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Prescribe careful hygiene to curb pruritus vulvae: topical treatments sometimes needed.

WHISTLER, B.C. -- Pruritus vulvae is a relatively common complaint in prepubescent girls, Dr. Sheryll Vanderhooft said at a clinical dermatology seminar sponsored by Medicis.

Girls of this age are susceptible to pruritus vulvae because the skin of the prepubertal vulva is thin and delicate due to lack of estrogen. Similarly, without estrogen, the vaginal mucosa is thin and atrophic and has a neutral pH, which makes it an excellent medium for microorganisms, said Dr. Vanderhooft of the pediatric dermatology clinic at the University of Utah, Salt Lake City.

Anatomy is also a contributing factor. In prepubertal girls, the anus is close to the introitus, making it vulnerable to contamination with feces and fecal pathogens. This may be complicated by the fact that maternal supervision in the toilet decreases as children get a little older, even if the child's self-cleaning skills are still a bit shaky.

Symptoms include itching, soreness, and burning on urination. The external genitalia usually appear normal, although some patients develop vulvar lesions. Anogenital bleeding, discharge, bruising, irritation, or redness are red flags for sexual abuse--although 46% of children who were sexually abused had completely normal examinations in one published account cited by Dr. Vanderhooft.

Inadequate hygiene is by far the most common cause of pruritus vulvae in this age group, but diagnosis sometimes presents a challenge: Approximately 75% of patients have no evidence of an infectious process and no primary dermatologic disorder of the vulva. The differential diagnosis should include a variety of infectious and noninfectious processes. (See box.)

Management includes greater attention to hygiene, minimizing contact with potential allergens or irritants, and eliminating any infectious agents. Basic hygiene includes always wiping from front to back after urinating or defecating, washing hands before as well as after using the toilet, taking 10 minute sitz baths once or twice a day (do not use bubble bath or perfumed soaps), and patting, not rubbing, the vulva when drying off. Dr. Vanderhooft also recommended that patients wear loose-fitting, white cotton underpants, which should be changed frequently. Wash clothes in unscented, hypoallergenic detergents, avoiding fabric softeners, and double rinse the laundry.

Patients should avoid spending prolonged periods of time in wet bathing suits and should not wear nylon tights, leotards, or tight-fitting pajamas.

Usually, these measures clear up most cases. If necessary, you can prescribe topical treatment with steroids, pimecrolimus cream, antipruritics, or antihistamines. Some patients may require oral antihistamines. In general, the prognosis for these patients is good, she said.

Differential Diagnoses

Noninfectious:

* Inadequate hygiene.

* Irritant dermatitis.

* Allergic contact dermatitis.

* Atopic dermatitis.

* Seborrheic dermatitis.

* Psoriasis.

* Lichen sclerosus.

* Lichen simplex planus.

* Lichen planus (relatively rare in young patients).

* Psychogenic causes.

Infectious:

* Bacterial infection, nonsexually transmitted (most common is streptococcus).

* Bacterial infection, sexually transmitted.

* Viral infection; most likely molluscum or condyloma acuminatum (genital herpes is relatively rare in young patients).

* Fungal infection; most likely candida or a dermatophyte.

* Infestation, most likely pinworms (a Scotch tape test can rule these out); scabies, lice.

* Urinary tract infection; rule out with a urine culture.

NORRA MACREADY

Los Angeles Bureau
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Title Annotation:Children's Health
Author:MacReady, Norra
Publication:Family Practice News
Geographic Code:1USA
Date:Jul 1, 2004
Words:505
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