermatitis

Eczema is an overarching term used to describe a certain type of inflammation of the skin, also known as dermatitis. Contact dermatitis (CD) is a specific type of eczema (dermatitis) in which the skin reacts to something it touches. The vulva is particularly vulnerable to development of CD because of its thin skin, microenvironment, and natural occlusion.

Contact dermatitis has two types: irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). ICD reflects cumulative skin barrier damage and is by far the most common culprit of contact dermatitis. Common irritants include urine, sweat, soap, water, or other hygiene products. Alternatively, ACD is a delayed, individualized immune response to an allergen exposed to the skin. This reaction to a specific trigger appears 18–96 hours after exposure to the allergen. Common allergens in the anogenitals are fragranced products, toileting products, menstrual or incontinence pads, personal lubricants, preservatives, botanicals, or topical medications. To make ACD more complicated, patients can actually become sensitized to a product they’ve used for years.

The initial management of ICD or ACD involves resetting the skin barrier through gentle hygiene and avoiding exposure to possible irritants or allergens. Important hygiene considerations include washing only with hands on mucosal skin (clitoral hood, labia minora, vestibule). Only use a gentle fragrance-free cleanser on hair-bearing, non-mucosal skin. Applying a bland barrier alleviates chafing or fissuring such as petroleum jelly or zinc oxide paste. Since urine is a common irritant exposure for many vulvas, appropriate management of urinary incontinence is warranted. Avoiding any non-prescription topical medications is essential, as these are common offenders for CD. If allergic contact dermatitis is suspected, referral for patch testing (distinct from prick testing) may be needed with a dermatologist or allergist who specializes in allergic contact dermatitis.

Lichen Sclerosus

Lichen sclerosus (LS) is a chronic inflammatory condition most frequently diagnosed in post-menopausal patients, but it can occur at any age, including in children. The cause is not known but autoimmunity is a leading hypothesis. Patients are typically itchy, irritated or sore, but some people have no symptoms. The skin findings of classic late-stage lichen sclerosus include porcelain-white, crinkled (tissue-paper) plaques, purpura (bruising), skin cracks (fissures), and a figure-of-eight distribution around the vulva and anus. Early in the disease process of LS, the skin findings are more subtle and nonspecific, such as swelling or redness. Without treatment, LS can cause scarring over time. This scarring may make the labia minora (inner lips) shrink or disappear, cause the clitoral hood to become tight or scarred down, and narrow the vaginal opening. Untreated LS also carries a 3–5% lifetime risk of squamous cell carcinoma, making early diagnosis and ongoing treatment and follow-up essential. First-line therapy is an ultra-potent topical steroid, and this can be started by any clinician suspecting LS. A key tip is instructing patients how much topical medication to use and to show them where to apply it on their own body using a mirror. The most common problem I encounter in LS patients is undertreatment from steroid fear. When used correctly, topical steroids are safe and effective. LS is a lifelong condition that does not yet have a cure, so it requires maintenance treatment, not a single course. Flares of symptoms are not uncommon and often require increasing frequency of medication use.

Lichen Planus

Lichen planus (LP) is a rare autoimmune inflammatory condition that may impact the vulva and vagina. Erosive LP is the most severe and is often debilitating due to pain. Skin findings include open red or raw areas. Scarring can also occur, leading to vaginal narrowing, loss of labia minora, and clitoral hood scarring. Unlike LS, LP more commonly involves the vagina, so intravaginal therapy is an important consideration to prevent scarring. Unresponsive disease may require systemic immunosuppression, multidisciplinary care, and long-term surveillance. Similar to LS, LP has a long-term risk for malignant transformation due to chronic inflammation. Earlier referral to a dermatologist for erosive mucosal LP is justified.

Lichen Simplex Chronicus

Lichen simplex chronicus (LSC) is a secondary skin condition. This means it occurs as an 'end result' of another cause, which is often another underlying skin condition or exposure that results in itch. Itch then leads to skin scratching or rubbing that eventually causes the skin to become thickened or leathery. I describe it to patients as the skin building "armor" against scratching, but frustratingly the armor actually continues to drive more inflammation and more itch, perpetuating the cycle. Treatment depends on breaking that itch-scratch cycle by consciously avoiding scratching the skin, removing itch triggers, repairing the skin barrier, treating with appropriate medicine, and supporting nighttime itch control. Cooling agents can help acutely to halt the itch signal to the brain to help alleviate that incessant need to scratch.

