Previous changes

May to June 2017 — reviewed. A literature search was conducted in May 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. 

May 2016 — minor update. Text updated to reflect the Medicines and Healthcare products Regulatory Agency (MHRA) safety update on the risk of QT interval prolongation and Torsade de Pointes with hydroxyzine.

December 2013 — minor update. A link to the NICE guidance on urinary incontinence has been replaced with a link to the CKS topic on Incontinence - urinary, in women.

May 2013 — minor update. The prescriptions for aqueous cream have been removed following advice issued by the MHRA regarding aqueous cream and the higher risk of skin irritation.

June 2011 — references updated due to an RCOG partial update. No changes made to the CKS topic. 

November 2010 to February 2011 — topic updated. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

October 2010 — minor update. Generic chlorphenamine is no longer licensed for the treatment of pruritus. Text and prescriptions amended to reflect this. Issued in October 2010.

December 2006 to March 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

July 2005 — updated to incorporate the Referral guidelines for suspected cancer published by the National Institute for Health and Clinical Excellence. 

July 2002 — reviewed. 

July 1999 — written, replacing guidance called Pruritus vulvae/pruritus of genital organs. Validated in October 1999 and issued in January 2000.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 September 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 September 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 September 2022.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 September 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 September 2022.

New policies

No new national policies or guidelines since 1 September 2022.

New safety alerts

No new safety alerts since 1 September 2022.

Changes in product availability

No changes in product availability since 1 September 2022.

Basis for recommendation

These recommendations are based on the British Association for Sexual Health and HIV (BASHH) UK national guideline on the management of vulval conditions [BASHH, 2014], the national guideline for the management of vulvovaginal candidiasis (2019) [BASHH, 2019], the 2021 European guideline for the management of vulval conditions [van der Meijden, 2021], and expert opinion in narrative reviews [Stewart, 2012; Alani, 2019; Woelber, 2020].

Basis for recommendation

These recommendations are based on the 2021 European guideline for the management of vulval conditions [van der Meijden, 2021], the British Association for Sexual Health and HIV (BASHH) UK national guideline on the management of vulval conditions [BASHH, 2014] and the national guideline for the management of vulvovaginal candidiasis (2019) [BASHH, 2019], the British Medical Journal (BMJ) Best Practice guide Assessment of pruritus [BMJ Best Practice, 2023], and expert opinion in narrative reviews [Alani, 2019; Woelber, 2020].

Which dermatological conditions can cause pruritus vulvae?

