Vulvovaginitis: Advice for Referrers

On examination there may be vulval or peri-vulval erythema, wrinkling of the skin, excoriation, and possibly some discharge. With consent, the perianal area should also be inspected to look for excoriation or the presence of threadworms, although worms are often not seen during the day³ (See link to Threadworms)

Around half the girls who have vulvovaginitis will have it more than once during their childhood. It usually gets better as girls grow up and will not cause them any long-term harm⁴.

Vulvovaginitis can generally be managed within the community using the advice below, however the following are reasons why referral to paediatrics would be appropriate:

• Persistent symptoms not responding to the strategies suggested below
• Uncertainty about diagnosis e.g. foreign body, bacterial infection
• The presence of pallor, erosions or ecchymosis should prompt referral to exclude lichen sclerosis. (Referral directly to paediatric dermatology would be appropriate).
• Concerns about anatomical variations in the context of persistent symptoms e.g. labial adhesions.

Please include the following points from the history in the referral letter:

• Length of symptoms, recurrent or new
• Presence of any discharge or concerns about possible foreign body
• Management advice already given (see below)
• Any relevant medical history (including constipation, recurrent UTIs)

Please include the following points from the clinical examination in the referral letter

• Clinical findings on examination
• Urinalysis results

Advice for carers

• Symptoms often resolve following the hygiene advice below
• Children do not need to use soap or bubble-baths for washing, and non-biological laundry powders should be used on their clothes with no fabric softeners. Avoid shampoo in the bath water. If children are having a bath, suggest hair is washed at the end and without sitting in the water
• Children may need supervision or help with their toileting and hygiene; wiping after urination or stooling should be from front-to-back. Some girls may need to rinse with water and then dry after passing urine or stool (avoid baby or feminine wipes). The shape of the pre-pubescent vagina / vulva can cause urine to pool and then come out later on, which may irritate the skin. Some girls may benefit from sitting backwards on the toilet (i.e. facing the cistern) to help urine drain more easily.
• Avoid tight clothing and artificial fabrics (e.g. jeans and tights) that increase sweating and friction
• Ideally, girls should not wear pants to sleep in. A 100% cotton nightdress is preferable to pyjama bottoms that may ride up around the perineal area. This will allow better airflow around the area and prevent dampness
• Girls can continue all their usual hobbies and activities. Chorine in swimming pool water can irritate; applying a barrier preparation beforehand, and a thorough shower then drying well afterwards can help prevent this
• Avoid hot tubs and hot baths
• Helping children who are overweight to manage their weight will help reduce friction and sweating in the area

Suggestions for management in primary care

• Barrier creams (e.g. Vaseline) can be helpful to prevent urine passing over the inflamed skin. These should be applied twice daily, and after showering and before swimming
• If there is any evidence of threadworms then the whole house should be treated, according to local formulary. (See link to Threadworms)
• Hand hygiene advice, including keeping nails short and clean, should be offered
• Swabs are mostly not helpful and not usually taken
• Persistent symptoms and signs of inflammation may indicate an eczematous response to irritation of the skin by urine and faeces. A mild topical steroid ointment e.g. Daktacort® ointment used once daily for 7 days can be tried during flares (ointments contain no preservatives and are less likely to irritate in this sensitive area) and continued one or two nights each week. If inadequately controlled with that, clobetasone butyrate ointment can be used for 7 nights during flares, but if flaring more than once each month despite twice weekly Daktacort®, a referral to Paediatric Dermatology should be made
• Persistent discharge without redness may be indicative of a foreign body, and further investigation may be required
• In most cases symptoms will improve with these measures, and as the child grows and produces more oestrogen, the issue will resolve.
• Perform urinalysis to ensure no concurrent UTI.
• Constipation is a common co-diagnosis - this should be looked for and treated
• In children who are not in nappies, candida infection is uncommon and antifungal medications are not indicated. If candida is identified in an older child, check a blood glucose as this can be a sign of Type 1 Diabetes Mellitus