VulvaDerm Differential & Atlas

Linked to:

• High risk HPV (16, 18) 
• Chronic inflammation

Diagnosed: Biopsy

Treatment: Surgical excision

Resources

1. Practical Gynecologic Pathology (Zhang): 
   • Wei, Jian-Jun & Hui, Pei. (2021). Practical Gynecologic Pathology Frequently Asked Questions: Frequently Asked Questions. 10.1007/978-3-030-68608-6. 
2. International Society for the Study of Vulvovaginal Disease. (n.d.). Vulvar intraepithelial neoplasia (VIN). ISSVD Vulvovaginal Atlas. https://vulvovaginaldisorders.org/atlas_topic/vulvar-intraepithelial-neoplasia-vin/

Diagnosed: Biopsy with invasion into the stroma

Treatment / Management

• Surgical excision
• Chemo/radiation pending staging
• Refer to gynecologic oncology for management

Resources

1. International Society for the Study of Vulvovaginal Disease. (n.d.). Malignant melanoma. ISSVD Vulvovaginal Atlas. https://vulvovaginaldisorders.org/atlas_topic/malignant-melanoma/

2. American College of Obstetricians and Gynecologists. (2024). Malignant vulvar melanoma. In In plain sight digital guidebook: Normalizing diverse clinical presentations in obstetrics and gynecology (p. 29). https://www.acog.org/education-and-events/publications/in-plain-sight-digital-guidebook

3. In Plain Sight 

   1. Melnick, A. (2023). Problem-focused reproductive endocrinology and infertility. Springer Cham. https://link.springer.com/book/10.1007/978-3-031-19443-6

4. Practical Gynecologic Pathology (Zhang)

   • Wei, Jian-Jun & Hui, Pei. (2021). Practical Gynecologic Pathology Frequently Asked Questions: Frequently Asked Questions. 10.1007/978-3-030-68608-6. 

Diagnosed: By menopausal state/age

Treatment / Management

• Consider HRT via systemic therapy if other symptoms are present 
• Vaginal estrogen if only local symptoms are present or systemic is contraindicated

Resources

1. Stewart, MD, FACOG, E. G., Bissonnette, CNM, MSN, I., Margesson, MD, FRCPC, DAAD, L., & Forbes, NP, D. P. (2022b). Vulvovaginal atrophy (genitourinary syndrome of menopause) archives - vulvovaginal disorders. Vulvovaginal Disorders. https://vulvovaginaldisorders.org/atlas_topic_category/vaginal-atrophy/
2. Melnick, A. (2023). Problem-focused reproductive endocrinology and infertility. Springer Cham. https://doi.org/10.1007/978-3-031-19443-6

Diagnosed: Confirmed with punch biopsy

Treatment / Management

• Surgery: wide local excision. 
• Topical treatments: Imiquimod creams
• Other options: 
  • Laser therapy
  • Radiotherapy
  • Chemotherapy (for invasive disease)

Resources

Diagnosis

• Clinical
  • Affects the vulva, upper body, breasts and arms (85% on anogenital skin). 
  • Skin loses pigmentation and becomes smooth. 
  • Typically hypopigmentation surrounded by hyperpigmentation, but some lesions can appear hyperpigmented in darker skin individuals. 
  • Characteristic distribution of a figure-of-eight, keyhole, hourglass, or lotus flower when skin shrinks. 
• Biopsy 
  • Can confirm diagnosis if doubtful-->hyperkeratosis, epidermal atrophy, band-like lichenoid infiltrate, upper dermal edema, homogenized sclerotic collagen

Treatment / Management

• Treat with superpotent topical corticosteroids (Clobetasol or halobetasol 0.05% ointment every 12-24 hrs for 1-3 months until skin normalizes) even if asymptomatic and f/u regularly. 
  • Maintenance therapy (2-3x/wk) is recommended to decrease risk of SCC. 
  • Can have secondary lichen simplex chronicus or superimposing allergic contact dermaittis. 
  • Untreated lichen slcerosis can lead to scarring of the vulva, causing erosions, fissures ans shrinking of the introitus (opening of the vagina) and is assoicated with a small increased risk of vulvar cancer (SCC and melanoma). 
• Alternative options include:
  • A mid potency steroid or tacrolimus ointment for maintenance therapy or mometasone furoate 0.1% ointment
  • Intralesional triamcinolone or steroid (potential hypopigmentation or atrophy) injections, 
  • 308-nm excimer laser, fractional CO2 laser, and platelet-rich plasma, but they do not decrease the risk of SCC. 
  • Oral therapies are available for resistant cases. 
• Should also recommend genital care including on soap or hypoallergenic soap, vaseline during flares and avoiding tight fitting clothing.