• Eczema (dermatitis). This may be:
  • Atopic dermatitis.
  • Allergic contact dermatitis. Common allergens include fragrances, topical antibiotics and anaesthetics, and components of other topical treatments.
  • Irritant contact dermatitis is the most common type of eczema causing pruritus vulvae, and one of the most common causes — it is an inflammatory reaction with itch as the main symptom. Lichenification and hyperpigmentation may occur when dermatitis is chronic. It can be caused by:
    • Proprietary creams (especially those containing local anaesthetics). 
    • Topical antibiotic preparations (for example, neomycin).
    • Barrier contraceptives or lubricants. 
    • Perfumes, soaps, bubble baths, or wet wipes.
    • Detergents, fabric conditioners, bleaches, or dyes.
    • Urine, particularly in those with urinary incontinence.
• Psoriasis — due to the moisture and friction of skin folds, the appearance may be different to classic psoriatis with scale being less common. There are well-defined erythematous plaques, but there may be no scale, or there may be fine silvery scales. Lesions on the outer labia majora may have thicker scales. However, typical psoriasis lesions may be present elsewhere on the body (elbows, knees, scalp). 
  • Genital skin is affected in up to 63% of people with psoriasis during their lifetime.
  • Genital areas may be the only region affected in 2 - 5% of patients.
  • For more information, see the CKS topic on Psoriasis.
• Seborrhoeic dermatitis — ill-defined border, some scaling, with or without involvement of other sites, such as the axillae, face (eyebrows or nasolabial folds), anterior chest, or scalp. This rarely affects the vulva but may affect flexures or the mons pubis.
  • For more information, see the CKS topic on Seborrhoeic dermatitis.
• Lichen simplex — a localized plaque of chronic eczematous inflammation created by repeated rubbing or scratching of the skin. It is more common in people with a personal or family history of atopy, but can be the result of any factors causing repeated scratching or rubbing.
  • It can affect the entire vulva and perianal area, or part of it. It can be localized, unilateral or bilateral, and the skin may appear leathery or lichenified, or may be pale and wrinkled.
  • There may be labial swelling and erythema, and some hair loss due to scratching.
  • There may be change in skin pigmentation (hyper-, hypo-, or depigmented areas).
• Lichen planus — a chronic inflammatory condition which affects the skin and /or mucosal surfaces.
  • Lesions may appear as erosive, glazed or glossy erythematous plaques; bluish-purple, shiny, flat-topped papules with small white dots or lines (Wickham's striae); or uniformly white hyperkeratotic plaques. 
  • There may be loss of vulvar architecture.
  • There is a small risk of squamous cell carcinoma developing in women with lichen planus (less than 3%).
• Lichen sclerosus — an inflammatory skin condition which affects the anogenital area more often than other cutaneous surfaces. 
  • It can occur at any age, but is most often diagnosed in women aged over 50 years.
  • Any area from the clitoral hood to the perianal area can be affected, but the vaginal mucosa is not affected. 
  • Lesions are hypopigmented-to-white, crinkled, fragile plaques classically distributed in a figure eight pattern around the vulva, perineal body, and perianal skin, although it may also be localised to the vulva alone. Bruises, blood blisters, or ulcers may appear after scratching, or from minimal friction. Purpura (ecchymosis) is common.
  • Scarring may cause loss of vulvar architecture, such as resorption of the labia minora, and mid-line fusing and stenosis of the introitus. The clitoral hood may be scarred, burying the clitoris. It mainly affects the inner, non-hair bearing areas of the vulva.
  • There is a small risk of squamous cell carcinoma developing in women with lichen sclerosus (less than 5%).
  • Early diagnosis is important to prevent scarring and malignant change.
• Fox–Fordyce disease (very rare) — small dome-shaped flesh-coloured to reddish papules which affect all hair follicles in the area.  
  • Intensely itchy and often presenting as lichenification (grossly thickened skin with accentuated skin markings).
  • Mainly occurs in women aged 13–35 years, however sometimes affects men and children.
• Hailey–Hailey disease (benign familial pemphigus) (very rare) — a blistering disease. Mainly affecting the skin folds, with moist fissured malodorous plaques and blisters.
  • Vesicles erupt causing pruritus, with or without involvement of the axillae and sides of the neck.
  • It is is an inherited autosomal dominant condition.
  • It is easily mistaken for tinea cruris or impetigo.
• Darier disease (very rare) — persistent, greasy, scaly papules, which are firm and may feel like sandpaper.
  • If papules coalesce, they form warty plaques, which may be macerated and malodorous.
  • Sites affected include seborrhoeic areas of the trunk, flank, and face, and skin folds.
• Symptomatic dermographism — a form of localized urticaria triggered by a direct firm touch, scratching, or rubbing.
  • Around 5% of women with pruritus vulvae are affected by dermographism, but only a minority experience symptoms.

Which infections and infestations can cause pruritus vulvae?

• Infections and infestations that can cause pruritus vulvae, include:
  • Candidiasis — for more information, see the CKS topic on Candida - female genital.
  • Trichomoniasis — for more information, see the CKS topic on Trichomoniasis.
  • Bacterial vaginosis — for more information, see the CKS topic on Bacterial vaginosis.
  • Threadworm — for more information see the CKS topic on Threadworm.
  • Genital herpes simplex — for more information, see the CKS topic on Herpes simplex - genital.
  • Pubic lice (Pediculus pubis) — for more information, see the CKS topic on Pubic lice.
  • Scabies (Sarcoptes scabiei) — for more information, see the CKS topic on Scabies.

Which pre-malignant and malignant conditions may cause pruritus vulvae?

