Therapeutic target
- Restoration of physiological conditions in the vulva area and thus avoidance of complications.
Therapy recommendations
- Vulvitis due to bacteria
- Vulvitis due to bacterial vaginosis: antibiosis/antibiotic therapy (oral, vaginal tablets, vaginal gel).
- Folliculitis, boils, impetigo contagiosa (bork lichen; pus lichen), carbuncles, vulvitis pustulosa: pathogen Staphylococcus aureus: antibiosis (oral).
- Erysipelas, impetigo contagiosa, vulvitis in little girls: Pathogen A streptococci: antibiosis (oral).
- Vulvitis caused by parasites
- Endoparasites (oxyurans, trichomonads): metronidazole (nitroimidazole), oral + vaginal antiseptic/disinfectant (dequalinium).
- Exoparasites (crabs, scabies): see below the disease.
- Vulvitis due to mycoses (fungal diseases): antifungals / antifungals (vaginal cream); if recurrent (recurring)/chronic vulvitis / colpitis: systemic antifungals (agents against fungi).
- Vulvitis caused by viruses: condylomata acuminata: local therapy with
- Interferon ß,
- Local gel treatment after vaporization (evaporation) with the CO2 laser.
- Podophyllotoxin (0.5%/0.15%)
- Imiquimod (5% cream)
- For more see below
- Herpes viruses: antivirals (agents that inhibit the multiplication of viruses): aciclovir (oral).
- Atrophic vulvitis/vulvovaginal atrophy: agent of choice is estriol (E3). Unlike estradiol (E2), it has no endometrial effect, ie, no effect on the endometrium.
- Vulvar vestibulitis syndrome (VVS): clindamycin (vaginal gel).
- Vulvitis in skin diseases (see below).
Bacterial vulvitis in combination with bacterial vaginosis (Atopobium vaginae, Gardnerella vaginalis, Bacteroides, Mycoplasma, Peptococcus) agents (main indication).
Antibiotics
| Active ingredient groups | Active ingredients |
| Nitroimidazoles | Metronidazole oral |
| Metronidazole vaginal tablets Metronidazole vaginal gel | |
| Lincosamide | Clindamycin |
Vaginal antiseptic
| Active ingredient group | Active ingredients |
| Quaternary ammonium compounds | Dequalinium |
Folliculitis, boils, carbuncles, vulvitis pustulosa: causative agent Staphylococcus aureus agents (main indication).
Impetigo contagiosa: causative agent occasionally Staphylococcus aureus, usually A streptococcus
| Drug group | Active ingredients |
| Staphylococcal penicillins (penicillinase-resistant β-lactam antibiotic). | Dicloxacillin |
| Flucloxacillin | |
| Oxacillin | |
| Cephalosporins | |
| Group 1 | Cefaclor oral |
| Cefalexin oral | |
| Cefazolin i.v. | |
| Cefadroxil orally | |
| Group 2 | Cefuroxime i.v. |
| Cefuroxime oral | |
| Group 3a | Cefixime oral |
| Cefotaxime i.v. | |
| Cefpodoxime orally | |
| Ceftriaxone i.v. | |
| Group 3b | Ceftazidime i.v. |
| Group 3b | Ceftibuten oral |
| Macrolides | Erythromycin |
| Lincosamide | Clindamycin |
| Active ingredient group | Active ingredients |
| Disinfectant/antiseptic | Povidone-iodine solution, ointment |
Erysipelas, impetigo contagiosa, vulvitis in little girls: Pathogen A streptococcal agents (main indication).
| Active ingredient group | Active ingredients |
| Benzylpenicillin | Penicillin G |
| Aminopenicillins | Amoxicillin |
| Cephalosporins from group 2/3 | see above under folliculitis |
Vulvitis caused by parasites
Active ingredients (main indication) in endoparasites:
- Oxyuras: see helminthiasis Therapy: albendazole, mebendazole.
- Trichomonads
| Active ingredient group | Active ingredients |
| Nitroimidazoles | Metronidazole |
Vaginal antiseptic
Dequalinium: application, dosage see above agents bacterial vaginosis.
Active ingredients (main indication) for ectoparasites:
- Crabs: see there, therapy: allethrin, permethrin, pyrethrum.
- Scabies: see there, therapy: allethrin/piperonoyl butoxide, benzyl benzoate, permethrin.
Vulvitis due to mycoses
Active ingredients (main indication)
| Active ingredient group | Active ingredients |
| Imidazole | Cotrimoxazole |
| Econazole | |
| Miconazole |
- Mode of action: fungistatic (fungicidal in high-dose therapy) by inhibition of ergosterol synthesis.
- Spectrum of action: dermatophytes, dimorphic fungi, yeasts, molds.
- Side effects: local skin irritation, lower abdominal cramps.
Vaginal antiseptic
Dequalinium: application, dosage see above active substances bacterial vaginosis.
Antifungals – Systemic therapy for recurrent chronic vulvitis / colpitis.
| Drug group | Active ingredients |
| Triazoles | Fluconazole |
| Itraconazole |
- Post-treatment with probiotics – (e.g. cultures of Bifidobacterium bifidum, Enterococcus faecium, Lactobacillus acidophilus, Lactobacillus casei, Lactococcus lactis, Lactobacillus salivarius; bacterial count: 2 x 109 CFU).