Resources

1. In Plain Sight Chapter 4: Vulvar Dermatoses p31 
   1. Melnick, A. (2023). Problem-focused reproductive endocrinology and infertility. Springer Cham. https://doi.org/10.1007/978-3-031-19443-6
2. Baylor College of Medicine. (2026). Vulvar dermatoses. Retrieved, from https://www.bcm.edu/healthcare/specialties/obstetrics-and-gynecology/ob-gyn-conditions/vulvar-dermatoses
3. Stewart, MD, FACOG, E. G., Bissonnette, CNM, MSN, I., Margesson, MD, FRCPC, DAAD, L. J., & Parks Forbes, NP, D. (2022). Lichen sclerosus archives - vulvovaginal disorders. Vulvovaginal Disorders. https://vulvovaginaldisorders.org/atlas_topic_category/lichen-sclerosus

Diagnosis

• Clinical:
  • Affects vulva, vagina, mouth and limbs (areas of friction)
  • Sometimes associated with Hep C
  • Lesions are often dark violet or slate gray with prominent brown-gray postinflammatory pigmentary change in patients with darker skin
  • Lesions are often pink rather than purple or violaceous in patients with lighter skin. 
• Biopsy:
  • Can confirm dx-->hyperkeratosis, wedge-shaped hypergranulosis, jagged saw-tooth acanthosis, civatte bodies, band-like lichenoid lymphocytic infiltrate, subepidermal clefting, melanophages (pigment incontinence)

Treatment / Management

• First line therapy includes topical or intralesional (can cause hypopigmentation and atrophy) corticosteroids BID-->can resolve in a few weeks. 
• For the vagina, hydrocortisone acetate suppositories 25 mg (commercially available) up to 100 mg (compounded) used nightly. 
• Oral corticosteroids for severe cases. 
  • Untreated lichen planus can cause scarring of the vuvla.

Resources

1. Baylor College of Medicine. (2026). Vulvar dermatoses. Retrieved, from https://www.bcm.edu/healthcare/specialties/obstetrics-and-gynecology/ob-gyn-conditions/vulvar-dermatoses
2. Dermatoses affecting the vulva (Ch 7)
   1. Melnick, A. (2023). Problem-focused reproductive endocrinology and infertility. Springer Cham. https://doi.org/10.1007/978-3-031-19443-6

Diagnosis

• Clinical
  • Affects vulva and neck (areas patient is able to scratch)
  • Ruling out other conditions with similar symptoms
  • Look for leathery plaques of thickened skin in which the normal skin markings are exaggerated
  • Plaques may be slightly erythematous and are often scaly and well-demarcated with hyperpigmentation and excoriations. 
  • In darker skin colors, lesions are often brown, violaceous, or grayish. 
  • Depigmented portions appear as pink or white areas. 
  • In lighter skin colors, LSC can be any shade or pink or red, or it may be violaceous.

Treatment / Management

• 1st line=topical steroids (low potency) or tacrolimus. 
• Oral antihistamines to decrease itching. 
• Chronicity results in thickening of the skin in and around the vulva

Resources

1. UptoDate: Margesson, L. J., & Haefner, H. (2026). Vulvar dermatitis. In R. F. Connor (Ed.), UpToDate. Wolters Kluwer. Retrieved February 4, 2026, from https://www.uptodate.com/contents/vulvar-dermatitis
2. Guerrero, A., & Venkatesan, A. (2015). Inflammatory Vulvar Dermatoses. Clinical obstetrics and gynecology, 58(3), 464–475. https://doi-org.proxy.cc.uic.edu/10.1097/GRF.0000000000000125
3. Lynch, P. J. (2004). Lichen simplex chronicus (atopic/neurodermatitis) of the anogenital region. Dermatologic Therapy, 17(1), 8–19. https://doi.org/10.1111/j.1396-0296.2004.04002.x
4. Ridley, C. M., & Neill, S. M. (Eds.). (1999). The vulva (2nd ed.). Blackwell Science. https://archive.org/details/ridleysvulva0000unse

Diagnosis

• Clinical
  • Check common locations( scalp, elbows, knees, etc)
• Family History

Treatment / Management

• Non-specific treatment : 
  • Avoid trauma, irritants (lotions, soaps, etc). 
  • For itch: ice or cold packs. 
  • Mild-moderate psoriasis: recommended to gentle cleanse daily. 