• Vulval intraepithelial neoplasia (VIN) is a pre-malignant skin lesion of the vulva.
  • There are three distinct types of VIN, which may be related to human papilloma virus (HPV) infection, or follow chronic skin conditions such as lichen sclerosis. These have differing aetiology, malignant potential and treatment. Epidemiology varies between countries, and this may partly relate to differing HPV prevalence. Women of all ages may be affected.
  • VIN may be completely symptom-free, however women may present with:
    • Vulval itching.
    • Vulval burning.
    • Vulval pain.
    • Dyspareunia.
    • Lumps or erosions.
  • Clinical appearance is highly variable. There may be one or more flat or slightly raised, well-defined or irregular skin lesions that may be pink, red, brown, or white.
  • If left untreated, VIN may resolve spontaneously (especially the low-grade VIN), or it may develop into an invasive cancer. This may take on average between 2-7 years, depending on the type of VIN. There is an association with other genital intraepithelial neoplasias and cancers.
• Malignant neoplasms of the vulva (uncommon). Squamous cell carcinoma (SCC) accounts for 90% of malignant disease of the vulva. Other less common neoplastic conditions include perianal intraepithelial neoplasia, basal cell carcinoma, melanoma, extramammary Paget's disease, and carcinoma of Bartholin's gland.
  • Squamous cell carcinomas. 
    • Certain types of HPV infection, VIN, vulval lichen sclerosus, and lichen planus predispose to vulval neoplasms. Risk is also increased by smoking and immunosuppression.
    • SCC of the vulva was historically a condition of postmenopausal women, and is still more common in older women, but the average age has fallen due to an increase in HPV infections worldwide, with the incidence in younger women increasing. Vulval cancer can affect women of all ages.
    • SCC of the vulva may be asymptomatic and be found incidentally on examination, but there may be itch, burning, pain, lumps, ulceration, weeping, or bleeding.
  • Extramammary Paget disease (very rare) — a cutaneous neoplasm with a chronic eczema-like rash of the anogenital region and vulva. A common symptom is a mild to intense itching of a lesion found around the groin, genitalia, perineum, or perianal area. Pain and bleeding may occur from scratching lesions that have been around for a long time. Thickened plaques may form that can become red, scaly, weeping, and crusty. Although they may appear similar to eczema, they fail to clear up with topical steroid creams.

What hormonal changes can cause pruritus vulvae?

• Atrophic vulvovaginitis
  • In peri- and postmenopausal women, declining oestrogen levels may contribute to vaginal and vulval changes that result in vulvovaginal itching, dryness, and sometimes burning. The vulvovaginal area will be dry, pale, and thin.
    • Cessation of menstruation and other symptoms, such as hot flushes, may indicate that the cause is the menopause. For more information, see the CKS topic on Menopause.
    • Physiological changes of menopause alone may cause vulval itching, but conditions such as lichen sclerosus are more common in postmenopausal women, and contact dermatitis may be more problematic in this age group.
  • In breastfeeding women, elevated prolactin levels can have an antagonistic effect on oestrogen production, and may result in low oestrogen levels. This can lead to vaginal dryness, itching, burning, and irritation.
• Pregnancy
  • Increased hormone levels in pregnancy are associated with increased physiological vaginal discharge, and an increased risk of candidal vulvovaginitis, both of which cause vulvular pruritus. 

How may gastrointestinal conditions and urinary incontinence cause pruritus vulvae?

• Gastrointestinal disease — irritable bowel syndrome, Crohn's disease, ulcerative colitis, other inflammatory bowel disease, and anal fissures may lead to prolonged contact of stool with the vulval skin due to faecal incontinence or poor perianal hygiene.
• Urinary and faecal incontinence — this can result in vulvar inflammation, which presents as pruritus. 

What neurological conditions can cause pruritus vulvae?

Neurological causes of itch are due to neural dysfunction, either neuropathic (injury or damage to nerve fibres) or neurogenic (changes in the stimulation pathway within the central nervous system without structural damage). Some of these may affect the vulva. Causes include:

• Nerve or nerve root compression at L4 to S2 level.
• Varicella zoster (shingles) reactivation and post-herpetic neuralgia.
• Systemic diseases which affect nerve fibres (for example, diabetes mellitus, sarcoidosis, amyloidosis, Vitamin B12 deficiency, and viral infections).
• Central nervous system conditions (such as brain tumours, brain injury, and multiple sclerosis).

What systemic conditions may cause pruritus vulvae?

• Any cause of generalized pruritus may cause vulvar pruritus, including: 
  • Drug reactions, for example tetracycline antibiotics, such as doxycycline, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.
  • Systemic diseases, such as renal or hepatic disease, diabetes, iron deficiency anaemia, lymphoma, other haematological abnormalities, viral infections, and thyroid dysfunction.
  • For more information on managing generalized pruritus, see the CKS topic on Itch - widespread.
• Psychological problems — may occasionally present as pruritus vulvae.
• Stress — may be a cause of itch, or if not an initial cause, an exacerbating factor causing prolongation of symptoms or a flare-up.

