Treatment Plans

Treatment action	Topical/behavioral	Oral meds	Intralesional meds	Testing/Notes
Comfort measures/ general care	Sitz bath, gentle cleansing, avoidance of irritants or tight clothing. Educate the patient: cause is unknown; may be one time occurrence or may be recurrent. May be associated with oral aphthae or not.			Herpes culture and/or titers (IgM and IgG) should always be done as well as other potential tests needed in the case of vulvar ulcers. There is no specific test for aphthous ulcers. Biopsy may diagnose them. LINK to Aphthous ulcers in Atlas for most the comprehensive approach to testing.
Pain relief	Topical xylocaine 5%, applied as needed, usually 4-6 times a day	Naproxen sodium 550 mg twice a day for the acute phase Oxycodone/Acetominophen 5/325 mg 1-2 tabs every 4-6 hrs for severe pain
Abbreviation of outbreak	Amlexanox 5% paste, applied four times a day in the mouth, or in the vulvar area (alternate with xylocaine) for 7 days
Anti-inflammatory action	Clobetasol or halobetasol 0.05% ointment (for the vulva) or gel (for the mouth) in a thin film twice a day, tapering with improvement (7-10 days)	Prednisone or methylprednisolone 40-60 mg every morning for 5 days, or tapering dose up to 7-10 days	Triamcinolone acetonide (Kenalog 10), 10 mg/mL diluted 1:1 with saline and using a 30-gauge needle injected under ulcer after application of EMLA (for large, painful, or unresponsive lesions)	For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting.
To abort an outbreak		Colchicine 0.6 mg twice daily on an ongoing basis to prevent or promptly abort lesions OR Prednisone 30 mg daily for 3-4 days to abort lesions
Antibiotics for superimposed infection		Cephalosporins or sulfonamides for broad-spectrum effect x 7-10 days

Updated 7/11/14 (LINK to Aphthous ulcers in Atlas)

Treatment action	Topical/Behavioral	Vaginal meds	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs; Use of topical moisturizer every three days: Vaseline or Replens.		Atrophy is diagnosed primarily with the history, exam, vaginal pH, and microscopy. Oral hormone replacement therapy is not necessary (and often does not work) for improvement of symptoms related to vulvovaginal atrophy. Absorption of vaginal estrogen does occur but does not approach pre-menopausal levels. ( LINK to Annotation P, pH values)
Increased comfort with vaginal penetrative sex	Use of lubricant with intercourse: vegetable oil, mineral oil, Astroglide, or SlipperyStuff, (the latter two safe for use with condoms) (LINK to LUBRICANTS) Topical xylocaine 5%, approximately 1 inch of ointment applied to vaginal opening, avoiding clitoris, for 10-15 minutes prior to sex. Wipe off first and then apply a lubricant. (Use no more than 15 grams a day). Warn patient that xylocaine stings when first applied.
Local estrogen replacement in the vagina (lowest to highest doses)		Vagifem tablets, 10 mcg intravaginally nightly for 7-14 days, then twice weekly (total 20 mcg/week) OR Estring, vaginal ring, 7.5 mcg/24 hr inserted vaginally once every 90 days (total 52.5 mcg/week) OR Estrace cream, (100 mcg estradiol/1g cream): 0.5 gm intravaginally, nightly for 7 days then twice weekly (total 100 mcg/week for maintenance) OR Premarin cream, (0.625 mg conjugated estrogens/1 g cream): 0.5 gm intravaginally, nightly for seven days, then twice weekly (total 600 mcg/week)	*The original Vagifem dose was 25 mcg twice weekly for maintenance. The company lowered the dose to 10 mcg twice weekly and this is usually sufficient, but not always. Some women respond better to 10 mcg three times a week and some need the addition of topical Estrace cream, ¼ tsp, applied to the vaginal opening twice weekly. Traditional dosing for the vaginal creams has been 1 gm vaginally twice a week for maintenance. Many clinicians have found that 0.5 gm twice weekly is enough.
For ongoing pain, with or without intercourse, despite the above treatments	Try adjunctive ¼ tsp of Estrace or Premarin cream topically applied to the vaginal opening nightly for 7 days, then 2-3 times a week. (This is usually temporary. The vaginal estrogen usually suffices for comfortable intercourse.) AND Consider pain from another condition: irritants, yeast infection, dermatosis, pelvic floor dysfunction, vulvodynia. Evaluate and treat appropriately.

