Vulvitis: Symptoms, Types, Causes and Treatment

Vulvitis—an inflammation of the vulva—can significantly impact quality of life, causing discomfort and distress in people of all ages. While it may sound straightforward, vulvitis is a complex condition with numerous causes, manifestations, and treatment approaches. Understanding its symptoms, types, causes, and treatment options is crucial for early recognition, effective management, and improved patient outcomes. This comprehensive guide synthesizes the latest research to empower patients and caregivers with clear, actionable knowledge.

Symptoms of Vulvitis

Vulvitis doesn't always look the same from one person to another. Symptoms can range from mild irritation to severe discomfort, and often mimic other genital or dermatologic conditions. Recognizing the key symptoms is the first step toward getting the right diagnosis and care.

Symptom	Description	Prevalence/Severity	Source(s)
Burning	Sensation of heat or stinging	Most common in PCV (80.6%)	1, 6, 2
Pruritus	Itching, sometimes intense	Frequent in various types	6, 2
Dyspareunia	Painful intercourse	Most severe symptom in PCV	1, 6, 7
Erythema	Redness, often bilateral	Main sign in GAS vulvitis	2, 6
Discharge	Vaginal or vulvar exudate	Common in infections	2, 7
Edema	Swelling of vulvar tissue	Seen in GAS and chronic cases	2, 3
Fissures	Cracks or splits in the skin	Noted in severe presentations	2
Shiny Lesions	Glistening or shiny skin appearance	Noted in PCV	6

Table 1: Key Symptoms

Burning and Stinging

Burning is the most frequently reported symptom in plasma cell vulvitis (PCV), experienced by over 80% of affected individuals. Patients may describe it as a persistent heat or stinging sensation, often severe enough to interfere with daily activities. Burning is also common in other forms of vulvitis, such as those triggered by infections or hypersensitivity reactions 1, 6, 2.

Pruritus (Itching)

Itching is another hallmark of vulvitis. While it can present in any type, it is particularly prevalent in infectious and inflammatory varieties. Chronic itching can lead to scratching, which exacerbates irritation and can cause skin breakdown 6, 2.

Dyspareunia (Painful Intercourse)

Pain during intercourse is reported as the most severe symptom by many patients with PCV and certain other chronic forms of vulvitis. This can have a significant impact on intimate relationships and psychological well-being 1, 6.

Erythema and Skin Changes

Redness (erythema) of the vulva is a classic sign, especially in group A streptococcal (GAS) vulvitis, where the redness is often bilateral and may be accompanied by oozing, swelling, or fissuring. A shiny or glistening appearance of lesions is particularly noted in PCV 2, 6.

Other Symptoms

• Discharge: Vulvar or vaginal discharge may signal infection, especially with GAS or Candida species 2, 5.
• Edema: Swelling is common in acute infections or chronic inflammatory types 2, 3.
• Fissures: Deep cracks or splits can develop, especially in severe or long-standing cases 2.
• Localized Lesions: Well-demarcated or solitary lesions, sometimes with erosions, are frequently seen in PCV 6.

Types of Vulvitis

Vulvitis is not a single disease but encompasses several distinct types. Each has its own patterns, underlying mechanisms, and preferred treatments. Knowing the subtypes is crucial for targeted therapy and better outcomes.

Type	Unique Features	Typical Triggers/Associations	Source(s)
Plasma Cell Vulvitis	Burning, shiny, well-demarcated lesion	Chronic inflammation, unknown	1, 6, 7
Streptococcal Vulvitis	Bilateral erythema, oozing, fissures	GAS infection, often with vaginitis	2
Granulomatous Vulvitis	Labial hypertrophy, chronic course	Crohn’s disease, cheilitis	3
Hormone Hypersensitivity	Cyclic symptoms, HRT link	Estrogen/progesterone sensitivity	4
Zoon’s Vulvitis	Chronic, burning, pruritus	Chronic inflammation, rare	9
Candidal Vulvitis	Itching, discharge, erythema	Candida infection	5

Table 2: Main Types of Vulvitis

Plasma Cell Vulvitis (PCV)

PCV, also called vulvitis circumscripta plasmacellularis or Zoon’s vulvitis, is a chronic, underrecognized condition characterized by prominent burning, well-demarcated shiny lesions, and sometimes erosions. Dyspareunia and pruritus are also common. Diagnosis often requires biopsy and histopathology, as it can be mistaken for other conditions 1, 6, 7, 9.