Resources

1. UptoDate: Margesson, L. J., & Haefner, H. K. (2026). Vulvar lesions: Differential diagnosis of red lesions. In R. F. Connor (Ed.), UpToDate. Wolters Kluwer. Retrieved February 4, 2026, from https://www.uptodate.com/contents/vulvar-lesions-differential-diagnosis-of-red-lesions
2. Ridley, C. M., & Neill, S. M. (Eds.). (1999). The vulva (2nd ed.). Blackwell Science. https://archive.org/details/ridleysvulva0000unse
3. Kapila, S. , Bradford, J. & Fischer, G. (2012). Vulvar Psoriasis in Adults and Children. Journal of Lower Genital Tract Disease, 16 (4), 364-371. doi: 10.1097/LGT.0b013e31824b9e5e.

Diagnosis

• Clinical
  • Based on history of exposure to irritants or allergens and the presence of vulvar erythema, edema, vesicles, or lichenification. 
  • Patch testing may be used to identify specific allergens in recurrent or severe cases. 
• A biopsy is rarely needed but may be considered to exclude other dermatoses if the presentation is atypical or persistent.

Treatment / Management

• Avoidance of irritants and allergens. 
• Symptomatic relief with anti-itch medications (hydroxyzine, doxepin), corticosteroid ointments, and anti-itch emollients. 
• Avoid frequent washing, excessive scrubbing, and overusing products on the vulva. 
• 1st line: Topical steroids or calcineurin inhibitors (tacrolimus ointment) + remove irritant/allergen

Resources

1. Gunther Stewart, MD, FACOG, E., Bissonnette, CNM, MSN, I., Margesson, MD, FRCPC, DAAD, L. J., & Parks Forbes, NP, D. (2022). Contact dermatitis, irritant and allergic archives - vulvovaginal disorders. Vulvovaginal Disorders. https://vulvovaginaldisorders.org/atlas_topic_category/contact-dermatitis-irritant-and-allergic/
2. Margesson, L. J., & Haefner, H. K. (2026). Vulvar lesions: Differential diagnosis of red lesions. In R. F. Connor (Ed.), UpToDate. Wolters Kluwer. Retrieved February 4, 2026, from https://www.uptodate.com/contents/vulvar-lesions-differential-diagnosis-of-red-lesions
3. Admani, S., Maghfour, J., & Jacob, S. E. (2021). Localized systemic contact dermatitis: The vulva as a clue to identify allergen ingestion. International Journal of Women's Dermatology, 7(5), 843–844. https://doi.org/10.1016/j.ijwd.2021.02.009
4. Margesson L. J. (2004). Contact dermatitis of the vulva. Dermatologic therapy, 17(1), 20–27. https://doi.org/10.1111/j.1396-0296.2004.04003.x

Diagnosis

• Clinical
  • Based on a firm, mobile, subcutaneous nodule in the vulvar region. 
• No imaging or labs are typically required. 
  • Ultrasound may be used in cases of diagnostic uncertainty, especially to differentiate from other vulvar masses. 
  • Histopathology after excision confirms the diagnosis if needed.

Treatment / Management

• If cysts cause symptoms, they are removed.

Resources

1. Fisher BK, Margesson, LJ. Genital Skin Disorders: Diagnosis and Treatment. Mosby, Inc., 1998. 202-203.
2. Neil S. White lesions. In Edwards L and Lynch PJ. Genital Dermatology Atlas, 2nd ed. Wolters Kluwer/Lippincott Williams & Wilkins. Philidelphia. 2011. 194.
3. Edwards L. Yellow and pustular lesions. In Edwards L and Lynch PJ. Genital Dermatology Atlas, 2nd ed. Wolters Kluwer/Lippincott Williams & Wilkins. Philidelphia. 2011. 118.
4. International Society for the Study of Vulvovaginal Disease. (n.d.). Epidermal cyst & milia. ISSVD Vulvovaginal Atlas. https://vulvovaginaldisorders.org/atlas_topic/epidermal-cyst-milia/

Diagnosis

• Clinical
  • Based on pelvic exam findings of a cystic mass adjacent to the urethral meatus. 
  • Differentiation from urethral diverticulum is important
• Workup
  • MRI or transvaginal ultrasound may be ordered if the diagnosis is unclear. 
  • Urinalysis may help rule out urinary tract infection or other causes of symptoms.

