Desquamative vaginitis

What is vaginitis?

Vaginitis means an inflamed vagina. The term is loosely used to refer to any vaginal condition that results in a vaginal discharge. it can be due to infectious and non-infectious causes.

What is desquamative vaginitis?

Desquamative vaginitis is characterised by:

• Persistent or intermittent, blood-stained or yellow, profuse or sticky vaginal discharge
• Painful intercourse (dyspareunia)
• Itch (pruritus vulvae) and/or burning (vulvodynia).

Other symptoms may include pain on passing urine (dysuria), bleeding after intercourse, malodour and dryness. These symptoms often persist for months or years.

Who gets desquamative vaginitis?

Desquamative vaginitis is rare. It affects adult women, who may be pre- or post-menopausal.

What is the cause of desquamative vaginitis?

The precise cause of desquamative vaginitis is unknown. It is now classified as a severe form of aerobic vaginitis.

By definition, it is not an infection, despite the usefulness of antibiotics in the treatment of many patients.

Examination findings in desquamative vaginitis

The vagina and the vaginal vestibule appear inflamed. Clinical signs include:

• Redness
• Swelling
• Atrophic epithelium
• Yellow secretions
• Purpura (bleeding under the skin)
• Contact bleeding
• A greyish film.

What is the differential diagnosis of desquamative vaginitis?

The differential diagnosis includes other forms of vaginitis, especially erosive lichen planus.

How is desquamative vaginitis diagnosed?

Desquamative vaginitis is diagnosed if there is at least one of the following symptoms:

• Vaginal discharge
• Dyspareunia
• Itch
• Burning

In addition:

• Wet mount should confirm vaginal inflammation with increased parabasal and inflammatory cells.
• Culture should exclude infection: Group A streptococcus, Staphylococcus aureus, trichomoniasis.
• Vaginal pH is > 4.5.

Investigations in desquamative vaginitis

Swabs should be taken from the vagina for microscopy (wet mount examination). Culture is also undertaken to detect infectious causes of vaginitis.

There is a reduction in normal lactobacilli. The laboratory may report the presence of mixed non-pathogenic bacteria (eg, non-haemolytic streptococcus species and coagulase negative staphylococci), epithelial and inflammatory cells (aerobic vaginitis).The AV score may be reported.

Biopsy of the affected tissue (vulva or vagina) are likely to reveal nondiagnostic and nonspecific inflammatory changes.

Treatment of desquamative vaginitis

The treatment of desquamative vaginitis is not always effective. General care should include gentle cleansing of the external genitalia with water and non-soap cleansers. Vaginal moisturisers may be helpful for dryness.

Topical antifungal agents should not be used in the absence of confirmed yeast infection (vulvovaginal candidiasis).

The most successful treatment for desquamative vaginitis appears to be the antibacterial and anti-inflammatory combination of:

• Clindamycin 2% vaginal cream
• Hydrocortisone 1% cream or 10% foam.

Treatment should be continued for at least several weeks and may be required long term (typically, twice weekly). If this is unsuccessful, other treatments that may be tried include:

• Other topical steroids
• Oral antibiotics
• Oestrogen cream.

What is the outcome for desquamative vaginitis?

Treatment usually leads to complete remission of symptoms, when treatment can be stopped, or reduced symptoms requiring at least intermittent on-going treatment. If treatment is ineffective, consider other diagnoses and change treatment.