Understanding and managing vulvovaginal itching
Clinical Applications
By Kathryn Schwarzenberger, MD, FAAD, October 1, 2025
In this month's Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with Gil Yosipovitch, MD, FAAD, and Kayla D. Mashoudy, MD, about their American Journal of Clinical Dermatology paper, 'Scratching the Surface: A Comprehensive Guide to Understanding and Managing Vulvovaginal Itching.'
DermWorld: You and your colleagues recently published a comprehensive guide on the management of vulvovaginal itching. What were your main goals in writing this guide?
Vulvar itch is a common complaint among women of all ages, yet many patients feel too embarrassed to bring it up. In busy clinical settings, it is often treated empirically without a thorough evaluation.
Our recent research has shown that genital itch is associated with significantly poorer quality of life compared to itch in other body regions and is strongly linked to elevated stress levels (JAAD Int. 2023;11:65–71; J Am Acad Dermatol. 2025 June 4). This underscores the need for greater awareness and confidence among dermatologists in addressing this condition.
DermWorld: Can you describe some of the primary causes of vulvovaginal itching?
Dr. Yosipovitch: Vulvovaginal pruritus has a broad differential, encompassing dermatologic, gynecologic, neurologic, and psychiatric causes. Common etiologies include:
Infectious: Candidiasis, bacterial vaginosis, trichomoniasis, scabies, tinea, herpes simplex, HIV
Inflammatory dermatoses: Atopic dermatitis, irritant/allergic contact dermatitis, inverse psoriasis, lichen sclerosis atrophicus, lichen simplex chronicus, lichen planus
Hormonal: Genitourinary syndrome of menopause (GSM)
Neuropathic: Lumbar or sacral nerve impingement, small fiber neuropathy, vulvodynia
Neoplastic and genetic: Squamous cell carcinoma, Paget’s disease, Hailey-Hailey disease, Darier disease
Importantly, many patients present with overlapping etiologies, making careful clinical assessment essential.
Dr. Mashoudy: One of the most enlightening aspects of this research was understanding how overlapping etiologies are the norm, rather than the exception. A patient might present with itch from lichen sclerosus, compounded by candidiasis, and exacerbated by psychogenic stress. To help demystify this complexity, I created a visual figure that maps out the diverse causes — from infectious and inflammatory to neuropathic and psychogenic — in a way that’s intuitive for practicing dermatologists. The sheer breadth of possibilities reinforces the need for careful history, targeted exams, and sometimes, a bit of detective work.
DermWorld: Do dermatologists have the appropriate training and tools to evaluate vulvovaginal pruritus? Should these patients be referred to gynecology?
Dr. Yosipovitch: Dermatologists are well equipped to evaluate vulvar dermatoses — particularly when inflammatory, irritant, allergic, or neoplastic causes are suspected. Ideally, care should be collaborative. Referral to gynecology is warranted if there is concern for intravaginal pathology or if infectious causes persist despite treatment. But in most cases involving the vulva, dermatologists should feel confident taking the lead in diagnosis and management.
Dr. Mashoudy: This was a central question that drove our work. While dermatologists are exceptionally well trained to evaluate inflammatory and neoplastic skin conditions, many receive minimal exposure to vulvar disease during residency. That doesn’t mean the tools aren’t there. It’s often a matter of confidence and awareness. Vulvar itch is not “just a gynecologic issue.” In fact, many of the most common causes — like lichen sclerosus, irritant dermatitis, and lichen simplex chronicus — are squarely within the dermatologic domain. By equipping dermatologists with a focused, evidence-based framework, we hope to empower them to take ownership of these cases and collaborate with gynecology when appropriate including cases involving intravaginal pathology.
Tackling itch
DermWorld: What are your top clinical pearls for managing vulvovaginal pruritus?
Dr. Yosipovitch: Several key principles guide effective management:
Assess itch severity with a simple numerical rating scale of 0-10.
Always examine the area thoroughly. In atypical or refractory cases, biopsy is essential.
Treat inflammation aggressively in conditions such as lichen sclerosus and lichen simplex chronicus. In moderate-to-severe cases, biologics targeting type 2 inflammation (e.g., dupilumab, currently in Phase 3 trials, and nemolizumab) may be beneficial.
Avoid soaps and antibacterial washes. These products increase skin pH, encouraging Candida overgrowth and activating itch-mediating receptors.
In early research, we showed that patients with type 2 diabetes have elevated pH in intertriginous areas, such as the inguinal folds, which increases susceptibility to candidal intertrigo. Later studies confirmed that high pH can activate PAR-2 receptors, intensifying itch (Diabetes Care. 1993;16(4):560–3; J Invest Dermatol. 2025;145(3):509–21). Thus, using topical acidifying agents or pH-balanced products can significantly improve symptoms.
