NEWPORT BEACH, CALIF. – All it takes to clear up vulvar pruritus in most young girls prior to puberty is a little reminder about proper toilet habits, according to Dr. Bethanee J. Schlosser.
“There are a whole slew of conditions that cause itching of the genitals in young girls, but the most common is poor hygiene,” explained Dr. Schlosser of the departments of dermatology and obstetrics and gynecology at Northwestern University in Chicago.
Afraid they might miss out on something, children often rush bathroom visits and don’t take the time to wipe properly. Itching and redness soon follow. Gentle guidance is mostly all that’s needed to clear the problem. Loose-fitting cotton underwear helps, too, along with quickly changing soiled underpants, avoiding wet wipes, and taking baths to make sure the genitalia are adequately rinsed, Dr. Schlosser said at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.
Simple as those steps are, they can be overlooked in the clinic. One study found that young girls are sometimes misdiagnosed with candidiasis, and treated with topical antifungals for years, even though yeast infections – the most common cause of vulvovaginal pruritus in adult women – are estrogen dependent, and so far less likely before puberty (Australas. J. Dermatol. 2010;51:118-23). After hygiene issues, lichen sclerosus is perhaps the next most common cause of vulvar pruritus in young girls, and tends to present with more urinary problems and bleeding than in adults, and more GI complaints, especially constipation. It’s “the most common inflammatory vulvar dermatosis that we see, with the possible exception of contact dermatitis,” Dr. Schlosser wrote (Arch. Dermatol. 2004;140:702-6). As in adult women, the first-line treatment is once-daily clobetasol propionate ointment 0.05% for several weeks, followed by maintenance therapy. Dr. Schlosser said she used to switch patients to a less potent topical steroid, but “then I had a couple patients get confused about which tube they were supposed to use at home, so now I taper the frequency of their clobetasol ointment” to once or twice a week instead of switching them to a less potent topical steroid. It’s easier for them, but as with any topical steroid, “you need to continue ongoing monitoring for cutaneous atrophy,” she said.
In general, pelvic exams in pediatric patients “require special consideration. These are not 5-minute visits. You have to take the time to make yourself available. Educate patients and parents about what’s going to happen,” and use the child’s own terms for her genitals, asking parents beforehand what they are, so that the child understands what she’s hearing, Dr. Schlosser said.
“When I see young girls,” mom is in the room and “I only have gauze, gloves, and maybe a Q-tip [swab] here and there. I often” begin by asking the child if it’s okay to look at her scalp, face, and hands, then “gradually work my way down. I think that gives patients some sense of comfort and control,” she said.
Dr. Schlosser said she prefers the frog-leg position, with very young girls in their mothers’ laps. The literature sometimes advocates the prone knee-to-chest position, but “I find it makes people feel very vulnerable. They can’t see you, and they have no idea of what’s going on. I don’t advocate it,” she said.
Dr. Schlosser said she has no relevant financial disclosures.
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