Updated 7/11/14 vaginal atrophy in Atlas and in Annotation

For the most up to date info on treatment of BV, go to https://www.cdc.gov/std/tg2015/bv/.htm

Treatment action	Topical/behavioral	Oral meds	Vaginal meds	Testing/Notes
Comfort measures, general care, and prevention	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing. Stop smoking. Use condoms. Partners do not need to be treated.			BV is not a cause of pain. Rule out atrophy in breastfeeding or postmenopausal women. Then, adhere to Amsel’s criteria for diagnosis: Homogeneous, thin, gray-white discharge coating vaginal walls Vaginal pH greater than 4.5 Positive whiff test: presence of fishy odor when 10% KOH is added to drop of discharge Presence of clue cells on wet mount (LINK to Anno P, Bacterial Vaginosis)
CDC- recommended treatment regimens¹for bacterial vaginosis in non-pregnant women		Metronidazole 500 mg orally twice a day for 7 days OR vaginal rx	Metronidazole gel, 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for 7 days	Avoid alcohol during treatment and for 24 hrs after treatment is completed with Metronidazole. Clindamycin cream may weaken latex condoms and diaphragms for 5 days after use. Never give women with connective tissue disease (e.g. lupus, scleroderma, polymyositis, rheumatoid arthritis, Sjögren) any form of metronidazole.
CDC -recommended alternative regimens² for bacterial vaginosis in non-pregnant women		Clindamycin 300 mg orally twice a day for 7 days OR Tinidazole 2 g orally once daily for 2 days OR Tinidazole 1 g orally once daily for 5 days OR vaginal rx	Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days	Same warnings. Avoid alcohol for 72 hrs after Tinidazole. Clindamycin ovules may weaken latex condoms or diaphragms, as well.
CDC-recommended treatment regimens for bacterial vaginosis in pregnancy³		Metronidazole 500 mg orally twice daily for seven days OR Metronidazole 250 mg orally three times daily for seven days	Clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for 7 days	There is no evidence for routine screening for BV in asymptomatic pregnant women at high or low risk for preterm birth. Treatment is recommended for symptomatic women. See CDC guidelines for current research on asymptomatic women and those at high risk of preterm birth. Tinidazole should be avoided during pregnancy.
Treatment of bacterial vaginosis in breastfeeding women	If treating, monitor infant for diarrhea, candidiasis (thrush or diaper rash) or, rarely, blood in the stool indicating possible antibiotic-associated colitis. Infant side- effects are less likely with vaginal than oral treatment. The AAP considers use of oral metronidazole and tinidazole of concern in nursing women because of an association of these drugs with carcinogenesis in rodents, although outcome data of maternal metronidazole use has not shown a significant increase in adverse events compared to use of other antimicrobials. Use of vaginal metronidazole has not been studied during breastfeeding. After vaginal administration, plasma levels are less than 2 percent of those after a 500 mg oral dose, so vaginal use of metronidazole during breastfeeding is unlikely to be of concern.	Clindamycin use is acceptable in breastfeeding women according to The American Academy of Pediatrics (AAP).⁴Clindamycin 300 mg orally twice a day for 7 days or vaginal rx	Clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for 7 days OR Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days	Lower oral Metronidazole doses are now considered compatible with breastfeeding. Do not use the single 2 g dose.
Treatment of recurrence and relapse in bacterial vaginosis		Metronidazole 500 mg orally twice a day x seven days followed by boric acid capsules 600 mg inserted vaginally for 21 nights, possibly followed by the Metronidazole gel regimen twice weekly	Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days then used twice weekly for four months.ORCompounded metronidazole 500 mg with 100,000 units of Nystatin ovules Insert vaginally once nightly for three months*	The compounded metronidazole and nystatin suppositories have been used in one study only and for five days only. This treatment is experimental. The couple must use condoms and cessation of smoking is recommended.
Treatment for candidiasis which is common with metronidazole use.		Fluconazole 150 mg orally every other day x 3 OR Vaginal rx	Any of the azole vaginal treatments. See treatment of candidiasis.

Updated 7/11/14 LINK to Bacterial Vaginosis, Annotation P.

References

https://www.cdc.gov/std/tg2015/bv.htm
https://www.cdc.gov/std/tg2015/bv.htm
https://www.cdc.gov/std/tg2015/bv.htm
American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001; 108:776.

Definitions of uncomplicated and complicated Candidiasis²

Uncomplicated candidiasis	Complicated candidiasis
Sporadic or infrequent episodes	Recurrent episodes (four or more per year)
Mild to moderate symptoms	Severe symptoms
Candida albicans infection	Non-albicans Candidal infection
Non-pregnant women without medical complications	Women with diabetes, severe medical illness, immunosuppression, pregnancy, other vulvovaginal conditions