Treatment / Management

• Removal of the cyst. 
  • Small cut made in the cyst followed by stitching of the inside edges of the cyst to the surface of the vulva.

Resources

1. Nickles, S. W., Burgis, J. T., Menon, S., & Bacon, J. L. (2008). Prepubertal Skene's abscess. Journal of Pediatric and Adolescent Gynecology, 21(1), 37–39. https://doi.org/10.1016/j.jpag.2007.11.004

Diagnosis

• Clinical
  • Based on pelvic exam as a unilateral, fluctuant, non-tender mass in the posterior introitus. 
• Workup
  • Biopsy is indicated in women over 40 years old or in cases of solid, painless, or recurrent masses to rule out malignancy. 
  • Imaging is rarely necessary unless malignancy is suspected.

Treatment / Management

• If patient is asymptomatic and under 40: May be treated with a Sitz bath or warm water soaking. Soaks should be done 2x/day for 10 - 15. 
• If patient is symptomatic and under 40: Incision and Drainage; Marsupialization, Surgical removal
• If patient is over 40: Surgical removal of entire cyst

Resources

1. Fisher BK and Margesson MJ. Genital Skin Disorders; diagnosis and treatment. Mosby, 1998. 196-197.
2. Eckert LO, Lentz GM. Infections of the lower genital tract. In: Katz VL, Lentz GM, Lobo RL, Gershenson DM, eds. Comprehensive Gynecology, 5th ed. Philadelphia, Mosby Elsevier, 2007, 572.
3. Edwards L and Lynch P. Genital Dermatology Atlas, second edition. Wolters Kluwer Health/Lippincott Williams and Wilkins, 2011. 208.
4. Wechter NE, Wu JM, Marzano D, et al. Management of Bartholin duct cysts and abscesses: a systematic review. Obstet Gynecol Surv. 2009; 64:395-404.

Diagnosis

• Clinical
  • Based on pelvic exam showing a unilateral, tender, erythematous, fluctuant mass in the posterior introitus, often with edema. 
• Workup
  • Abscess material may be cultured if drainage occurs spontaneously or after incision. 
  • STI testing can be performed if risk factors or patient request are present. 
  • Biopsy is considered if malignancy is suspected, particularly in women over 40.

Treatment / Management

• Antibiotics. 
• Incision into abscess followed by insertion of catheter for drainage. 
• If abscess refills after being drained, marsupialization may be done, which creates a permanent opeing for continuous drainage.

Resources

1. Omole, F., Kelsey, R. C., Phillips, K., & Cunningham, K. (2019). Bartholin Duct Cyst and Gland Abscess: Office Management. American Family Physician, 99(12), 760–766.

2. Lazenby, B. G., Thurman, A. R., & Soper, D. E. (2026). Vulvar abscess. In R. F. Connor (Ed.), UpToDate. Wolters Kluwer. Retrieved February 4, 2026, from https://www.uptodate.com/contents/vulvar-abscess

3. Mayeaux, E. J., Jr., & Cooper, D. (2013). Vulvar procedures: Biopsy, Bartholin abscess treatment, and condyloma treatment. Obstetrics and Gynecology Clinics of North America, 40(4), 759–772. https://pubmed.ncbi.nlm.nih.gov/24286999/
   
    

Diagnosis

• Clinical
  • Careful History
• Workup
  • Serum IgE is elevated in 80% of patients
  • Tzanck smear, viral culture and/or viral PCR

Treatment / Management

• Localized disease on the body - Mild-potency topical corticosteroids 
  • Triamcinolone cream (0.1%)-apply twice daily
  • Mometasone cream-apply twice daily
  • Fluocinolone cream-apply twice daily
  • Tacrolimus ointment BID
  • Pimecrolimus cream BID
  • Tapinarof cream
• Management: 
  • Counsel patients on avoiding triggers (stress, inappropriate bathing habits, infection, irritants, sweating, and environmental allergens)
  • Appropriate skin care (gentle non-soap cleansers should be utilized)

Resources

1. Gunther Stewart MD, FACOG, E., Bissonnette, CNM, MSN, I., Margesson MD, FRCPC, DAAD, L. J., & Parks Forbes NP , D. (2024, January 27). Eczematous dermatitis (related to atopic dermatitis) - vulvovaginal disorders. https://vulvovaginaldisorders.org/atlas_topic/eczematous-dermatitis/

