Desquamative Vaginitis—How to Recognize and Treat It

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

Diagnosing Vaginitis – Why the Office Visit Still Matters

CLINICAL ACTIONS:

A patient presents with vaginal inflammation with discharge, pain and/or itching. Next steps should include

Problem-focused history

• BV
  • Fishy odor | Thin homogeneous discharge (possibly worse after intercourse)
• Candidiasis
  • No odor | White, thick, ‘curdlike’ or ‘cheesy’ discharge | Itching and/or burning
• Trichomoniasis
  • Foul odor | Green or yellow, frothy discharge | Vaginal pain or soreness
• Atrophic vaginitis
  • Thin, clear discharge | Dryness | Dyspareunia | Itching
• Irritant/allergic vaginitis
  • Burning and/or soreness
• Desquamative Inflammatory vaginitis
  • Green or yellow (purulent) discharge | Burning | Dyspareunia

Exam including inspection of the vulva, vagina and cervix

• BV
  • Inflammation not usually present
• Candidiasis
  • Erythema | Edema
• Trichomoniasis
  • Inflammation | Strawberry Cervix
• Atrophic vaginitis
  • Inflammation | Thin/friable mucosa
• Irritant/allergic vaginitis
  • Erythema
• Desquamative Inflammatory vaginitis (DIV)
  • Varying vestibular and vaginal erythema

Appropriate laboratory testing

• Collection of and microscopic examination of a 10% KOH and saline prep (wet mount), pH testing and ‘whiff test’ constitute the office-based clinical testing of samples
• Culture (if necessary)
  • Yeast: Obtain if recurrent candidiasis or possible non-albicans Candida (suspect if blastospores ‘only’ or persistent treatment after treatment) | Negative microscopy with signs and/or symptoms of candidiasis
  • Trichomoniasis: ACOG recommends culture with a negative wet mount in the following circumstances
    • Persistent symptoms following treatment | high vaginal pH and WBCs on microscopy | Pap suspicious for T. vaginalis | patient desire for screening
    •  Note: CDC considers NAAT screening more sensitive for T. vaginalis then culture (previous gold standard) or wet mount
  • Mucopurulent cervicitis: Test (DNA or cultures) for gonorrhea or chlamydia
  • HSV: If any vulvar fissure/lesion suggestive of herpes simplex virus, perform viral culture or PCR assay for HSV DNA by swabbing the lesion
    • Type-specific HSV serologic assays might be useful in the following scenarios: 1) recurrent genital symptoms or atypical symptoms with negative HSV PCR or culture; 2) clinical diagnosis of genital herpes without laboratory confirmation (CDC STD Guidelines)

Perform “Whiff Test” with 10% KOH and Microscopy with Saline

• Positive whiff test
  • Negative (-) for WBC: Treat for bacterial vaginosis (BV)
  • Positive (+) for WBC: Review signs/symptoms for trichomoniasis or mixed bacterial vaginosis or cervicitis
• Negative whiff test
  • negative (-) for WBC: Noninfectious

Determine Vaginal pH

• If pH is normal (<4.7) consider the following
  • Infectious: Vulvovaginal candidiasis | Genital herpes
  • Noninfectious: Physiologic leukorrhea | Vulvodynia | Dermatitis/dermatoses

If pH is Elevated (>4.7) Consider the Following

• Infectious
  • Bacterial vaginosis | Trichomoniasis | Cervicitis
• Noninfectious
  • Blood | Semen | Atrophic vaginitis | Lichen planus | Desquamative inflammatory vaginitis (DIV)

SYNOPSIS:

Vaginitis is a general term for disorders of the vagina, but does not indicate the underlying cause.  Vaginitis may result from infection, inflammation, or may reflect changes in the normal vaginal microbiome.  The disorder is termed vulvovaginosis when the vulva is involved. When patients present with symptoms of itching/burning/irritation/dyspareunia/discharge consider a broad range of possibilities including but not limited to the triad of bacterial vaginosis (BV), trichomoniasis and vulvovaginal candidiasis.  Office based tests such as those above also have a low sensitivity. Accurate diagnosis may require a combination of a careful history, vulvar or vaginal biopsy and appropriate culture.

KEY POINTS:

• Self-diagnosis and treatment, while convenient, may be unreliable and results in frequent misuse of OTC products
• FDA approved commercial tests for BV
  • ACOG acknowledges that direct DNA probe assays for G vaginalis or chromogenic point-of-care assays for sialidase activity have acceptable performance vs Amsel criteria and Nugent scoring
  • However, because these tests only pick up one organism (i.e., G vaginalis) “the diagnostic utility of a test that identifies only a single organism (eg G vaginalis) is still being investigated and is not currently supported”
• No microscope
  • Vaginal pH testing narrows the differential diagnosis of vaginitis for BV and trichomoniasis
  • Candidiasis: History | Exam | Culture
  • Obtain vaginal secretions slide for future Gram stain if possible
• Incidental findings on Pap test
  • Not diagnostic
  • BV on Pap
    • Symptomatic: pH, amine test, and wet mount
    • Asymptomatic: Do not treat
  • Trichomoniasis on Pap
    • High false-positive rate (8% standard and 4% liquid-based)
    • Wet mount for confirmation
    • If wet mount negative, NAAT or culture
    • If diagnostic tests not available, can consider metronidazole, but high rate of unnecessary treatment

Learn More – Primary Sources:

ACOG Practice Bulletin 215: Vaginitis in Nonpregnant Patients 

Vaginitis: Diagnosis and Treatment

Advances in Diagnosing Vaginitis: Development of a New Algorithm