Streptococcal (GAS) Vulvitis

Though rare in adults, GAS vulvitis presents with striking, bilateral, and sometimes oozing erythema, often involving both the vulva and perianal region. It frequently co-occurs with asymptomatic vaginal or anal infections and may be associated with underlying skin diseases like psoriasis or lichen sclerosus 2.

Granulomatous Vulvitis

Marked by labial swelling and chronic inflammation, granulomatous vulvitis may be related to systemic diseases such as Crohn’s disease or cheilitis granulomatosa. Its presentation can precede or coincide with other granulomatous disorders 3.

Hormone Hypersensitivity Vulvitis

Some women experience cyclic or persistent vulvitis due to hypersensitivity to endogenous hormones (estrogen, progesterone), or after starting hormone replacement therapy (HRT). Symptoms are often resistant to standard treatments and may resolve after cessation of HRT or menopause 4.

Zoon’s Vulvitis

A rare, chronic inflammatory condition, Zoon’s vulvitis is characterized by burning, pruritus, and distinctive lesions confirmed by biopsy. It may overlap clinically with PCV and is responsive to high-potency topical steroids 9.

Candidal Vulvitis

This common form is caused by Candida species, leading to intense itching, discharge, and redness. It is a frequent cause of vulvitis, especially in women with recurrent vaginal yeast infections 5.

Causes of Vulvitis

The underlying causes of vulvitis are diverse, ranging from infections to immune reactions and even hormonal influences. A nuanced understanding of these factors is essential for effective prevention and management.

Cause	Example Conditions	Mechanism / Risk Factors	Source(s)
Infectious	GAS, Candida, HSV	Microbial invasion, imbalance	2, 5, 8
Autoimmune/Inflammatory	PCV, granulomatous, Zoon’s	Immune-mediated inflammation	1, 6, 3, 9
Hormonal	HRT-induced, cyclic hypersensitivity	Hormonal fluctuations, HRT	4
Dermatological	Psoriasis, lichen sclerosus	Underlying skin disorders	2
Allergic/Contact	Irritants, detergents	Hypersensitivity, direct irritation	4
Idiopathic	Unidentified	Unknown	6, 9

Table 3: Major Causes of Vulvitis

Infectious Causes

• Bacterial: Group A Streptococcus (GAS) can cause acute vulvitis, often as part of a wider vulvovaginitis. Other potential bacterial pathogens include Staphylococcus and less commonly, anaerobes 2.
• Fungal: Candida species are the main culprits in candidal vulvitis. Disruption of the normal vaginal flora (e.g., antibiotics, diabetes, immunosuppression) increases risk 5.
• Viral: Herpes simplex virus (HSV) can trigger recurrent vulvitis with erosions and pain. Notably, HSV antigens have been detected in lesions of some chronic vulvitis cases, suggesting a possible role 8.

Autoimmune & Inflammatory

• Plasma Cell Vulvitis and Zoon’s Vulvitis: These are considered immune-mediated, with a dense plasma cell infiltrate on histology. The exact trigger remains unclear, but chronic inflammation is central 1, 6, 9.
• Granulomatous Vulvitis: Associated with systemic inflammatory disorders like Crohn’s disease or cheilitis granulomatosa. These conditions involve granulomatous inflammation of the vulva 3.

Hormonal Factors

• Hypersensitivity to estrogen or progesterone can lead to vulvitis that flares cyclically or after hormone therapy. Diagnosis is confirmed by skin testing, and symptoms often remit after hormonal manipulation or menopause 4.

Dermatological & Allergic Causes

• Skin disorders such as psoriasis, lichen sclerosus, and contact dermatitis frequently involve the vulva and may present with vulvitis. Exposure to irritants, scented hygiene products, or detergents can also provoke allergic or irritant vulvitis 2, 4.