Diagnosis

• A blood test can detect antibodies to HSV-1 and/or 2

Treatment

• Valacyclovir or acyclovir may be given during outbreaks or as prophylaxis to reduce risk of recurrent outbreaks or spread to others
• Symptomatic and supportive measures can be used (ie loose clothing, pain-relievers, warm baths, cold compresses)
• May be spread to partners between outbreaks and with the use of condoms

Resources

1. Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
2. CDC website with more provider resources on STI Guidelines
3. Gunther Stewart MD, FACOG, E., Bissonnette, CNM, MSN, I., Margesson MD, FRCPC, DAAD, L. J., & Parks Forbes, NP, D. (2022). Herpes simplex archives - vulvovaginal disorders. Vulvovaginal Disorders. https://vulvovaginaldisorders.org/atlas_topic_category/herpes-simplex/
4. In Plain Sight Chapter 5: Vulvar Dermatoses p39 
   1. Melnick, A. (2023). Problem-focused reproductive endocrinology and infertility. Springer Cham. https://doi.org/10.1007/978-3-031-19443-6

Diagnosis

• Diagnosed visually
• Warts are caused by low risk HPV (like 6 and 11)
• Biopsy can confirm with findings of papillary architecure and koilocytotic changes and testing of tissue for HPC

Treatment

• Imiquimoid 3.75 or 5% cream
• Podofilox 0.5% solution/gel
• Sinecatechins 15% ointment
• Cryotherapy
• Surgical removal
• TCA or BCA solution - regimen pending which topical solution is chosen

Resources

1. Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
2. CDC website with more provider resources on STI Guidelines
3. In Plain Sight Chapter 5: Vulvar Dermatoses p37 
   1. Melnick, A. (2023). Problem-focused reproductive endocrinology and infertility. Springer Cham. https://doi.org/10.1007/978-3-031-19443-6
4. Orfanos, C. E., Zouboulis, C. C., & Assaf, C. (Eds.). (2018). Pigmented ethnic skin and imported dermatoses: A text-atlas. Springer.

Diagnosis

• Blood tests (treponemal or non-treponemal)
• Traditional or reverse algorithms for testing

Treatment

• IM penicillin G,  the dosage depends on stage of syphilis

For penicillin-tolerant patients, prescribe:

• Benzathine penicillin G 2.4 million units IM (1.2 million units per buttock) in a single dose. (It is important to use the correct penicillin: Bicillin L-A, NOT Bicillin C-R in the United States.

 Follow with the CDC for guidance.
For penicillin-allergic patients, the CDC recommends desensitization; when this is not possible, prescribe:

• Doxycycline 100 mg by mouth twice a day x 14 days.
  OR
• Tetracycline 500 mg orally 4 x a day x 14 days.
  Repeat serology at six and 12 months and a CSF examination if there are any neurologic signs or the patient is HIV positive.
• Benzathine penicillin G 2.4 million units IM in a single dose

OR

• Doxycycline 100 mg by mouth twice a day x 4 weeks   

Resources

1. Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
2. CDC website with more provider resources on STI Guidelines
3. Orfanos, C. E., Zouboulis, C. C., & Assaf, C. (Eds.). (2018). Pigmented ethnic skin and imported dermatoses: A text-atlas. Springer.

Diagnosis

• Nucleic Acid Amplification Test (NAAT), using urine samples or swabs (vaginal, cervical, urethral, anal, or throat)

Treatment / Management

• Start antibiotic treatment even if asymptomatic (doxycycline or azithromycin). 
  • Non-pregnant patients: first-line-doxycycline; Alternative: azithromycin OR levofloxacin 
  • Pregnant patients: Preferred: azithromycin; Alternative: amoxicillin
• Advise patients to abstain from sexual intercourse until all the following criteria are met: 
  • Completion of a 7-day regimen ot for 7 days after a single-dose regimen. 
  • Symptom resolution, all sexual partners have completed treatment. 
• Report all cases to local health department.

Resources

• Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
• CDC website with more provider resources on STI Guidelines

Diagnosis

• Nucleic Acid Amplification Test (NAAT), using urine samples or swabs (vaginal, cervical, urethral, anal, or throat)

Treatment / Management

• Preferred treatment: 
  • IM ceftriaxone 
  • Expedited partner therapy with cefixime 
  • Instruct the patient to avoid all sexual contact until: 7 days after treatment of the patient and their sexual partners, symptoms have resolved.