Other Inflammatory Conditions

Other common skin conditions that can occur in the vulva include genital psoriasis, seborrheic dermatitis, atopic dermatitis, or other vesiculobullous or erosive mucosal diseases. These skin conditions often require referral to a dermatologist for diagnosis and treatment.

How Can Gentle Skin Care Help Reduce Vulvar Irritation?

Reducing irritation helps nearly every vulvar condition. This can be done by avoiding fragrance, deodorants, botanicals, and other unnecessary products. Don't scrub or use soap on the vulvar mucosal surfaces. Bland ointments or emollients can help the barrier of inflamed vulvar skin. Stop unnecessary over-the-counter treatments when symptoms are chronic or unclear. When exposure can't be avoided, choose products with minimal, well-characterized ingredients.

When Should Patients Be Referred to a Vulvar Specialist?

For clinicians, it is imperative to normalize the conversation around vulvar skin. Many patients have carried these symptoms in silence and suffered unnecessarily. Patients impacted by persistent vulvar symptoms deserve a correct diagnosis and treatment. Too many patients spend years, sometimes decades, searching for answers. If the skin doesn't look normal, doesn't respond as expected, or the discomfort keeps returning, referral to a clinician with vulvar expertise can be life changing for patients.

Refer to a vulvar specialist or vulvar dermatologist when:

• Symptoms persist beyond 6–8 weeks despite appropriate management, or the diagnosis is uncertain. 
• There is scarring, architectural change, adhesions, or vaginal narrowing. 
• Any focal lesion, ulcer, pigment change, or non-healing area is present.
• Pediatric lichen sclerosus or suspected erosive lichen planus is identified. 
• Patch testing, systemic therapy, or multidisciplinary care is needed. 

Key Takeaways

Inflammatory vulvar skin conditions are common, yet they often go unrecognised or are mistaken for other conditions, delaying appropriate treatment. Careful examination of the vulvar skin, gentle skin care practices and timely referral where appropriate can help improve diagnosis and patient outcomes. By increasing awareness of these conditions and recognising when specialist care is needed, clinicians can play an important role in helping patients receive effective treatment sooner.

 

Visit the WaterWipes® Advice & Care Hub to explore expert-led articles on intimate skin health, sensitive skin, feminine hygiene and everyday care. You'll also find more information about the WaterWipes® Feminine Care range, developed to support gentle intimate cleansing with minimal ingredients and sensitive skin in mind.

Audrey Rutherford, MD, FAAD
 Board-certified dermatologist specializing in vulvar disease

Frequently Asked Questions About Vulvar Skin Health

1. What is the difference between the vulva and the vagina?

The vulva refers to the external female genital area, including the labia, clitoris and surrounding skin. The vagina is the internal muscular canal that connects the uterus to the outside of the body. Although these areas are closely connected, they are different parts of the anatomy and can experience different types of health concerns.

1. Why is my vulva itchy or irritated?

Vulvar itching and irritation can happen for many reasons, including skin sensitivity, contact with irritating products, inflammatory skin conditions, infections or hormonal changes. Because many different conditions can cause similar symptoms, persistent or recurring irritation should be assessed by a healthcare professional.

1. Can sensitive skin affect the vulvar area?

Yes. The vulvar area contains delicate skin that can be more vulnerable to irritation from friction, moisture, cleansing products and certain ingredients. Using gentle care practices and avoiding unnecessary products may help support the skin barrier and reduce irritation.

1. Are scented products safe to use on vulvar skin?

Fragranced products may cause irritation or allergic reactions for some people, particularly on sensitive skin. Many healthcare professionals recommend avoiding unnecessary fragrance and choosing products with minimal, well-characterised ingredients when caring for the vulvar area.

1. Can menopause cause vulvar itching or irritation?

Yes. During menopause, declining oestrogen levels can affect the vulva, vagina and surrounding tissues. This may contribute to symptoms such as dryness, itching, burning, increased sensitivity and discomfort during intimacy.