• History
    • Symptom duration and possible triggers
    • Is itching constant or is there premenstrual exacerbation?
    • Are symptoms felt ‘outside’ on the skin or ‘inside’ the vagina and associated with entry dyspareunia?
    • What treatments have been used and have these led to improvement or worsening of symptoms?
    • Have antibiotics caused aggravation of symptoms?
    • Is hormonal contraception or replacement therapy used?
    • Is there any personal or family history of skin disorders (especially eczema or psoriasis, diabetes or autoimmune thyroid disease)
  • Examination
    • General skin examination
    • Evidence of facial/hand/flexural dermatitis?
    • Erythema and scale of scalp, pitting of nails/onycholysis, thickening of extensor aspects of elbows/knees (psoriasis)?
    • Examine vulval and perianal skin
      • Is erythema present? Diffuse or well defined? Spares or extends into folds?
      • Is there lichenification or pigmentation (vitiligo, lichen sclerosis, lichen simplex chronicus, vulval neoplasia)?
      • Associated vaginitis?
      • Is there pallor or alteration in texture?
      • Is there epithelial loss (erosions/ulcers) on vulval skin or mucosa (aphthous ulcers, lichen planus, immunobullous disease)?
  • Investigations
    • Low vaginal swab all first presentations
    • Biopsy may be helpful in diagnosis
  • Management
    • Environmental modification, non soap cleanser, loose cotton clothing
    • Avoid irritants (vaginal discharge, incontinence, fragrances/douches, lubricants/condoms, sanitary pads/liners, g-strings, tight jeans, gym clothing, swimming/sauna/spas)
    • Topical corticosteroids mainstay for inflammatory vulval disorders – ointments better tolerated as less stinging, 2-3 weeks tapering usually sufficient then hydrocortisone for 2-3 weeks
      • Ultrapotent – Betamethasone in optimised vehicle 0.05%
      • Potent – Betamethasone 0.05%, Methylprednisolone 0.1%
      • Weak – Hydrocortisone 1%
    • For chronic or recurrent psoriasis consider LPC 2% in aqueous cream or calcipotriene ointment as steroid sparing agent