Treatment action	Topical/behavioral	Vaginal meds	Oral meds	Testing and notes
Comfort measures and general treatment for uncomplicated candidiasis	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs	CLOTRIMAZOLE (non-prescription):Gyne-Lotrimin 1% cream; 1 applicatorful vaginally at bedtime x 7 daysGyne-Lotrimin-3 2% cream; 1 applicatorful vaginally at bedtime x 3 days Gyne-Lotrimin 100 mg vaginal tablet (not available in the USA); 1 tab vaginally at bedtime x 7 days or 2 tabs x 3 days MICONAZOLE (non-prescription) Monistat-7 2% cream; 1 applicatorful vaginally at bedtime x 7 days Monistat-3 4% cream; 1 applicatorful vaginally at bedtime x 3 days Monistat-7 100 mg vaginal suppository; 1 vaginally at bedtime x 7 days Monistat-3/Vagistat-3 (generic) 200 mg vaginal suppository; 1 vaginally at bedtime x 3 days Monistat-1, 1,200 mg vaginal suppository, 1 vaginally at bedtime x 1 NYSTATIN (not available in the US) 100,000 unit vaginal tablet; 1 tablet vaginally x 1 TERCONAZOLE (prescription only) Terazol or Zazole-7 0.4%; 1 applicatorful vaginally at bedtime x 7 days Terazol or Zazole-3 0.8%; 1 applicatorful vaginally at bedtime x 3 days Terazol or Zazole-3 80 mg vaginal suppository; 1 vaginally at bedtime x 3 days TIOCONAZOLE (non prescription) Vagistat-1 or 1-day from Monistat 6.5% ointment; 1 applicatorful vaginally x 1 BUTOCONAZOLE (prescription only) Gynazole-1 2% cream; 1 applicatorful vaginally x 1	Fluconazole 150 mg oral tablet, one tablet in single dose	pH and microscopy are first line tests. Unless pseudohyphae are seen clearly on microscopy, send a yeast culture. Budding spores are associated with either albicans or non-albicans Candida. Cultures help with speciation and direct treatment. For uncomplicated yeast, any topical azole can be used. Any topical azole can cause increased symptoms of vulvar burning or irritation. Make patients aware of this potential side effect. Fluconazole has potential drug-to-drug adverse interactions. It is thought that the low doses we use for treatment or suppression of vulvovaginal yeast are unlikely to cause these interactions³ but awareness of the possibility is important. In addition, in a nationwide cohort study in Denmark, use of oral fluconazole in pregnancy was associated with a statistically significant increased risk of spontaneous abortion compared with risk among unexposed women and women with topical azole exposure in pregnancy. Until more data on the association are available, Fluconazole should not be prescribed in pregnancy, especially prior to 25 weeks. Although the risk of stillbirth was not significantly increased, this outcome should be investigated further. ⁵ For more information on candidiasis, see LINK Annotation P: candidiasis and The Atlas, candidiasis)
*Comfort measures and general treatment for complicated candidiasis, severe symptoms*	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs	Any intravaginal azole used for 7-14 days	Fluconazole 150 mg orally x 1 and again in 72 hours; in severe cases, may be used a third time.
Treatment of recurrent albicans candidiasis	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs	Any intravaginal azole used for 7-14 days followed by the same azole used once or twice weekly for four to six months (frequency dependent on strength of medication)	Fluconazole 150 mg orally every 72 hours x 3 followed by 150 mg orally once a week for four-six months
Treatment of non-albicans yeast in symptomatic non-pregnant women (therapy depends on strain of yeast identified)	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs	For C. glabrata: Compounded boric acid capsules or suppositories, 600 mg intravaginally, nightly x 14 daysANDIf not effective, prescribe a second treatment with boric acid capsules or suppositories intravaginally: 600 mg suppository nightly x 14 days followed by compounded flucytosine cream 17%, 5 grams intravaginally for 14 daysORAmphotericin B compounded suppositories, 50 mg intravaginally nightly for 14 daysFor C. Krusei: Intravaginal Clotrimazole, Miconazole, or Terconazole for 7-14 days	For species other than glabrata or krusei: Fluconazole 150 mg orally x 1 and again in 72 hours	Asymptomatic non-albicans yeast does not always need treatment. Rule out other causes for symptoms before deciding on treatment.
Treatment of candidiasis in pregnancy		CLOTRIMAZOLE Gyne-Lotrimin 1% cream; 1 applicatorful vaginally at bedtime x 7 daysORMICONAZOLE Monistat-7 2% cream; 1 applicatorful vaginally at bedtime x 7 days		Symptomatic, recurrent candidiasis can be problematic in pregnancy; the vaginal azole may need to be repeated or used for a longer course. There is no association with adverse outcomes from vaginal candidiasis in pregnancy.⁶Terazol should not be used in pregnancy. There is a warning attached to Terazol that there have been cases of anaphylaxis with it. Oral fluconazole should not be used in pregnancy.⁷ (
*Treatment of candidiasis* in the immunocompromised woman**		Any azole vaginally for 7-14 days:	Fluconazole 150 mg orally x 1 and again in 72 hours; in severe cases, may be used a third time.

