Skin rash - genital

Overview

Genital rashes are common and many patients assume that they are associated with an STI, whereas they are often simply a dermatological condition.

Possible causes

  • Candida
  • Lichen simplex chronicus, lichen sclerosus and lichen planus
  • Dermatitis, psoriasis and pruritis ani.

Clinical presentation

SymptomsComments/Considerations
Itch Associated with the need to scratch
Burning, dysaesthesia Unpleasant sensation not associated with an irresistible need to scratch
Colour change in skin Red, white or haemorrhagic patches
Change in texture of skin Thickened or thin areas of skin in normal skin background

Diagnosis

DiagnosisSite/SpecimenTest
Candida Vulva swab, high vaginal swab or self-collected vaginal swab Microscopy, gram stain and culture
Lichen simplex, planus or sclerosus Vulva Biopsy
Dermatitis or psoriasis Vulva Biopsy
Pruritis ani Perianal swab Swab for culture

Investigations

  • Skin biopsy for candida where swabs are negative and erythema with splitting is present.
  • Biopsy area of skin with worst appearance or take multiple biopsies if areas look markedly different.

Specimen collection

Clinician collected |
Self-collection

Special considerations

  • Infection with uncommon species of candida may require sensitivity testing.
  • Always confirm recurrent candida with repeat testing as not all itch is candida.
  • Re-biopsy if an unusual area appears after successful treatment.

Management

Principal Treatment Options
DiagnosisRecommendedAlternative
Candida - simple vaginal Vaginal azole creams (eg. clotrimazole 10% vaginal cream, 1 applicatorful intravaginally at night, as stat dose or 3-7 days course) Fluconazole 150mg PO, stat
Candida - recurrent or chronic vaginal Treat each episode with longer course of azole cream (rather than stat dose) and/or induction with fluconazole 150mg PO, for 3 doses, 3 days apart, followed by maintenance with fluconazole 100mg PO, weekly for 6 months Itraconazole 100mg PO, daily until asymptomatic then 100mg weekly for 6 months
Candida - vulval skin At least 21 days of topical azole cream, TDS May require longer treatment
Lichen simplex Daily topical mid strength corticosteroid ointment Oral antihistamines may help to break the itch-scratch-itch cycle
Lichen planus Daily high strength topical corticosteroid ointment May require specialist review
Lichen sclerosus Daily high strength topical corticosteroid ointment May require specialist review
Dermatitis Daily topical mid strength corticosteroid ointment Cream if weeping skin
Psoriasis Daily topical mid strength corticosteroid ointment Coal tar and emollients
Pruritis ani Daily mild topical corticosteroid ointment Oral antihistamines may help to break the itch-scratch-itch cycle

Treatment advice

  • Infection with uncommon species of candida may require specialist review
  • Treat until symptoms and signs have resolved
  • Lichen planus and lichen sclerosus require long term maintenance topical steroid and regular review. Commencing these treatments without biopsy confirmed diagnosis is not recommended
  • Dermatitis and psoriasis may require long term maintenance or may be treated intermittently
  • Ointment is most useful for dry skin and cream for wet, weeping skin
  • Creams have preservatives that may cause irritation. Consider this as a cause if not responding.

Other immediate management

  • Avoid soap, perfumed products, bleaches and other irritants or allergens
  • Ensure skin hygiene is maintained with cool water and a soft cloth but avoid over-cleaning
  • Wear loose cotton clothing and avoid overheating
  • Burow’s solution (13% aluminium acetate) diluted 1:20-1:40 with cold water applied as a cold compress BD may be helpful for burning itchy skin
  • Use daily sorbolene for moisturising skin. 

Follow up

  • Follow up one month after commencement of treatment
  • Reduce regularity of treatment application after symptoms or signs have resolved
  • Review patients with lichen planus or lichen sclerosus at least annually once stable.

Auditable outcomes

90% of patients with lichen sclerosus and lichen planus under regular review.

References

  1. Russell D, Bradford D and Fairley C. Sexual Health Medicine. 2nd edition. IP Communications. 2011
Last Updated: Thursday, 03 March 2016