Dr. Mashoudy: The biggest pearl I’d offer is to listen carefully to what patients aren’t saying. Many of the women I encountered during this research and in clinic were hesitant to speak up about their symptoms due to embarrassment or previous experiences of being dismissed. A simple, nonjudgmental question like, “Are you experiencing any itching or discomfort down there?” can open the door. From a treatment perspective, I’ve learned the importance of going beyond symptom suppression — understanding the why behind the itch. That might mean addressing hormonal atrophy, switching to pH-balanced washes, or considering neuropathic drivers.
One particularly overlooked intervention is topical acidification, which helps restore the disrupted barrier and lower skin pH — an approach that can meaningfully reduce itch, especially in diabetic or postmenopausal patients.
DermWorld: Are there concerns about using high-potency corticosteroids on vulvar skin?
Dr. Yosipovitch: This is a common concern, but when used appropriately, high-potency topical corticosteroids are both safe and effective, particularly for lichen sclerosis. Physicians should educate the patient on correct application, use a tapering regimen after initial control is achieved, and monitor with regular follow-up. Importantly, inflamed vulvar skin is less prone to atrophy, though maintenance therapy with milder agents is preferred long-term.
Dr. Mashoudy: I echo Dr. Yosipovitch’s guidance. When used correctly, high-potency topical steroids are both safe and essential, particularly in managing lichen sclerosus. Patient education and close follow-up are critical. I remember one case in clinic where a woman had suffered for months with severe vulvar itch due to undertreatment. Once we initiated appropriate steroid therapy and provided a clear tapering plan, her symptoms and quality of life improved dramatically. Reassuring patients through clear, confident counseling can itself be therapeutic, often alleviating fears around steroid use and improving adherence to care.
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DermWorld: Does topical estrogen have a role in treating vulvovaginal pruritus?
Dr. Yosipovitch: Yes, but primarily in postmenopausal women with genitourinary syndrome of menopause (GSM). Topical estrogen can restore mucosal integrity, improve hydration, and reduce itch and discomfort due to atrophic changes. It is not generally indicated for inflammatory dermatoses but can be a helpful adjunct in selected cases.
Dr. Mashoudy: While seeing patients in gynecology clinic, I often encountered women whose itching stemmed from undiagnosed atrophic changes. In these cases, topical estrogen significantly improved mucosal integrity, hydration, and symptom relief. Though not used for inflammatory dermatoses, it’s a valuable adjunct when hormonal atrophy coexists with other causes — an overlap we discussed in our paper as surprisingly common.
DermWorld: What preventive advice can we offer to patients with vulvovaginal pruritus?
Dr. Yosipovitch: Patient education and reassurance are essential. Prevention strategies include:
Avoid scented soaps, douches, and harsh cleansers.
Use gentle, pH-balanced products (pH ≤ 5.5).
Wear breathable, non-occlusive clothing.
Apply bland emollients with or without pramoxine (a topical anti-pruritic) regularly for those with dryness or irritation.
Normalize the conversation — many patients feel embarrassed or dismissed; validating their symptoms can improve trust and adherence.
With a structured, empathetic approach, dermatologists can take a central role in diagnosing and managing vulvovaginal pruritus. A deeper understanding of the diverse causes — and confidence in targeted treatments — will lead to better patient outcomes and improved quality of life.
Dr. Mashoudy: I fully agree with Dr. Yosipovitch’s emphasis on avoiding irritants, using pH-balanced cleansers, and applying bland emollients to maintain skin barrier integrity. These are simple yet powerful steps. In gynecology clinic, I found that many patients unknowingly exacerbate their symptoms through daily habits like wearing tight synthetic underwear or using fragranced wipes. Empowering patients with this knowledge — and reassuring them that vulvar itch is a valid and manageable concern — can make a lasting difference in both symptom prevention and patient trust.
Gil Yosipovitch, MD, FAAD, is the Stiefel chair of medical dermatology, director of the Miami Itch Center and UCare Center Dr. Phillip Frost department of dermatology Miller School of Medicine, at the University of Miami, Florida.
Dr. Yosipovitch disclosure of interests: Abbvie, Arcutis, Almiral, Amgen, Attovia, Celldex (advisory board member), Clexio, Escient Health, Eli Lilly (investigator research support), Galderma, GSK, Kiniksa, LEO Pharma, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, Vifor.
Kayla D. Mashoudy, MD, is a former student fellow at the Miami Itch Center, Dr. Phillip Frost department of dermatology Miller School of Medicine at the University of Miami, Florida. Dr. Mashoudy does not have any relevant financial and/or commercial conflicts of interest.
Their paper appeared in the American Journal of Clinical Dermatology.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.
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