Managing Common Vulvar Skin Conditions
Proper diagnosis and treatment are essential to relieve vulvar itching and other irritating conditions.
Reviewed by Toni Golen, MD, Editor-in-Chief, Harvard Women’s Health Watch; Member of the Editorial Advisory Board, Harvard Health Publishing; Contributor
Many women have learned to think beyond “itching equals a yeast infection.” But the vulva — the external genital area surrounding the vagina — is subject to a range of skin issues, many of which are unknowingly self-inflicted.
And with age, the drop in estrogen after menopause makes women more prone to various conditions that irritate vulvar skin. These issues often go unnoticed by healthcare professionals, and women aren’t receiving the relief they deserve.
Vulvar skin conditions and their treatment
Several vulvar skin conditions are common elsewhere on the body but may be harder to recognize when they affect the vulva. These include:
Eczema
This inflammatory skin condition disrupts the skin’s surface, causing red patches, fine cracks, oozing, and crusting.
On the vulva, crusts are less likely, but eczema can trigger a cycle of itching and scratching that leads to chronic lichen simplex — thickened, intensely itchy skin.
If eczema affects an area of the vulva called the vestibule (the smooth skin near the vaginal opening and extending up toward the clitoris), it can cause burning and soreness. Sometimes, eczema begins in early childhood with an unknown cause. More often, it is triggered by exposure to an irritant or allergen.
To diagnose vulvar eczema, your doctor will ask about your symptoms; your history of eczema, allergies, and related conditions; your vulvar hygiene habits; and any products that may have come into contact with the vulva. During the exam, they’ll look for redness, scaling, cracking, and thickening.
All eczema requires gentle skin care. In simple cases, patients use topical corticosteroid ointments twice daily for two to four weeks, then gradually reduce frequency as symptoms improve. Severe cases may require a short course of high-potency corticosteroid ointment.
During treatment, scratching must stop — your doctor may prescribe an antihistamine (often taken at night to avoid daytime drowsiness). A cold compress can also help soothe itching.
Psoriasis
Psoriasis is a common condition where new skin cells are produced too quickly, leading to thick, scaly patches of inflamed, red skin in various areas of the body.
On the vulva, skin is usually too moist for dry scaling, so psoriasis is more likely to appear as pink patches with distinct borders. It most often affects the labia majora and may cause dry, scaly, itchy patches in hair-bearing areas. If the skin breaks, irritation or infection may occur.
You may have treated psoriasis flares elsewhere with remedies too harsh for the vulva. Your doctor can prescribe a topical steroid cream or ointment.
Lichen sclerosus
Although it can occur elsewhere on the body, this inflammatory skin disorder typically affects the vulvar or anal area in postmenopausal women. According to some estimates, one in 30 older women has lichen sclerosus. It is especially common in women with psoriasis.
Itching is usually the first symptom and can become severe enough to interrupt sleep and daily life. During an exam, your doctor may notice white patches (sometimes wrinkled or shiny). Some may show tears or red areas from bleeding (often caused by scratching), which can be painful and itchy. As the condition progresses, there’s a risk of scarring and shrinking of vulvar tissues.
Lichen sclerosus is diagnosed by its appearance and sometimes by biopsy. Regardless of severity, it should always be treated to prevent progression. The usual treatment involves applying a high-potency corticosteroid ointment for several weeks, then tapering off.
Women also need regular follow-ups after treatment for lichen sclerosus, as the condition can make affected skin more prone to skin cancer. Early treatment and prompt attention to new sores or lesions that don’t heal will further reduce risk.
Lichen planus
This skin condition, believed to result from an overactive immune system, can affect the vulva, vagina, inside the mouth, and other skin surfaces. On most parts of the body, lichen planus causes itchy purple bumps, sometimes streaked with white.
On vulvar skin, the most common symptoms are pain, burning, and rawness. The vulva may appear pale or pink, sometimes with a white lace-like pattern. If the skin breaks down, eroded areas appear moist and red. Lichen planus often affects the vagina as well, causing sticky yellow discharge and erosions that can make intercourse painful.
Eventually, lichen planus can affect both surface and underlying tissues, leading to scarring that alters vulvar shape and may result in near disappearance of the labia minora.
Lichen planus is diagnosed by its appearance (though it can be difficult to distinguish from estrogen-deficiency atrophy or steroid overuse) and confirmed with a biopsy. The condition can begin as a reaction to certain medications, so be sure to tell your doctor about anything you’re taking.
The most common first-line treatment is high-potency topical steroids. Unfortunately, lichen planus is persistent and often requires long-term maintenance therapy.
Irritants and allergens that can affect the vulva
Many substances can cause allergic reactions or irritate vulvar skin. Here are some of the main culprits:
Irritants
Upon exposure, irritants can cause immediate stinging or burning. These include:
- soap, bubble baths and salts, detergent, shampoo, conditioner
- adult or baby wipes
- panty liners and their adhesives
- nylon underwear, chemically treated fabrics
- vaginal secretions, sweat, and urine
- douching, yogurt
- spermicides, lubricants
- perfume, talcum powder, deodorants
- alcohol and astringents
- scented toilet paper
- sensitivity to certain fabrics
Allergens
Allergic symptoms may not appear until several days after exposure. Common allergens include:
- benzocaine
- neomycin
- chlorhexidine (in K-Y jelly)
- imidazole antifungals
- propylene glycol (a preservative used in many products)
- fragrances
- tea tree oil
- latex (in condoms and diaphragms)
Adapted from The V Book by Elizabeth G. Stewart, M.D., and Paula Spencer (Bantam Books, 2002).