Basis for recommendation

Dermatological conditions

The information about dermatological conditions which can cause pruritus vulvae is based on the British Association for Sexual Health and HIV (BASHH) UK national guideline on the management of vulval conditions [BASHH, 2014], the 2021 European guideline for the management of vulval conditions [van der Meijden, 2021], expert opinion in narrative reviews [Patel, 2018; Alani, 2019; Stewart, 2012], and DermNet New Zealand reviews Genital psoriasis [DNNZ, 2014], Darier disease [DNNZ, 2016b], Hailey-Hailey disease [DNNZ, 2016c], Itchy vulva [DNNZ, 2016a], Lichen sclerosus [DermNet, 2016], Fox-Fordyce disease [DNNZ, 2021], and Lichen simplex [DNNZ, 2022].

Infection and infestations

Information about infections and infestations which can cause pruritus vulvae can be found in the individual CKS topics linked in this section, with the basis for the recommendations made being found within those separate topics.

Malignant conditions

The information about pre-malignant and malignant conditions which can cause pruritus vulvae is based on the British Association for Sexual Health and HIV (BASHH) UK national guideline on the management of vulval conditions [BASHH, 2014], the Vulval cancer guidelines from the British Gynaecological Cancer Society (BGCS) [BGCS, 2020], the 2021 European guideline for the management of vulval conditions [van der Meijden, 2021], background information in a Cochrane review [Lawrie, 2016], DermNet New Zealand topic reviews Extramammary Paget disease [DermNet NZ, 2020][DermNet NZ, 2020; DermNet NZ, 2020]; Vulval cancer [DermNet NZ, 2022]; and Vulval intraepithelial neoplasia [DermNet NZ, 2017], and expert opinion in narrative reviews [Olawaiye, 2021; Raef, 2021].

Hormonal changes

The information about hormonal changes which can cause pruritus vulvae is based on expert opinion in narrative reviews Overview of vulvar pruritus through the life cycle [Bohl, 2005], Vulvar dermatoses: a practical approach to evaluation and management [Stewart, 2012], and Identification and management of vulval problems of the postmenopausal woman - Tips and tricks [Spring, 2020].

Gastrointestinal causes and urinary incontinence

The information relating to gastrointestinal causes and urinary incontinence is based on expert opinion in narrative reviews Vulvar dermatoses: a practical approach to evaluation and management [Stewart, 2012], and Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus [Thorstensen, 2012], and information within the 2021 European guideline for the management of vulval conditions [van der Meijden, 2021]. 

Neurological causes

The information about neurological causes of pruritus vulvae is based on information in the BMJ Best Practice review Assessment of Pruritus [BMJ Best Practice, 2023], the 2021 European guideline for the management of vulval conditions [van der Meijden, 2021], and expert opinion in the narrative review Vulvar Pruritis: A review of clinical associations, pathophysiology and therapeutic management [Raef, 2021].

Systemic causes

The information about systemic causes of pruritus vulvae is based on the British Association for Sexual Health and HIV UK national guideline on the management of vulval conditions [BASHH, 2014], the British Medical Journal (BMJ) Best Practice guide Assessment of pruritus [BMJ Best Practice, 2023], the 2021 European guideline for the management of vulval conditions [van der Meijden, 2021], and expert opinion in narrative reviews Vulvar pruritus - causes, diagnosis and therapeutic approach [Woelber, 2020], and Vulvar pruritus: A review of clinical associations, pathophysiology and therapeutic management [Raef, 2021].

How should I manage pruritus vulvae with a known cause?

• A comprehensive discussion of the management of specific causes of pruritus vulvae is beyond the scope of this topic. A brief discussion follows, with links to other relevant CKS topics.
• Most women who present with pruritus vulvae have an identifiable cause which can be managed, including:
  • Dermatological conditions.
  • Infections and infestations.
  • Possible neoplasm.
  • Hormonal changes.
  • Gastrointestinal disease and urinary incontinence.
  • Neurological conditions.
  • Systemic causes.

How should I manage pruritus vulvae with an unknown cause?

The aim of treatment is to provide symptomatic relief, reduce inflammation, restore the skin barrier and prevent and/or treat secondary infection. 

• Offer symptomatic treatment with an emollient.
• Offer self-care advice.
• Consider a mildly anxiolytic antihistamine (such as hydroxyzine) or low dose of a tricyclic antidepressant (such as amitriptyline or doxepin) if sleep is affected.
• Consider prescribing a short trial (1–2 weeks) of low potency topical corticosteroids (hydrocortisone 1% ointment).
• Consider prescribing a combination corticosteroid/antifungal, or corticosteroid/antibacterial if a co-existing infection is suspected.
• If symptoms persist despite treatment with an emollient, an antihistamine or tricyclic antidepressant, and a trial of low potency topical corticosteroids, refer for further investigation to a dermatologist, gynaecologist, or vulval clinic depending on local referral pathways. 
• Advise the woman to continue using an emollient while awaiting specialist appointment, and an antihistamine or low dose tricyclic antidepressant if these have been helpful.