Updated 7/14/14. Candidiasis in annotations and in Atlas.

References

Sobel JD. Candida vulvovaginitis. UpToDate. 2014, Wellesley, Massachusetts.
Sobel JD. Candida vulvovaginitis. UpToDate. 2014, Wellesley, Massachusetts.
Ditte Mølgaard-Nielsen, MSc; Henrik Svanström, PhD; Mads Melbye, MD, DrMedSci; Anders Hviid, MSc, DrMedSci; Björn Pasternak, MD, PhD. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58-67. doi:10.1001/jama.2015.17844
Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR Recomm Rep 2010 (RR-11); 55:1-95.
Ditte Mølgaard-Nielsen, MSc; Henrik Svanström, PhD; Mads Melbye, MD, DrMedSci; Anders Hviid, MSc, DrMedSci; Björn Pasternak, MD, PhD. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58-67. doi:10.1001/jama.2015.17844

Treatment action	Topical/behavioral	Oral meds	Intramuscular meds	Intralesional meds	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs.				Always do pH, wet prep, and yeast culture. Consider bacterial culture if superimposed infection is suspected. Biopsy if unsure of diagnosis. (LINK to biopsy) Consider North American Series patch testing to identify irritants. LINK to Contact or irritant dermatitis in Atlas.
Reduction of itching or pain	Topical xylocaine 5%, applied as needed, usually 4-6 times a day (no more than 15 grams a day)	Hydroxyzine 10 to 25 mg orally 1-2 hrs prior to bedtime; (may start at 10 mg and increase nightly to a maximum of 75 mg) OR Benadryl 25-50 mg orally 1-2 hrs prior to bedtime, stopping meds as symptoms subdue.			Hydroxyzine and Benadryl both cause sedation.
Anti-inflammatory action	1% to 2.5% hydrocortisone or desonide 0.05% ointment applied once or twice daily for mild inflammation. This dose may be used once more potent steroids have improved the condition. Betamethasone 17-valerate 0.1% ointment applied twice a day in a thin film until improved x 1 monthOR Triamcinolone acetonide 0.1% ointment applied twice a day in a thin film until improved x 1 month OR Clobetasol or halobetasol 0.05% ointment applied twice a day, in a thin film, tapering with	Prednisone or methylprednisolone 40-60 mg every morning for 5 days, or a tapering dose up to 7-10 days (for diffuse inflammation, or for those unresponsive to topical treatment)	Triamcinolone acetonide 40 mg/ml (Kenalog 40) 1 mg per kg intramuscularly, single dose for diffuse inflammation or for those unresponsive to topical treatment	Triamcinolone acetonide (Kenalog 10), 10 mg/mL diluted 1:1 with saline and using a 30-gauge needle; injected under plaque after application of EMLA (for large, thick areas or those unresponsive to topical treatment)	For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting. Do not withdraw needle when giving IM shots until the syringe is emptied.
Treatment for concomitant candidiasis		Fluconazole 150 mg orally every 72 hrs x 3, then weekly until symptoms are gone.
Antibiotics for superimposed infection		Dicloxacillin 250-500 mg orally 4 x a day for 10 days OR Cephalexin 250-500 mg orally 4 x a day for 10 days
Reduction of the habit of scratching	Counsel to bring importance of this to patient’s awareness.	SSRIs may be helpful; dosing should start low and slowly build; tapering off the medication should be done very slowly:Fluoxetine (Prozac) 10-20 mg orally, dailyOR Citalopram (Celexa) 10-20 mg orally daily OR Other SSRIs

Updated 7/11/14 LINK to Contact or irritant dermatitis in Atlas.

Comfort measures, general treatment	Topical medication (useful for erythema and scale without pustules or papules)³	Oral medication (useful for thick plaques, follicular involvement)
Keep area cool and dry.	Clotrimazole 1% twice daily x 14 days	Fluconazole 150-200 mg orally once a week x 3-4 weeks. Check for drug interactions
Wash with a triclosan solution (Tersaseptic), rinse well, pat dry.	Miconazole 2% twice daily x 14 days	Terbinafine (Lamisil) 250 mg orally daily x 2 weeks.
Loose clothing.	Ketoconazole 2% twice daily x 14 days	Itraconazole (Sporanox) 100-200 mg orally twice a day for one week. Watch for interactions with other medications.
Treat tinea pedis or onychomycosis if present.	Econazole 2% twice daily x 14 days	Ketoconazole (Nizoral) 200-400 mg orally daily x 2 weeks. May cause hepatotoxicity.
Put on socks before other clothing.	Terbinafine 1% twice daily x 14 days	Griseofulvin 500 mg orally daily x 2-6 weeks. (May cause nausea or headache).
	Ciclopirox olamine 1% twice daily x 14 days Nystatin not effective!