Idiopathic

• In many cases, no clear cause is found, especially in chronic or recurrent vulvitis. These cases may require thorough evaluation to rule out hidden infections, autoimmune diseases, or hypersensitivity reactions 6, 9.

Treatment of Vulvitis

Effective treatment of vulvitis hinges on accurate diagnosis and addressing the underlying cause. Approaches range from topical therapies to systemic interventions. Early recognition and tailored management can alleviate symptoms and prevent complications.

Approach	Indication	Common Agents/Methods	Source(s)
Topical Steroids	Inflammatory, PCV, Zoon’s, chronic	Clobetasol 0.05%, potent steroids	6, 9, 4
Topical Immunomodulators	Refractory PCV	Tacrolimus 0.1%, imiquimod	6, 7
Antimicrobials	Infectious (GAS, Candida, HSV)	Antibiotics, antifungals, antivirals	2, 5, 8
Hormonal Manipulation	Hormone hypersensitivity	Ceasing HRT, hormone suppression	4
Alternative Therapies	Candidal vulvitis	Boric acid, tea tree oil (cautious)	5
Systemic Agents	Severe/refractory cases	Interferon alpha, oral steroids	8, 4
Partner Treatment	Infectious cases	Screening/treating partners	2

Table 4: Main Treatment Options

Topical Corticosteroids

High-potency topical steroids (e.g., clobetasol propionate 0.05%) are first-line for inflammatory vulvitis, including PCV and Zoon’s vulvitis. They can rapidly relieve symptoms and resolve lesions in many cases. For some, long-term or repeated courses may be necessary 6, 9.

Topical Immunomodulators

For steroid-refractory cases, topical agents like tacrolimus ointment or imiquimod have shown efficacy. Imiquimod, for instance, has led to improvement in stubborn cases of PCV 6, 7.

Antimicrobial Therapy

• Bacterial Infections: Appropriate antibiotics are essential for GAS or other bacterial vulvitis. Screening and treating sexual partners or household members can prevent reinfection 2.
• Fungal Infections: Antifungal agents (topical or oral) are standard for candidal vulvitis 5.
• Viral Infections: Antivirals may be necessary for HSV-associated vulvitis. There is some evidence of benefit from interferon alpha injections in chronic, herpes-associated cases 8.

Hormonal and Hypersensitivity Management

In hormone-induced or cyclic vulvitis, ceasing hormone replacement therapy or using therapies to lower endogenous estrogen may be effective. Some patients respond to potent topical steroids if hormonal manipulation is not possible 4.

Alternative and Complementary Therapies

Alternative treatments—such as boric acid, tea tree oil, propolis, and garlic—are used by some women for candidal vulvitis. While some have antifungal properties, these therapies are not universally safe or clinically proven, and may cause irritation or allergic reactions if misused 5.

Systemic Therapies

For severe, chronic, or refractory cases, systemic agents like oral steroids or intralesional interferon alpha may be considered, especially when local therapies have failed 8, 4.

Partner and Household Management

In infectious vulvitis, especially with GAS, partners or household members may harbor the organism and require screening and treatment to prevent recurrence 2.

Conclusion

Vulvitis is a diverse and often underrecognized condition. Understanding its symptoms, types, causes, and treatments helps ensure timely diagnosis and tailored, effective care. Here are the main points:

• Symptoms: Burning, pruritus, dyspareunia, erythema, discharge, edema, fissures, and shiny lesions are key indicators.
• Types: Major forms include plasma cell vulvitis, streptococcal vulvitis, granulomatous vulvitis, hormone-induced vulvitis, Zoon’s vulvitis, and candidal vulvitis.
• Causes: Range from infections (bacterial, fungal, viral) and autoimmune/inflammatory mechanisms to hormonal, dermatologic, and idiopathic factors.
• Treatment: Depends on the cause and may involve topical steroids, immunomodulators, antimicrobials, hormonal management, systemic agents, and partner treatment. Some alternative therapies may help but require caution.

Early recognition, thorough evaluation, and individualized management are vital for relief and prevention of complications in people affected by vulvitis. If you or someone you know experiences persistent vulvar symptoms, seeking timely medical attention is the first step toward recovery.