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Recurrent vulvar itching.

CASE: A 25-year-old woman requests a second opinion about management of recurrent vaginal infections. Her local gynecologist suspects a “resistant infectious process” because the patient has recurrent vulvovaginal discharge and irritation despite the use of “various topical and oral anti-infectives.” Over the past 18 months, she has been treated with 7 courses of antibiotics, with either a brief response or no improvement of her symptoms. On questioning, the patient describes severe intermittent vulvar burning, intermittent itching, and constant mild-to-moderate vulvar pain. Additionally, she notes occasional dysuria and urinary frequency, but urine cultures have been negative. She denies urinary or fecal incontinence. Although she is currently using no medications or over-the-counter products, over the past half year she has used metronidazole and clindamycin vaginal creams, clindamycin vaginal ovules, Burow’s solution (Bayer Consumer Care, Morris Township, NJ) soaks, over-the-counter vaginal moisture solution, perineal cleansing pads, and panty shields with baking soda. Her medical history is remarkable for migraines and a laparoscopic tubal ligation. She is married, monogamous, and does not smoke, drink alcohol, or use illicit drugs. The patient reports using the following household products: scented dryer sheets, various laundry detergents depending on which is on sale, deodorant soap, scented liquid body wash, and topical lubricating jelly before intercourse. On examination (Fig.1), the vulva is markedly erythematous, without lesions, ulcerations, or excoriations. The skin markings are exaggerated, and there is mild edema. When the labia minora are separated, significant erythema is noted. The vestibule is also erythematous. Microscopy is normal, without yeast, clue cells, trichomonads, or inflammatory changes. The maturation is normal, and lactobacilli are present. A yeast culture is subsequently found to be negative. The woman is referred to a specialist in vulvar disease.