References

Edwards L and Lynch P. Genital Dermatology Atlas, second edition. Wolters Kluwer/Lippincott Williams & Wilkins, New York. 2011. 68.

Treatment Action	Topical/behavioral	Vaginal meds	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing		DIV is diagnosed through pH and microscopy. (LINK to Annotation P and also microscopy tables). In post menopausal women and those who are breastfeeding, rule out atrophy before assuming DIV since they can look similar under the microscope. Candida may also cause increased numbers of WBC’s and some parabasal cells on wet prep. If you do not see yeast, wait for yeast culture before presuming DIV. DIV is also thought to be associated with or a manifestation of vaginal lichen planus. (LINK vaginal lichen planus, Annotation P)
Anti-inflammatory action for mild DIV		Hydrocortisone suppositories 25 mg (use Anusol rectal suppositories vaginally); 1 vaginally at bedtime for 14-30 days, then every other day till seen again in one month.	Mild DIV may present with a borderline pH, hovering near normal, some parabasal cells, and >1:1 ratio of WBCs to epithelial cells (LINK to microscopy slide with mild DIV)
Anti-inflammatory action for strong evidence of DIV or recalcitrant DIV		Hydrocortisone compounded suppositories, 100 mg; insert one vaginally nightly x 14-30 nights, then every other night for 14-30 days, then 2-3 times weekly. Re-evaluate at 1 month intervals. OR Clindamycin 2% cream; 5 g intravaginally, nightly x 14 days (used rarely but has anti-inflammatory properties) AND Because hydrocortisone has the potential for overgrowth of yeast, consider adding 2% Clotrimazole to the compounded suppositories (Hydrocortisone 100 mg suppositories with 2% Clotrimazole) OR Treat incidental yeast with oral Fluconazole.	Moderate to severe DIV presents with elevated pH, many parabasal cells and many WBCs. (LINK to microscopy slide with moderate to severe DIV)

Treatment Action

Topical/behavioral

Vaginal meds

Testing/Notes

Comfort measures, general care

Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing

DIV is diagnosed through pH and microscopy. (LINK to Annotation P and also microscopy tables). In post menopausal women and those who are breastfeeding, rule out atrophy before assuming DIV since they can look similar under the microscope. Candida may also cause increased numbers of WBC’s and some parabasal cells on wet prep. If you do not see yeast, wait for yeast culture before presuming DIV.

DIV is also thought to be associated with or a manifestation of vaginal lichen planus. (LINK vaginal lichen planus, Annotation P)

Anti-inflammatory action for mild DIV

Hydrocortisone suppositories 25 mg (use Anusol rectal suppositories vaginally); 1 vaginally at bedtime for 14-30 days, then every other day till seen again in one month.

Mild DIV may present with a borderline pH, hovering near normal, some parabasal cells, and >1:1 ratio of WBCs to epithelial cells
(LINK to microscopy slide with mild DIV)

Anti-inflammatory action for strong evidence of DIV or recalcitrant DIV

Hydrocortisone compounded suppositories, 100 mg; insert one vaginally nightly x 14-30 nights, then every other night for 14-30 days, then 2-3 times weekly. Re-evaluate at 1 month intervals.

Clindamycin 2% cream; 5 g intravaginally, nightly x 14 days (used rarely but has anti-inflammatory properties)

AND

Because hydrocortisone has the potential for overgrowth of yeast, consider adding 2% Clotrimazole to the compounded suppositories (Hydrocortisone 100 mg suppositories with 2% Clotrimazole)

Treat incidental yeast with oral Fluconazole.

Moderate to severe DIV presents with elevated pH, many parabasal cells and many WBCs.
(LINK to microscopy slide with moderate to severe DIV)

Updated 7/11/14, Desquamative Inflammatory Vaginitis in annotation P and in the Atlas.

