Vaginal Burning and Itching: Causes, Differential Diagnosis, and Management

Infectious Causes

Condition	Key Features	Diagnosis	Treatment
Vulvovaginal Candidiasis (VVC)	Intense pruritus, burning, thick white "cottage cheese" discharge, vulvar erythema/edema	KOH prep (pseudohyphae), culture if recurrent	Topical azoles (clotrimazole, miconazole) 1-7 days; oral fluconazole 150 mg single dose
Bacterial Vaginosis (BV)	Thin gray-white discharge, fishy odor (amine), minimal inflammation; 50% asymptomatic	Amsel criteria (3/4) or Nugent score; clue cells	Metronidazole 500 mg BID×7d or gel; clindamycin cream; secnidazole 2g single dose
Trichomoniasis	Frothy yellow-green discharge, intense pruritus, dysuria, strawberry cervix, partner often asymptomatic	NAAT (preferred), wet mount (motile trichomonads), culture	Metronidazole 2g single dose (partner simultaneously); tinidazole alternative
Genital Herpes (HSV-1/2)	Vesicles → ulcers, burning, dysuria, lymphadenopathy; primary severe, recurrences milder	PCR (swab), serology (type-specific)	Acyclovir/valacyclovir/famciclovir; episodic or suppressive
Chlamydia/Gonorrhea	Often asymptomatic; cervicitis, urethritis, PID risk	NAAT (urine/swab)	Ceftriaxone 500mg IM + doxycycline 100mg BID×7d

Non-Infectious Dermatologic

Condition	Features	Management
Lichen Sclerosus	White, atrophic, "cigarette paper" plaques (figure-8 perianal/vulvar); intense pruritus, dyspareunia, scarring	Clobetasol 0.05% ointment nightly × 4-12 wks → maintenance; lifelong surveillance (SCC risk 4-5%)
Lichen Planus	Erosive/reticular; vaginal desquamation, synechiae; oral lesions common	Topical corticosteroids; hydroxychloroquine; specialist co-management
Contact Dermatitis	Acute: erythema, vesicles; Chronic: lichenification; irritant (soaps, detergents) or allergic (fragrances, preservatives, latex)	Identify/avoid trigger; low-potency topical steroid short course; barrier emollients
Atopic Dermatitis	Chronic relapsing; personal/family atopy; flexural + genital	Emollients, topical calcineurin inhibitors (tacrolimus), intermittent steroids
Psoriasis (Inverse)	Well-demarcated red plaques (less scale in intertriginous); Koebner phenomenon	Low-potency steroids, vitamin D analogs, biologics if severe

Hormonal and Physiologic

• Genitourinary Syndrome of Menopause (GSM): Estrogen deficiency → atrophy, dryness, burning, dyspareunia, urinary symptoms. Treatment: Vaginal estrogen (cream, tablet, ring), DHEA (prasterone), ospemifene, moisturizers/lubricants.
• Pregnancy: Increased discharge, pH change → candidiasis risk; vulvar varicosities.

Chronic Pain Syndrome

• Vulvodynia: Chronic vulvar pain ≥3 months without identifiable cause. Subtypes: provoked (vestibulodynia), unprovoked, mixed. Management: Multimodal – topical lidocaine, pelvic floor PT, cognitive-behavioral, neuromodulators (gabapentin, amitriptyline), vestibulectomy (refractory localized).

Hygiene and Behavioral Factors

• Over-cleansing, douching, scented products, tight synthetic underwear, prolonged wetness (swimwear, pads).
• Correction: Water-only vulvar cleansing, cotton underwear, prompt change after swimming/exercise, unscented products.

When to Seek Care

• Symptoms >1 week despite OTC antifungal
• Recurrent (≥4/year VVC; ≥3/year BV)
• STI risk factors or partner notification
• Postmenopausal bleeding or new symptoms
• Skin changes: ulceration, pigmentation, thickening
• Systemic symptoms: fever, pelvic pain

Accurate diagnosis requires clinical exam + targeted testing. Self-treatment with wrong agent (e.g., steroid for yeast, antifungal for lichen sclerosus) delays resolution and risks complications.