What symptomatic treatment should I offer a woman with pruritus vulvae?

• For all women with pruritus vulvae, consider prescribing:
  • A simple emollient — advise the woman to apply the emollient directly to the vulval area regularly as well as using it as a soap substitute.
    • When used regularly (even when there are no symptoms), an emollient protects the skin against local irritants (for example, urine or menstrual blood) and may help to prevent flare-ups.
    • For more information on prescribing emollients, see the section on Emollients in the CKS topic on Eczema - atopic.
  • A mildly anxiolytic antihistamine or low dose tricyclic antidepressant at night, such as hydroxyzine, amitriptyline (10mg), or doxepin (25mg) to reduce nocturnal itching.
    • Do not prescribe hydroxyzine in the elderly, if the woman has a prolonged QT interval, or risk factors for QT interval prolongation. For more information, see the section on prescribing information in the CKS topic on Itch - widespread.

What self-care advice should I give to women with pruritus vulvae?

• Advise the woman:
  • To shower rather than bath, and to clean the vulval area (a maximum of once a day) with a simple, unscented emollient as a soap substitute — over cleaning may aggravate vulval symptoms. Once the vulval area is clean, gently dab the vulval area dry with a soft towel or use a hairdryer on a cool setting held well away from the skin.
  • To keep nails short to avoid skin damage from scratching.
  • Cooling of the area may be helpful to manage the itching, with a cool flannel or cool gel packs.
• Advise women with pruritus vulvae to avoid:
  • Washing with water only, or with soap, as these cause dry skin and make itching worse.
  • Contact of the vulval skin with:
    • Shampoo.
    • Bubble bath.
    • Over-the-counter preparations used on the vulva.
    • Wet wipes (feminine or baby).
    • Perfumed sanitary towels and panty liners.
    • Sponges or flannels — these may irritate the skin.
    • Antiseptics.
  • Tight-fitting garments or synthetic clothes, for example nylon underwear, as these may irritate the vulval area.
  • Fabric conditioner or fragranced washing powder when washing underwear.
  • Use of spermicidally-lubricated condoms.
  • Coloured or scented toilet paper.
  • Wearing nail varnish on fingernails if they are scratching.
  • Shaving the pubic hair.
  • Scratching (Explain the itch-scratch cycle).
• Give women with pruritus vulvae written information regarding self-care, or the link to access it. For example, the patient information leaflet from the British Association of Dermatologists on care of vulval skin.

When should I refer a woman with pruritus vulvae?

• Referral to a vulval clinic, or dermatologist or gynaecologist with expertise in managing vulval disease is indicated if:
  • The cause of the pruritus vulvae is unclear and symptoms persist.
    • The urgency of the referral will depend on the nature of the symptoms and degree of concern (if any) about cancer.
  • The cause is known, but symptoms persist despite primary care management:
    • For example, some women with contact dermatitis may require referral to try and identify the irritant or allergen. If allergic contact dermatitis is suspected, then patch test investigations may be initiated. Those with psoriasis may need secondary care advice.
  • A potentially pre-malignant condition, such as vulval intraepithelial neoplasia, lichen sclerosus, or lichen planus, is suspected. Where vulval intraepithelial neoplasia is suspected, referral should be made on an urgent or two-week basis, depending on the clinical situation and local pathways.
• Urgent referral (within 2 weeks) is indicated if:
  • Vulval carcinoma is suspected (for example if the woman has an unexplained vulval lump, ulceration or bleeding).
  • Lymphoma is suspected. 
• Also consider referral to the appropriate specialist if the underlying cause of pruritus vulvae is systemic disease or urinary or faecal incontinence.

Basis for recommendation

This indication is not listed in the British National Formulary or product information [BNF, 2022; EMC, 2021; EMC, 2022]. The recommendations regarding use of amitriptyline and doxepin for this condition are based on those in the British Association for Sexual Health and HIV guideline UK national guideline on the management of vulval conditions [BASHH, 2014], the American College of Obstetricians and Gynecologists 2020 guideline Diagnosis and management of vulvar skin disorders [ACOG, 2020], the 2021 European guideline for the management of vulval conditions [van der Meijden, 2021], and expert opinion in narrative reviews [DNNZ, 2016a; Patel, 2018; Stewart, 2012; Woelber, 2020].