Treatment action	Topical/behavioral	Oral meds	Intramuscular meds	Intralesional meds	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs. Teach patient that this condition needs to be controlled, rather than cured.				Always do pH, wet prep, and yeast culture. Consider bacterial culture if superimposed infection is suspected. Biopsy if unsure of diagnosis. (LINK to biopsy) Steroid medications can enhance development of infectious conditions such as candidiasis, herpes simplex, and condyloma. Consider ordering North American Series Patch testing for identification of possible irritants if symptoms persist. Link to Eczematous Dermatitis in Atlas.
Reduction of itching or pain	Topical xylocaine 5%, applied as needed, usually 4-6 times a day (no more than 15 grams a day)	Hydroxyzine 10 to 25 mg orally 1-2 hrs prior to bedtime; (may start at 10 mg and increase nightly to a maximum of 75 mg) OR Benadryl 25-50 mg orally 1-2 hrs prior to bedtime, stopping meds as symptoms subdue.			Hydroxyzine and Benadryl may be sedating.
Anti-inflammatory action	1% to 2.5% hydrocortisone or desonide 0.05% ointment applied once or twice daily for mild inflammation. This dose may be used once more potent steroids have improved the condition. Betamethasone 17-valerate 0.1% ointment applied twice a day in a thin film until improved x 1 month OR Triamcinolone acetonide 0.1% ointment applied twice a day in a thin film until improved x 1 month OR Clobetasol or halobetasol 0.05% ointment applied twice a day, in a thin film, tapering with improvement or reducing to one of the mid-low potency steroid ointments	Prednisone or methylprednisolone 40-60 mg every morning for 5 days, or a tapering dose up to 7-10 days (for diffuse inflammation, or for those unresponsive to topical treatment)	Triamcinolone acetonide 40 mg/ml (Kenalog 40) 1 mg per kg intramuscularly, single dose for diffuse inflammation or for those unresponsive to topical treatment	Triamcinolone acetonide (Kenalog 10), 10 mg/mL diluted 1:1 with saline and using a 30-gauge needle; injected under plaque after application of EMLA (for large, thick areas or those unresponsive to topical treatment)	For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting. Do not withdraw the needle with IM shots until the syringe is empty.
Treatment for concomitant candidiasis		Fluconazole 150 mg orally every 72 hrs x 3, then weekly until symptoms are gone.
Antibiotics for superimposed infection		Dicloxacillin 250-500 mg orally 4 x a day for 10 days OR Cephalexin 250-500 mg orally 4 x a day for 10 days
Reduction of the habit of scratching	Counsel to bring importance of this to the patient’s awareness.	SSRIs may be helpful; dosing should start low and slowly build; tapering off the medication should be done very slowly: Fluoxetine (Prozac) 10-20 mg orally, daily OR Citalopram (Celexa) 10-20 mg orally daily OR Other SSRIs

Updated 7/11/14 Link to Eczematous Dermatitis in the Atlas.

http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm#a2

Treatment action	Topical/behavioral	Oral meds	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum; Avoid irritants, daily panty liners, tight clothing, douching, or feminine hygiene products. Cool gel packs may help. Counsel to avoid having sex when having prodromal symptoms or an overt outbreak. For severe pain with urination, have pt dilute urine with a peri-bottle or by sitting in water when voiding.		Herpes cultures can and should be done at the time of a fresh blister or ulcer. They are not always reliable if negative. Herpes titers can give information about whether or not the patient has ever been exposed to the herpes virus. IgM relates to new-onset infection, IgG to long-term infection. Titers positive for Type 1 will not reveal whether the patient has a history of “cold sores” or whether she has had genital herpes Type 1. Type 2 herpes is almost always located in the genital area. Herpes can appear in “new” locations in the genital area and may not always look classical with blistering and erosions or ulcers. It can also occur without eruption, with redness and tingling alone. Link to Herpes Simplex in Atlas.
Reduction of itching or pain	Topical xylocaine 5%, applied as needed, usually up to 4-6 times a day (no more than 15 grams a day) Warn the patient that xylocaine stings when first applied.
Anti-viral action for an initial outbreak		Acyclovir 400 mg orally three times a day for 7-10 days OR Acyclovir 200 mg orally five times a day for 7-10 days OR Famciclovir 250 mg orally three times a day for 7-10 days OR Valacyclovir 1 g orally twice a day for 7-10 days	*Treatment can be extended if healing is incomplete after 10 days of therapy.
Anti-viral treatment for episodic outbreaks		Acyclovir 400 mg orally three times a day for 5 days OR Acyclovir 800 mg orally twice a day for 5 days Acyclovir 800 mg orally three times a day for 2 days OR Famciclovir 125 mg orally twice a day for 5 days OR Famciclovir 1,000 mg orally twice a day for 1 day OR Famciclovir 500 mg once followed by 250 mg twice a day for 2 days OR Valacyclovir 500 mg orally twice a day for 3 days OR Valacyclovir 1 gram orally once a day for 5 days
Anti-viral treatment for suppressive therapy		Acyclovir 400 mg orally twice a day OR Famiciclovir 250 mg orally twice a day OR Valacyclovir 500 mg orally once a day* OR Valacyclovir 1 gram orally once a day	*Valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in patients who have very frequent recurrences (i.e. > 10 episodes per year). Herpes does not always suppress easily and increased dosing may be necessary.

