Female genital skin disorders

What are female genital skin disorders?

Female genital skin disorders are conditions that affect the vulva, the skin around the entrance to the vagina, causing symptoms such as itching, soreness or changes in how the skin looks. Some, such as eczema and psoriasis, are skin conditions you can get anywhere on the body, while others, such as lichen sclerosus, mainly affect genital skin.

What are the symptoms of female genital skin disorders?

The most common symptoms across these conditions are:

• itching, which is often the first and most persistent symptom
• pain, soreness, burning or stinging
• a change in the colour of the skin, for example redder, paler or white patches
• a change in the texture of the skin, such as thickening, crinkling or scarring
• splits or cracks in the skin (fissures)
• pain during sex.

Symptoms are often made worse by moisture, heat, rubbing or scented products. Which symptoms you get, and how severe they are, depends on the underlying condition: for example, lichen sclerosus usually starts with itching that can disturb sleep, while lichen planus tends to cause more pain and burning than itching.

STIs such as genital herpes and genital warts can also present with vulval skin changes similar to those of genital skin disorders, so if there's a chance you may have caught an STI, you should see a GP or go to a sexual health clinic to get tested.

What are the causes of female genital skin disorders and who is at risk?

Causes vary by condition. Lichen sclerosus and lichen planus are both thought to involve the immune system reacting against the skin, though the exact trigger isn't known.

Vulval atrophy happens when oestrogen levels fall, usually after the menopause, while eczema and dermatitis are often triggered by irritants or allergens that come into contact with sensitive vulval skin.

Everyday irritants that can trigger or worsen symptoms include:

• soap, bubble bath, shampoo and other cleansing products
• panty liners, sanitary towels and their adhesives
• synthetic or dyed underwear, and tight clothing
• sweat, urine and vaginal secretions
• perfume, talcum powder and scented toilet paper.

Some conditions run alongside other health issues. Having psoriasis elsewhere on the body raises your risk of lichen sclerosus. Thyroid disease, diabetes or Crohn's disease can also be linked to vulval skin problems. Friction and rubbing can make lichen sclerosus worse, and it may run in families.

Are there different types of female genital skin disorder?

Several distinct conditions can affect the vulva, and it's common for them to be confused with a simple yeast infection:

• Lichen sclerosus: This is a long-term inflammatory condition, most common in women in their 40s onwards, especially after the menopause, though it can also affect girls before puberty. Around 1 in 30 older women is affected
• Lichen planus: This causes pain and burning more than itching, and can affect the mouth as well as the vulva. Around half of women with lichen planus develop vulval or vaginal changes
• Vulval dermatitis, eczema and lichen simplex chronicus: This is the most common vulval skin problem, often linked to sensitive skin or an irritant, and made worse by the itch-scratch cycle
• Psoriasis: This appears on the vulva as moist, well-defined pink patches rather than the dry, scaly patches seen elsewhere on the body. It affects the genital skin of 50 to 60% of women who have psoriasis more generally
• Vulval atrophy: This is pale, thin skin caused by low oestrogen, usually after the menopause
• Candida (thrush): This causes irritation and soreness of the vulva, more than the discharge often associated with vaginal thrush
• Vulval intraepithelial neoplasia (VIN): This is pre-cancerous skin changes, sometimes linked to lichen sclerosus, that can only be confirmed with a biopsy
• Vulvodynia: This is pain without an obvious visible cause – around 15% of women experience one form of this at some point.

Apart from candida, none of these conditions are infectious or can be passed to a sexual partner.

How are female genital skin disorders diagnosed?

Your doctor will ask about your symptoms, any other skin conditions or health problems (such as thyroid disease, diabetes or eczema), your family history, and any products you've used on the skin.

If you consent to it, they'll examine your vulva, and may also check your mouth, scalp, elbows, knees, nails and the skin around your anus for signs of a condition affecting other parts of your body too.

Depending on what they find, you might also have:

• swabs to check for infection
• blood tests, if a more general health problem is suspected
• a vulvoscopy, where the skin is examined more closely using a magnifying instrument
• a biopsy, where a small skin sample is taken under local anaesthetic to confirm the diagnosis

Biopsies are usually done in an outpatient clinic and shouldn't be painful, as the area is numbed first.

How are female genital skin disorders treated?

Non-surgical treatments

Whatever the cause, gentle skin care helps. Using a soap substitute instead of soap, avoiding scented products, and keeping the area moisturised with a plain emollient can ease symptoms and reduce flare-ups.

For lichen sclerosus, lichen planus, eczema and psoriasis, a corticosteroid ointment is the main treatment – usually a strong steroid used daily at first and then gradually reduced. This is safe for genital skin under medical guidance, and most women's symptoms improve. However flare-ups are common and long-term, lower-dose treatment is often needed to keep the condition controlled. Around 1 in 10 women with lichen sclerosus don't respond well to steroids and are referred to a specialist clinic.

Other condition-specific treatments include antihistamines if itching disrupts your sleep, oestrogen cream for vulval atrophy, and antifungal tablets or creams for candida, sometimes continued for six months if infections keep coming back.

Surgical treatments

Surgery isn't the main treatment for most of these conditions, but it does have a role for VIN: the affected skin is usually removed surgically. If a large area needs removing, reconstructive surgery may be needed afterwards to prevent excessive scarring or problems with sex. Laser treatment or creams are sometimes used instead, though these aren't suitable for everyone.

When should I see a doctor?

It's important to see a doctor about any new or ongoing vulval symptoms, so the cause can be identified and you can get the right treatment and advice.

If you've already been diagnosed with a condition such as lichen sclerosus or lichen planus, go back to your doctor without delay if you notice a new lump, ulcer, or a red or thickened area that doesn't respond to your usual treatment, as these conditions carry a small risk of skin cancer that's easier to treat when caught early.