Resources

• Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
• CDC website with more provider resources on STI Guidelines

Diagnosis

• Have a high index of suspicion for a T vaginalis infection in sexually active women seeking care for vaginal discharge and odor
• Careful inspection of saline prep is important
• Sometimes the T vaginalis is adherent to WBCs, making dx more difficult
• Look for moving shapes under the microscope

Treatment

• Metronidazole 500 mg BID for 7 days
• Tinidazole 2 g po

Resources

1. Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
2. CDC website with more provider resources on STI Guidelines
3. Khan, Munazzah, et al. “The Tell-Tale Strawberry Cervix: Clinical Insights into Trichomoniasis.” Journal of Skin and Sexually Transmitted Diseases, vol. 7, no. 7, 4 Mar. 2025, pp. 130–131, jsstd.org/the-tell-tale-strawberry-cervix-clinical-insights-into-trichomoniasis/, https://doi.org/10.25259/jsstd_7_2025.

Daignosis

• Clinical diagnosis. 
  • High clinical suspicion for the underlying cause of the vaginitis should prompt further testing. 
• See sections on Bacterial vaginosis, Candidiasis, and Trichomonas for diagnosis. 
  • Most cases of vaginitis (around 90%) are usually caused by one of these three conditions. 
  • Wet mount microscopy, gram stain, or cultures may all be required in order to diagnose the underlying cause of the issue

Treatment / Management

• Usually the treatment is focused around treating the underlying cause of the inflammation. 
  • For Bacterial Vaginosis, the CDC Recommends: 
    • Metronidazole 500 mg orally twice daily for 7 days
    • Metronidazole gel 0.75%, 1 full applicator (5 g) intravaginally, once daily for 5 days
    • Clindamycin cream 2%, 1 full applicator (5 g) intravaginally at bedtime for 7 days

Resources

• Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
• CDC website with more provider resources on STI Guidelines
• Baylor College of Medicine. (2026). Vaginitis. Retrieved, from https://www.bcm.edu/healthcare/specialties/obstetrics-and-gynecology/ob-gyn-conditions/vaginitis
• Neal CM, Kus LH, Eckert LO, Peipert JF. Noncandidal vaginitis: a comprehensive approach to diagnosis and management. Am J Obstet Gynecol. 2020 Feb;222(2):114-122. [PubMed], https://www.ncbi.nlm.nih.gov/books/NBK470302/

Diagnosis

• This is usually a diagnosis of exclusion. 
• The cotton swab test is used to help rule vulvodynia in or out. 
  • The clinician can start by asking the patiet where the pain is localized and using a cotton swab, the clinician systematically assesses pain by starting from the outer areas and moving inward toward the vestibule. 
  • The evaluation typically begins at the inner thigh, then proceeds to the labia majora, inner labial sulcus, clitoris, clitoral hood, perineum, and various points within the vestibule. 
  • The patient can rate their pain or the sensation that they are feeling at each site on a scale from 1 to 10. 
  • Pinprick test to assess for normal, hypo or hypersensitive reactions.

Treatment / Management

• Conservative Modalities: 
  • The treatment for vulvodynia is centered around self-care around avoiding irritant like tight clothing and wearing loose fitting and breathable clothing.
  • Pyschotherapy, yoga, mindfulness, and neurostimulation are also treatments that can be considered. 
• Pharmacology: 
  • Oral pain blocking meds (TCAs like nortriptyline can also be used, SNRIs, and anticonvulsants) can also be used to alleviated pain.
  • Nortripryline has been reported to have the least amount of side effects. 
  • Topical pain meds directly to the vulva are typically compounded formulations that include lidocaine, estrogen, testosterone, or gabapentin, used individually or in combination. 
• Physical therapy: 
  • For management of pelvic floor muscle dysfunction, including weakness and spasms. 
• Surgery:
  • Removing the parts of the affected vestibule is a last resort
  • Minor surgical issues to address problems like keratin pearls can also be addressed. 