Vulvitis due to viruses
In this framework, only condylomata acuminata and herpes viruses will be discussed
Condylomata acuminata agents (main indication).
Therapy recommendations
- Elimination of the viruses is usually not possible.
- Optional forms of local therapy:
- Interferon ß, local gel treatment after vaporization with the CO2 laser.
- Podophyllotoxin (0.5%/0.15%)
- Imiquimod (5% cream)
- Trichloroacetic acid (85% cream)
- Epigallocatechin gallate, sinecatechins
- Potassium hydroxide solution (KOH), 5%.
- Vaccination (for anogenital warts, vaccination reduces the HPV-6 and HPV-11 burden) (see prophylactic vaccination from 9-14 years of age).
Surgical ablation of skin lesions (see under “Surgical Therapy”) is usually the last therapeutic option after local therapy (see above) has been exhausted.
| Drug group | Active ingredients | Special features |
| Cytokine | Interferon ß (interferon beta, IFN-β) | Local gel treatment After vaporization with CO2 laser. |
Other forms of therapy
| Drug group | Active ingredients | Special features |
| Polyphenols (green tea extract) | Epigallocatechin gallate, sinecatechins. | Duration of therapy max 16 weeks. Not in anus, urethra, vagina. |
| Topical chemotherapeutic agents | Imiquimod (5% cream) | Duration of therapy: max 16 weeks Side effects: Irritation, swelling (in the case of anogenital warts, the amount of HPV-6 is reduced |
| Trichloroacetic acid | Trichloroacetic acid (85%) | To be performed by physician Applicable in gravidity. |
| Cytostatics | 5-fluorouracil | Local use Do not contact intact skin, mucous membranes, or eyes |
| Podophyllotoxin (0.5%/0.15%) | Use as a solution (for men only) or cream |
Herpes virus active ingredients (main indication).
| Active ingredient group | Active ingredients |
| Viroustatic agents | Aciclovir |
| Aciclovir |
Special forms
Atrophic vulvitis/vulvovaginal atrophy.
Agents (main indication).
Therapy consists primarily of local rarely of systemic estrogen administration. Only local therapy will be discussed here. The agent of choice is estriol (E3). Unlike estradiol (E2), it has no endometrial effect (no effect on the endometrium).
| Active ingredient group | Active ingredients |
| Estrogens | |
| Estriol (E3) | Estrogen vaginal cream |
| Estrogen vaginal ovulum/tablet/suppository | |
| Estradiol (E2 | Estradiol vaginal tablet |
Vulvitis plasmacellularis agents (main indication)
This is a condition with a history of chronic fluoride and many different treatment attempts with antibiotics and antifungals (antifungals). It also often resembles trichomonad colpitis. It is likely that the causes are different. There is no detectable causative agent as yet. Therefore, the diagnosis is made solely by therapeutic success (about 90%) with clindamycin, which is indicated when suspected. Also, there is no typical histologic finding.
| Drug group | Active ingredients |
| Lincosamide | Clindamycin vaginal gel |
Vulvar vestibulitis syndrome (VVS; synonyms: Burning vulva, painful vulva, vestibulodynia, vestibulitis, vulvodynia, vestibulitis syndrome, vestibulitis vulvae syndrome)
Active ingredients (main indication).
Vulvar vestibulitis syndrome is still a largely unknown disorder with a prevalence (disease incidence) of approximately 9%, whose diagnosis is often made as a diagnosis of exclusion only after many years of unsuccessful different therapeutic attempts. For further information see Diagnosis
Therapy: There is no established therapy. Currently, the preferred treatment is:
- Systemic
- Tricyclic antidepressants (amitriptyline, nortriptyline).
- Anticonvulsants (gabapentin, pregabalin, topiramate).
- Local therapeutics are often ineffective (botulinum toxin A, cytokine-containing cream) is recommended care with fatty ointments.
- Extirpation of the affected areas (vestibuloplasty, vestibulectomy) is recommended for complaints >6 months.
Vulvitis in skin diseases
Details s. at the diseases; below only brief information:
- Behçet’s disease: Treatment is with corticosteroids in the acute stage, and immunosuppressants (azathioprine, ciclosporin (cyclosporin A), chlorambucil, cyclophosphamide) in severe cases and frequent relapses. If this also does not lead to the desired success, infliximab or thalidomide therapy can be prescribed.
- Lichen ruber/ planus erosivus: therapy: cortisone preparations in the form of ointments, creams or adhesive pastes.
- Lichen sclerosus: Therapy: In early stages estriol-containing creams, shock therapy with highly potent cortisone (clobetasol propionate), immunomodulation with calcineurin inhibitors.
- Psoriasis: Basically, systemic and topical (“local”) therapy are considered:
- Topical therapy: calcineurin inhibitors, dithranol, glucocorticosteroids, coal tar, tazarotene, vitamin D and analogues.
- Systemic therapy: adalimumab, ciclosporin (cyclosporin A), etanercept, fumaric acid esters, infliximab, methotrexate, retinoids* * , ustekinumab* .
For the vulva,vaginal area, glucocorticoids are agents of choice. * Red Hand Letter (11/22/2014) on ustekinumab: occurrence of exfoliative dermatitis (erythroderma) and exfoliation of the skin* * Oral retinoids acitretin, alitretinoin, and isotretinoin should be used in women of childbearing age only with adherence to a pregnancy prevention program.
