Is Atopy to Blame for Chronic Vulvitis?

Several of my female patients have chronic itchy, burningvulvitis. Oral and topical antifungal agents, topical corticosteroids,and estrogen vaginal preparations have not beeneffective. The mucous membranes and perineal areas usuallyappear normal, except for scratch marks. Generally, resultsof potassium hydroxide evaluations are negative.How often does atopic dermatitis affect the vulva?I have prescribed doxepin; however, one patient complainedof sleepiness. What can be done about this side effect?
-- L. Van Houten, ARNP
    Lake City, FlaChronic pruritus of the vulva is a challengingproblem, and a full discussion lies outsidethe scope of this response. To treat burningvulvitis effectively, it is necessary to know thecause. When no obvious cause is evident, anextensive history taking, physical examination, and laboratorystudies are required, and a multidisciplinary approachthat involves dermatologic, genitourinary, and gynecologicconsultations may be useful.¹Atopic dermatitis can affect the vulva, but it is an uncommoncause of chronic vulvar pruritus in postpubertalfemales. However, patients with sensitive skin are morelikely than patients without a history of atopy to developcontact or irritant dermatitis as a reaction to hygienic products,clothing, detergents, fabric softeners, and so forth.Often, the source of the burning sensation cannot beidentified. In such cases, symptomatic treatment is unfortunatelythe best that can be offered for this frustratingproblem. Both topical and systemic treatments can providesymptomatic relief; however, avoid sensitizing medications,such as topical benzocaine. Doxepin is an effective antipruriticthat should be reserved for bedtime use because ofits soporific properties.
-- David L. Kaplan, MD
    University of Missouri, Kansas City
    University of Kansas