Resources

1. Gunther Stewart, M.D., FACOG, E., Bissonnette, CNM, MSN, I., J Margesson M.D., FRCPC, DAAD, L., & Parks Forbes, NP, D. (2015, June 23). Vulvodynia - vulvovaginal disorders. Vulvovaginal Disorders. https://vulvovaginaldisorders.org/atlas_topic/vulvodynia/
2. Kairys, N., & Garg, M. (2023). Bacterial vaginosis. In StatPearls. StatPearls Publishing. Retrieved, from https://www.ncbi.nlm.nih.gov/books/NBK430792/

Diagnosis

• Positive swab test (vestibular point tenderness when touched with cotton swab)
• Focal or diffuse vestibular erythema

Treatment / Management

• Referral to support group
• Topical estradiol cream, 0.01% (Estrace Vaginal Cream) twice daily
• Intralesional interferon injection
• Physical therapy with biofeedback
• Low-oxalate diet
• Oral calcium citrate

Resources

• Ledger, W. J., Kessler, A., Leonard, G. H., & Witkin, S. S. (1996). Vulvar vestibulitis—A complex clinical entity. Infectious Diseases in Obstetrics and Gynecology, 4(5), 269–275. https://doi.org/10.1155/S106474499600052X

Diagnosis

• Persistent or recurrent difficulty with ≥ 1 of the following:
  • Vaginal penetration during sexual intercourse
  • Severe vulvovaginal or pelvic pain during vaginal intercourse or attempted penetration
  • Severe anticipatory anxiety related to vulvovaginal or pelvic pain during attempted vaginal intercourse or attempted penetration
  • Severe tightening of pelvic floor muscles during attempted vaginal penetration (historically referred to as vaginismus)

Treatment / Management

• Pelvic floor physical therapy
• Vaginal dilation
• Psychotherapy
• Treatment of any causes of dyspareunia in women (e.g., lubricants and moisturizers for vaginal dryness)

Resources

• Female Sexual Dysfunction ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician–Gynecologists, Number 213

Diagnosis

• Thin, homogenous, uniformly adherent, white discharge
• Vaginal pH > 4.5
• Fishy odor before or after addition of 10% KOH (whiff test)
• Clue cells (epithelial cell margins obscured by bacteria) on microscopic examination of vaginal smear

Treatment

• Metronidazole 500 mg BID PO for 7 days
• Metronidazole vaginal gel 0.75%, 5g intravaginally, once daily for 5 days
• Clindamycin vaginal cream 2% 5g intravaginally at bedtime for 7 days
• Alternative tx: 
  • Clindamycin 300 mg BID PO for 7 days
  • Secnidazole 2 g oral granules in a single dose
  • Tinidazole 2 g po for 2 days 
  • Tinidazole 1 g po for 5 days

Management 

• Consideration for HIV and STI testing
• Cure rates for BV increase by as much as 50% if the patient refrains from sexual activity or uses condoms

Resources

• Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
• CDC website with more provider resources on STI Guidelines
• International Society for the Study of Vulvovaginal Disease. (n.d.). Bacterial. ISSVD Vulvovaginal Atlas. https://vulvovaginaldisorders.org/annotation/annotation-p/#Bacterial

Diagnosis

• KOH prep reveals budding yeast, spores, and occasionally pseudohyphae
• pH of vaginal secretion is usually normal
• Look for non-albicans yeast in poorly responding cases
• Note that up to 40% of cases can have negative KOH and wet prep
• if unsure of the dx, vulvar and vaginal yeast cultures are invaluable as they can both detect small amounts of infection and can be sent for both sensitivities and speciation

Treatment

• OTC Intravaginal agents: 
  • Clotrimazole 1% cream 5 g intravaginally for 7-14 days
  • Clotrimazole 2% cream 5 g intravaginally q day for 3 days
  • Miconazole 2% cream 5 g intravaginally qday for 7 days
  • Miconazole 4% cream 5 g intravaginally qday for 3 days
  • Miconazole 100 mg vaginal suppository 1 suppository daily for 7 days
  • Miconazole 200 mg vaginal suppository 1 suppository for 3 days
  • Tioconazole 6.5% ointment 5 g intravaginally in a single application
• Prescription: 
  • Butoconazole 2% cream, 5 g intravaginally in a single application
  • Terconazole 0.4% cream 5 g intravaginally daily for 7 days
  • Terconazole 0.8% cream 5g intravaginally daily for 3 days
  • Terconazole 80 mg vaginal suppository, 1 suppository daily for 3 days
• Oral: 
  • Fluconazole 150 mg po, 1 tab
  • Ibrexafungerp 150 mg po tabs, 2 tabs BID q day

Management: 

• If not responding to antifungal tx, consider the possibility of a coexistent vulvar dermatological condition requiring further evaluation