Vulvar anatomy
The vulva (Latin for womb or covering) consists of several layers that cover and protect the sexual organs and urinary opening. The outer fleshy lips, the labia majora, are covered with pubic hair and contain fat that cushions the area. Inside the labia majora are thinner, more pigmented, and delicate folds of skin called the labia minora. The labia minora join at the top to enclose the clitoris.
The labia majora, labia minora and clitoris are made of erectile tissue, i.e. tissue that can swell with blood. The area between the labia minora, the vestibule, contains the openings to the urethra and vagina, as well as the Bartholin’s glands, which lie on either side of the vaginal opening and produce lubricant for the vestibule.
The flesh between the vaginal opening and the anus (not part of the vulva, but often involved in vulvar skin problems) is the perineum. This is where the incision called an episiotomy is sometimes made during childbirth, and also where tears can occur on their own during normal labor.
Getting a Diagnosis for Vulvar Skin Conditions
Vulvar skin conditions are highly treatable, but treatment depends on the specific cause. Identifying the underlying diagnosis can be very challenging.
Tell your doctor about any past or present medical conditions (including bladder and bowel problems), as well as any skin issues elsewhere on your body.
For example, psoriasis anywhere on the body increases the risk of lichen sclerosus. Crohn’s disease, a chronic inflammatory bowel condition, can cause abscesses or draining fistulas in the vulvar area, and vulvar skin problems are often among its earliest symptoms. Lichen planus is another possible cause of vulvovaginal symptoms. (The term “lichen,” when applied to skin disorders, whimsically refers to skin lesions that resemble the plant-like growths on rocks.)
Long-term treatment with oral steroids, immunosuppressants, or antibiotics can affect vulvar skin and increase the risk of infection.
Your doctor will also want to know how you care for your vulvar skin, as this can help identify potential sources of irritation. Even if you can’t pinpoint a recent change, that doesn’t mean your usual routine isn’t the culprit. Sometimes vulvar issues are the cumulative effect of long-standing practices.
It’s often what you’ve done day after day, year after year, that causes the problem. If you wear abrasive clothing and engage in friction-heavy activities like biking or spinning, and wear tight workout gear that exposes your vulva to sweat or detergent and soap residues, it may eventually take a toll.
Report any concerning symptoms, including itching, burning, pain, discoloration, discharge, bumps, or rashes on the vulva. It also helps to provide a symptom history and note what seems to improve or worsen the condition.
Your doctor will examine the vulva — possibly using a magnifier — and may insert a speculum to inspect the vagina. They may test the vaginal pH (acid-base balance) and take samples of secretions to examine under a microscope or culture for yeast. Remember, even with an experienced physician, multiple visits may be necessary to diagnose and manage certain vulvovaginal conditions.
The Problem with Self-Treatment
When vaginal or vulvar itching occurs, women often assume it’s a yeast infection and treat it with an over-the-counter antifungal cream. This may work — but not always. Instead, symptoms could stem from dry skin, a sexually transmitted infection, a bacterial infection, a less common yeast strain requiring different medication, or irritation or allergic reactions to everyday products like soaps, creams, and lotions.
If yeast isn’t the issue, antifungal creams won’t solve it. And if the skin is already irritated, applying these products may worsen the condition by introducing preservatives (like alcohol or propylene glycol) and other ingredients found in many antifungal remedies. That’s why it’s important to consult a gynecologist or dermatologist if symptoms persist after trying a standard antifungal cream.
Another common response to discharge or itching is to scrub the vulvar skin vigorously, assuming this will disinfect the area or eliminate irritants. But harsh cleaning can worsen irritation and won’t fix the root cause. Until the issue is properly diagnosed, it’s best to follow a gentle skin care routine (see “Gentle Vulvar Care”).
In fact, gentle cleansing applies whether or not you have a vulvar skin condition: wash the area gently using your fingertips or a soft cloth, then pat dry with a soft towel. Avoid using rough washcloths or scrubbing the skin.
Gentle Vulvar Care
Whether you have a vulvar skin condition or are simply prone to irritation, gentle care is essential. The following tips can help relieve itching, dryness, and irritation:
- Wear loose-fitting clothing.
- Choose cotton underwear (or go without it at home).
- To cleanse the area, use your fingers instead of a washcloth and opt for a non-alkaline, fragrance-free cleanser like Cetaphil or Basis (plain water is also fine).
- Soak for five minutes in warm water to remove sweat, lotions, or product residues.
- Pat the area dry and apply any prescribed medication or a soothing, protective substance like petroleum jelly or olive oil.
- Avoid products with multiple ingredients. Even those marketed for vulvar care — like original A&D ointment, baby lotion, or Vagisil — often contain chemicals that may irritate or cause contact dermatitis.
- In the bathroom, skip wet wipes. If you want moisture, use a spray bottle with plain water and then pat dry.
- After bathing, wait a few minutes before getting dressed to allow moisture to fully evaporate. Some women with vulvar skin issues may benefit from estrogen therapy (delivered vaginally via ring, tablet, or cream, or applied directly to the vulva), which can help reverse atrophy and inflammation, making vulvar skin less prone to irritation.
