The heartbreak of itchy vulva
One of the most common reasons that people ask to see a gynecologist is “yeast infections”. I don’t particularly love that term as it’s not really an infection at all. You’re supposed to have yeast in your vagina. What we call “yeast” is an organism called candida and it’s part of a healthy microbiome. The microbiome is the garden of microorganisms that helps your body stay healthy.
If yeast overgrows, it can cause symptoms of itching, soreness, redness, swelling and chunky white odourless discharge. If you’re a person who menstruates, up to four episodes of yeast overgrowth per year is considered normal. The estrogen rich environment of the vagina has a complex ecosystem that encourages candida to grow. In most cases, treating with over-the-counter products works well, especially if you treat for a week rather than a few days to decrease the starting level of candida and give you more time before it overgrows again to the point of causing symptoms.
In postmenopausal people, candida overgrowth is very uncommon. The exceptions to this rule are people with diabetes and people treated with vaginal estrogen. If you are over 53 and have symptoms of itching and soreness without a vaginal swab that shows yeast, you should be seen in a Colposcopy Clinic to rule out other problems.
Some people notice itching that doesn’t go away with yeast treatment. They tend to be referred to me as “chronic yeast infection” but their vaginal swabs are normal. Many of these people do not have candida problems at all. They have a condition called Lichen Simplex Chronicus (LSC). This is a very fancy term that means long-term benign skin disease.
LSC is a skin condition caused by chronic itching and scratching. LSC often follows this pattern:
It starts when something rubs or scratches the skin or after exposure to irritants (yeast, detergents, cleansers)
The person begins to rub or scratch the itchy area. Constant scratching (often during sleep) causes the skin to thicken.
The thickened skin itches and this leads to more scratching. This ultimately results in a rough, scratched (excoriated) area.
The skin may become leathery and brownish in the affected area.
The main symptom is itchiness that is long-term (chronic), intense, and increases with periods of stress. Patients often tell me it’s worse at night when they sit down to rest or lie down to sleep.
Then we see the start of the itch-scratch cycle: when you scratch you damage the skin and the damaged cells release signals to call the repair cells. One of these signalling agents is histamine, which causes itching. So you scratch more, so you release more histamine, so you feel more itchy. Eventually the cause of the skin condition is actually your own self-inflicted damage.
The thing to remember with LSC is that the initial irritant is often long gone. I had an elderly lady tell me that she’d had a rash on her shoulder that went away 30 years ago and she still felt itchy in that spot. Your brain has a tendency to supercharge the neurons that monitor inflammation in a spot that has been inflamed. Eventually this leads to interpreting normal sensations as itching.
This isn’t the easiest condition to treat. We can’t use long-term steroids to treat the itching because eventually the only prompt to scratch comes from the brain, not the resolved skin condition. So trying to use steroids to treat normal skin is the wrong approach, we need to treat the brain!
Step 1: Avoid irritants by following the instructions in the skin care handout.
Step 2: STOP SCRATCHING! The only cure for this condition is behaviour change. You may need socks on your hands to prevent skin damage from nighttime scratching or a change in routine to avoid triggers.
Step 3: Settle inflammation with a short course of steroid ointment, then soothe and moisturize regularly with Vaseline or coconut oil
Step 4: Decrease itching with allergy pills like Reactine. If your main issue is nighttime itching, consider Benadryl 2 hours before bedtime to improve sleep and decrease itching (*no driving after Benadryl). Some patients find more relief with prescription anti-histamines, but usually over-the-counter products work well.