CLINICAL ACTIONS:

Desquamative inflammatory vaginitis is a form of vaginitis occurring primarily in perimenopausal white women.  The etiology is unknown.  The syndrome includes vaginal inflammation, rash and purulent discharge along with dyspareunia.

• Consider desquamative vaginitis in women presenting with
  • Chronic vaginal symptoms, specifically
    • Discharge | pruritis |burning| irritation
  • Dyspareunia
• Exam findings may include
  • Vaginal inflammation (‘fiery red’)
  • Purulent discharge
  • Spotted vaginal rash
  • Areas of a white reticulated pattern
  • Erosions in a spotted or linear pattern
  • Areas of hemorrhage or ecchymosis
  • Lack of Lactobacillus predominance
• Vaginal pH is typically ≥5
• Microscopy shows increased parabasal cells and inflammatory cells (neutrophils)
  • Inflammatory to squamous cell ratio is 1:1
• Rule out trichomoniasis
  • WBCs my be present with similar pH
  • However, parabasal cells less likely to be present and motile T. vaginalis organisms can be seen on microscopy
• Look for oral, cutaneous or vulvovaginal lesions that may be suggestive of lichen planus

SYNOPSIS:

Desquamative inflammatory vaginitis should be in the differential diagnosis for all menopausal and perimenopausal women presenting with complaints of chronic vaginitis.  It is important to rule out other entities such as BV, trichomonas, and STDs prior to beginning treatment. Treatment is generally of longer duration than for other causes of vaginitis.  Cause is unknown, with disproved theories including estrogen deficiency, bacterial infection, or vitamin D deficiency. Possible underlying mechanisms include a noninfectious disease with a genetic predisposition for an abnormal immune attack on elements in the vaginal mucosa.

KEY POINTS:

• Treatment is topical and can be either antibiotic or steroid based (official guidance on treatment not yet developed)
  • Clindamycin 2% cream: Intravaginally once daily (bedtime) for 1-3 weeks; Consider maintenance once or twice a week for 2 to 6 months or
  • 10% hydrocortisone cream 300-500 mg: Intravaginally daily (bedtime) for 3 weeks; Consider maintenance once or twice a week for 2 to 6 months or
  • Cortisone acetate 25 mg suppository: Twice daily for 4-6 weeks or
  • Clobetasol propionate: Intravaginally daily (bedtime) for 1 week; Maintenance duration not evidence-based
  • Consider addition of Fluconazole 150 mg orally once a week as maintenance therapy or topical vaginal estrogen twice a week in addition to clindamycin or glucocorticoid
• Reevaluate 4 weeks after treatment is concluded and if residual symptoms persist and clinical findings are only partially controlled, offer additional treatment such as
  • Reverse treatment—if initially on clindamycin, switch to hydrocortisone and vice versa
  • Combine treatment—use both clindamycin and hydrocortisone together
  • Increase hydrocortisone to 15% strength cream
• Cure rates are low
  • 26% cure at 1 year
  • 58% will be controlled (require maintenance therapy)
• Diagnosis code: N76.1

Learn More – Primary Sources:

Prognosis and Treatment of Desquamative Inflammatory Vaginitis

Bacterial Vaginosis and Desquamative Inflammatory Vaginitis

Vaginitis: Beyond the Basics

Management of Persistent Vaginitis

Related ObG Topics:

Diagnosing Vaginitis – Why the Office Visit Still Matters

Persistent Vaginitis: Tools and Tips in Diagnosis and Treatment

What is ‘Mixed’ Vaginitis? How and When to Treat

Trichomoniasis: CDC Diagnosis and Treatment Guidelines