Updated 7/11/14 Link to Herpes Simplex in the Atlas

For more on herpes zoster, see the CDC website: http://www.cdc.gov/shingles/index.html

Treatment action	Topical/behavioral	Oral meds	IV meds	Testing/Notes
Comfort measures, general care	Cool sitz baths or cool gel packs or compresses may help to decrease swelling. Use gentle cleansing, topical petrolatum; Avoid irritants, daily panty liners, tight clothing, douching, or feminine hygiene products. Avoid having sex when having prodromal symptoms or blisters.			Diagnosis is usually based on morphology, remembering that although herpes zoster resembles herpes simplex, the lesions are unilateral and follow dermatomes. Direct fluorescent antibody testing (DFA) on scrapings from active vesicular skin lesions that have not yet crusted can distinguish between herpes simplex and herpes zoster. (LINK to Herpes Zoster in Atlas)
Reduction of itching or pain	Topical xylocaine 5%, applied as needed, usually up to 4-6 times a day (no more than 15 grams a day) Warn the patient that xylocaine stings when first applied. OR Topical Lidocaine 2.5%/Prilocaine 2.5% (EMLA) cream in a thick layer topped off with a piece of saran wrap for 20 min. For severe pain with urination, have pt dilute urine with a peri-bottle or by sitting in water when voiding. Catheterization and sedation may be necessary.			Herpes zoster of the vulva and the dermatomes S1 through S4 can be incapacitating and depressing. Early institution of gabapentin or Pregabalin may reduce the zoster-associated pain complex. Usually the lesions settle in three to four weeks with some degree of scarring and, in the elderly, post-herpetic neuralgia may result. The use of prednisone to prevent the neuralgia is controversial
Anti-viral action for early or mild outbreak		Acyclovir (Zovirax) 800 mg orally at 7:00 AM, 11:00 AM, 3:00 PM, 7:00 PM, and 11:00 PM x 7 days. OR Famciclovir (Famvir) 500 mg orally 3 times a day x 7 days OR Valacyclovir (Valtrex) 1g orally 3 times a day x 7 days if renal function is normal
Anti-viral action for severe skin outbreak			Acyclovir (Zovirax) 10 mg/kg IV q8h x 7 days
Anti-viral action for immunocompromised patients if intolerant of acyclovir			Foscarnet (Foscavir) 40 mg/kg IV q8h x 7 to 10 days
For severe pain management		Acetaminophen and codeine 15 to 30 mg orally q3- 4h OR Gabapentin 300 mg at bedtime. Increase by 300 mg every two days to 1000 mg OR Pregabalin 50 mg at bedtime. Increase by 50 mg every three days to 150-300 mg if needed.
Prevention	Prescribe the herpes zoster vaccine for prevention.

Hurley’s Clinical Staging⁷ for Hidradenitis Suppurativa (essential for treatment decisions)

Stage I	Abscess formation, single or multiple, without sinus tracts and cicatrization.
Stage II	Recurrent abscesses with tract formation and cicatrization. Single or multiple, widely separated lesions
Stage III	Diffuse or near-diffuse involvement, or multiple interconnected tracts and abscesses across entire area. Delay in diagnosis is an average of seven years, and can be decades. Multiple clinicians incise and drain the “boils” and no one recognizes the pathology occurring. Misdiagnosis leads to inability to sit or walk without pain from large, draining sinuses with significant odor, need to wear diapers for the drainage. There may be difficulties with employment, social isolation, and depression, dysfunction, suicide. All of this is preventable.