Resources

1. International Society for the Study of Vulvovaginal Disease. (n.d.). Vaginal yeast infection. ISSVD Vulvovaginal Atlas. https://vulvovaginaldisorders.org/annotation/annotation-p/?highlight=Vaginal%20yeast%20infection

Diagnosis

• Nucleic Acid Amplification Test (NAAT), using urine samples or swabs (vaginal, cervical, urethral, anal, or throat)

Treatment / Management

• Start antibiotic treatment even if asymptomatic (doxycycline or azithromycin). 
  • Non-pregnant patients: first-line-doxycycline; Alternative: azithromycin OR levofloxacin 
  • Pregnant patients: Preferred: azithromycin; Alternative: amoxicillin
• Advise patients to abstain from sexual intercourse until all the following criteria are met: 
  • Completion of a 7-day regimen ot for 7 days after a single-dose regimen. 
  • Symptom resolution, all sexual partners have completed treatment. 
• Report all cases to local health department.

Resources

• Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
• CDC website with more provider resources on STI Guidelines

Diagnosis

• Nucleic Acid Amplification Test (NAAT), using urine samples or swabs (vaginal, cervical, urethral, anal, or throat)

Treatment / Management

• Preferred treatment: 
  • IM ceftriaxone 
  • Expedited partner therapy with cefixime 
  • Instruct the patient to avoid all sexual contact until: 7 days after treatment of the patient and their sexual partners, symptoms have resolved.

Resources

• Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
• CDC website with more provider resources on STI Guidelines

Diagnosis

• Have a high index of suspicion for a T vaginalis infection in sexually active women seeking care for vaginal discharge and odor
• Careful inspection of saline prep is important
• Sometimes the T vaginalis is adherent to WBCs, making dx more difficult
• Look for moving shapes under the microscope

Treatment

• Metronidazole 500 mg BID for 7 days
• Tinidazole 2 g po

Resources

1. Summary of CDC STI Treatment Guidelines, 2021 - Wall Chart
2. CDC website with more provider resources on STI Guidelines
3. Khan, Munazzah, et al. “The Tell-Tale Strawberry Cervix: Clinical Insights into Trichomoniasis.” Journal of Skin and Sexually Transmitted Diseases, vol. 7, no. 7, 4 Mar. 2025, pp. 130–131, jsstd.org/the-tell-tale-strawberry-cervix-clinical-insights-into-trichomoniasis/, https://doi.org/10.25259/jsstd_7_2025.

Diagnosis

• Clinically 
  • Through symptoms especially if women in menopausal state/age. 
  • Additional test to support are vaginal maturation index and vaginal pH.

Treatment / Management

• Systemic hormone therapy 
• Topical Vaginal estrogen

Resources

• Kaufman, R. H., Friedrich, E. G., Jr., & Gardner, H. L. (1989). Benign diseases of the vulva and vagina (3rd ed.). Year Book Medical Publishers.
• Hewitt, J., Pelisse, B., & Paniel, J.-P. (1991). Diseases of the vulva. McGraw-Hill.
• Casanova, R., Chuang, A., Goepfert, A. R., Hueppchen, N. A., Weiss, P. M., Beckmann, C. R. B., & Ling, F. W. (2018). Beckmann and Ling's obstetrics and gynecology (8th ed.). Wolters Kluwer.

Diagnosis

• Diagnosed clinically through symptoms especially if women in menopausal state/age. 
• Additional test to support are vaginal maturation index and vaginal pH.

Treatment / Management

• Systemic hormone therapy 
• Topical Vaginal estrogen

Resources

• Kaufman, R. H., Friedrich, E. G., Jr., & Gardner, H. L. (1989). Benign diseases of the vulva and vagina (3rd ed.). Year Book Medical Publishers.
• Hewitt, J., Pelisse, B., & Paniel, J.-P. (1991). Diseases of the vulva. McGraw-Hill.
• Casanova, R., Chuang, A., Goepfert, A. R., Hueppchen, N. A., Weiss, P. M., Beckmann, C. R. B., & Ling, F. W. (2018). Beckmann and Ling's obstetrics and gynecology (8th ed.). Wolters Kluwer.

Diagnosis

• Diagnosed via physicial and complete pelvic exam. 
• Some test include urinalysis blood test, testing for STIs and a pap smear.

Treatment / Management

• Identify, remove and avoid irritates
• Hydrocortisone ointment
• Topical estrogen cream
• Taking regular sitz bath