Vulval itching/lesion

• Candidiasis (Thrush): Intense pruritus, white curd-like discharge, erythema, and oedema of the vulva.
• Herpes Simplex Virus (HSV): Painful vesicles or ulcers on erythematous base, associated with burning or itching sensation.
• Human Papillomavirus (HPV): Genital warts (condylomata acuminata), cauliflower-like lesions, typically painless but can cause itching.
• Bacterial Vaginosis: Thin, grey discharge with fishy odour, possible mild irritation of the vulva.
• Trichomoniasis: Frothy, yellow-green discharge, strawberry cervix, vulval irritation or itching.
• Scabies: Intense itching, particularly at night, burrows or small erythematous papules on the vulva.
• Pubic Lice: Itching in the pubic area, visible lice or nits on pubic hair.
• Syphilis: Painless ulcer (chancre) in primary stage, secondary stage may include condylomata lata (broad, flat warts).

• Lichen Sclerosus: Chronic condition causing thin, white, wrinkled skin, intense itching, and vulval discomfort.
• Lichen Planus: Erosive or ulcerative lesions on the vulva, with pruritus and burning sensation.
• Lichen Simplex Chronicus: Thickened, hyperpigmented plaques with intense itching due to chronic scratching.
• Contact Dermatitis: Red, itchy, and inflamed skin due to irritants or allergens (e.g., soaps, sanitary products).
• Vulvar Intraepithelial Neoplasia (VIN): Pre-cancerous changes, may present with persistent itching, pain, or visible lesion.
• Psoriasis: Well-demarcated, scaly plaques, may involve vulva with pruritus.
• Squamous Cell Carcinoma: Vulval cancer, often presents with persistent ulcer or lesion, may be itchy or painful.
• Melanoma: Pigmented lesion on the vulva, may be itchy, asymmetrical with irregular borders.

Assess the specific symptoms presented by the patient:

• Onset and Duration: Acute vs. chronic onset, any recurrent episodes.
• Character of Itching: Intensity, timing (e.g., worse at night), any relieving or aggravating factors.
• Lesion Characteristics: Appearance, size, colour, any changes over time, presence of pain or ulceration.
• Associated Symptoms: Discharge, burning, pain, systemic symptoms (e.g., fever, malaise).
• Sexual History: Recent sexual activity, use of protection, history of sexually transmitted infections.

Gather a detailed background including:

• Past Medical History: Previous episodes of vulval itching or lesions, history of skin conditions, diabetes, or immunosuppression.
• Drug History: Recent use of antibiotics (predisposing to candidiasis), immunosuppressants, or topical agents.
• Family History: Any family history of skin conditions, autoimmune disorders, or cancers.
• Social History: Smoking, hygiene practices, use of new hygiene products, sexual practices, recent travel.

• Inspection of the Vulva: Look for erythema, swelling, lesions, plaques, ulcers, or warts, assess the distribution and symmetry.
• Palpation: Assess for tenderness, induration, or masses in the vulval area.
• Speculum Examination: If discharge is present, assess the vagina and cervix for abnormalities.
• Lymph Node Examination: Palpate inguinal lymph nodes for enlargement or tenderness.
• Systemic Examination: Check for signs of systemic illness (e.g., rash, joint symptoms) that could suggest an underlying condition like lichen planus or psoriasis.

• Swabs: High vaginal and vulval swabs for microscopy, culture, and sensitivity to identify bacterial, fungal, or parasitic infections.
• Biopsy: For any suspicious lesions or if lichen sclerosus, VIN, or vulvar cancer is suspected, histological examination.
• Blood Tests: Full blood count, glucose levels, and autoimmune screen if systemic involvement or underlying conditions are suspected.
• Patch Testing: If contact dermatitis is suspected, to identify specific allergens.
• Viral PCR: For HSV if active vesicular lesions are present.
• Colposcopy:  For detailed examination and guided biopsy if there is concern about VIN or malignancy.