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Probability diagnosis

Atopic dermatitis/seborrhoeic dermatitis

Chronic vulvovaginal candidiasis

Irritant contact dermatitis (e.g. douches, bubble baths)

Allergic contact dermatitis (e.g. perfumes, topical antimicrobials)

Fissuring from the above dermatoses

Trauma: ‘dry’ coitus

Serious disorders not to be missed


  • squamous cell carcinoma

  • lymphomas, etc. → pruritus

  • melanoma


  • streptococcal vulvovaginitis

  • herpes simplex virus; herpes zoster


  • vulval vestibular syndrome (provoked vestibulodynia)

Pitfalls (often missed)

Lichen sclerosus

Urinary incontinence → ammoniacal vulvitis

Faecal soiling

Tinea cruris

Trichomonal vaginitis

Atrophic vaginitis

Aphthous ulcers

Dysaesthetic vulvodynia


Lichen planus


  • threadworms

  • pubic lice

  • scabies

Masquerades checklist



Drugs (e.g. antibiotics)

Spinal dysfunction (?dysaesthesia)


Is the patient trying to tell me something?

Common: psychosexual problems.

Key history

  • Appropriate history including atopic skin diseases.

  • Gynae-urological history (e.g. oestrogen status, faecal or urinary incontinence, vaginal discharge, ‘thrush’)

  • Check allergens and irritants (e.g. panty liners, soap, bubble bath, perfumes, condoms, douches)

  • Sporting activity (e.g. bike riding and costumes)

  • Check psychosexual history (e.g. dyspareunia, partnership issues, depression)

Key examination

  • General health

  • Inspection of vulva and rest of skin, scalp nails

  • Vaginal examination

Key investigations

  • Vaginal swab

  • Pap smear

  • Consider need for vulval biopsy and patch testing

Diagnostic tips

  • The previously named vulvar vestibular syndrome or vestibulitis is now termed provoked vestibulodynia, whereby a vestibule tender to pinpoint pressure and variable erthythema is found, typically, in young nulliparous women.

  • Always biopsy a focal lesion on the vulva.

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