Skin rash - genital

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

Symptoms	Comments/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	Site/Specimen	Test
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

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.

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.

Principal Treatment Options
Diagnosis	Recommended	Alternative
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

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.

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 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.

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

Russell D, Bradford D and Fairley C. Sexual Health Medicine. 2^nd edition. IP Communications. 2011

Last Updated: Thursday, 03 March 2016