Treatment action	Topical/behavioral	Oral meds	Intralesional meds	IM/SC/IV meds	Surgery	Testing/Notes
Comfort measures, general care	Reduce heat, sweating, friction (weight loss, loose clothing, tampons, antiperspirants, avoidance of hot environments all can help). Avoid any pressure and friction from panty hose, girdles, or other garments rubbing in the area. The use of ventilated cotton clothing (that is, cotton boxer shorts) is essential. Cleanse gently with triclosan solution once or twice a day. Topical 2% clindamycin in a mixture of isopropyl alcohol and propylene glycol twice a day is prescribed to avoid minor folliculitis. Bleach baths are helpful for large, draining, foul-smelling areas. (LINK, bleach bath handout). Stop smoking; nicotine avoidance is imperative. Stop all dairy foods (casein, whey, milk solids); change to low glycemic-load diet. The diet is helpful to prevent new lesions and for efficacy of therapy for existing nodules. Dairy products contain multiple hormones and androgens that exacerbate HS. Control insulin resistance (metformin).					Biopsies may or may not be helpful. Consult a dermatologist if not comfortable treating this condition. Surgical intervention is advised for Stage III and may be necessary for Stage II. HS is not contagious, not caused by poor hygiene. Diet may be more valuable than surgery. Hormone control is more valuable than antibiotics. Surgery undertaken early in the disease need not be mutilating, expensive, or painful. Primary closure of any unroofed or excised hidradenitis lesion leads to recurrence. Link to Hidradenitis Suppurativa in the Atlas.
Treatment: Hurley Stage I (Only a few flares yearly, single or multiple abscess formation without tracts or cicatrization)		Antibiotics are used for 7–10 days or longer for their anti-inflammatory effect: Tetracycline 250-500 mg orally 4 x a day OR Doxycycline 50 mg/d to 100 mg/d orally 2 x a day OR Minocycline 100 mg orally 2 x a day OR Erythromycin 1 gm orally, 1 x a day OR Amoxicillin + Clavulinic acid 500 mg to1 gm orally every eight hours OR Clindamycin 150-300 mg orally 2 x a day OR Dicloxacillin 1-2 gm orally 2 x a day OR Trimethaprim-sulfamethoxazole DS 1 tab orally 2 x a day AND Zinc Gluconate 30-60 mg/d orally (anti-inflammatory, anti- androgenic) AND Oral contraceptives with ethinyl estradiol and low androgen-potential progestins such as ethynodiol diacetate or norethindrone + spironolactone 25-100 mg/day.	For acute painful nodules: Triamcinolone 10 mg/ml injection brings immediate relief. Shake vial well and withdraw 10 mg (one ml), then dilute with two ml saline or 0.25% Marcaine. Shake well before injection. Inject 0.5 ml into center of painful lesions with 27-gauge needle.			For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting.
Treatment: Hurley Stage II (>1 flare/month or severe flares; sinus tracts or cicatrization present, single or multiple lesions still widely spaced)		Antibiotics are used for 7–10 days or longer for their anti-inflammatory effect: Clindamycin 300 mg orally 2 x a day + Rifampin 300 mg orally 2 x a day x 3 months AND Prednisone 40-60 mg orally x 3-4 days, then taper over 7-10 days AND Zinc Gluconate 30-60 mg/day (anti-inflammatory and anti-androgenic) AND Avlosulfone (Dapsone) 50-100 mg/day (Use only if you are comfortable prescribing this medication) AND Anti-androgen treatment may be necessary. Newer oral contraceptives with desogestrel or norgestimate provide less androgenic effects. Spironolactone 100 to 150 mg a day can be added to these or to regular birth control pills for additional or long-term control. In Europe a truly androgen-blocking combination of ethinyl estradiol 35 μg and cyproterone acetate 2 mg (Diane 35) is available and is very effective. Finasteride 5 mg daily, a 5-alpha-reductase inhibitor which transforms testosterone into dihydrotestosterone is reported helpful. Due to possible feminization of a male fetus is case of pregnancy the drug must be prescribed with caution. Avoid Depot-MPA and LNG IUD	Triamcinolone 5-10 mg/ml (0.1-0.5 ml) once monthly for 1 to 3 injections		Early, local unroofing may help; I&D only to relieve painful pressure.Follow with Antibiotics: (Amox, then doxy).
Treatment: Hurley Stage III (diffuse or near-diffuse involvement or multiple, interconnected tracts and abscesses across entire area)	Treatment is palliative, used in preparation for surgery.	Anti-inflammatory/antibiotics: Clindamycin 30 mg orally 2 x a day+ rifampin 300 mg orally 2 x a day AND Prednisone 40-60 mg/day orally x 3-4 days, then taper over 7-10 d OR Triamcinolone IM 1 mg/kg up to 60-80 mg intralesionally x 1 OR Cyclosporine 4-5 mg/kg/day orally for 5 to 30 wks		Tumor Necrosis Factor Alpha Inhibitors: Infliximab (Remicade) IV infusion 5 mg/kg (available if patient has Crohn disease plus HS) Adalimumab (Humira):Autoinjection 40 mg every other week Etanercept (Enbrel): self-SQ injections 25-50 mg 1-2X/wk	Surgery is extensive, with special wound care and avoidance of primary closure. Deroofing the sinus tracts, removal of all granulation tissue, and slow healing by secondary intention is effective

Updated 8/31/14 Link to Hidradenitis Suppurativa in the Atlas

References

Hurley HJ. Axillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa, and familial benign pemphigus: surgical approach. In: Roenighk RK, Roenigk HH, eds. Dermatologic surgery. Marcel Dekker, New York, 1989, 729-39

Treatment action	Topical/behavioral	Oral meds	Testing/Notes
Comfort measures, general care	It is imperative to address the precipitating factors and, at all costs, to prevent the skin-on-skin contact that causes this condition. Short term comfort: Sitz bath, gentle cleansing with gentle drying of skin surfaces, topical petrolatum or drying agents, avoidance of irritants or tight clothing or any chafing, application of cool gel packs. May use T-shirt fabric or other soft, cotton fabric between skin folds to prevent chafing or maceration. Long term comfort: Loose weight, improve incontinence and its management.		Most intertrigo is fungal in origin, the most common yeast being C. Albicans. It is commonly diagnosed clinically. In the genital area, it is found in the crural folds. (Also under breasts or under panus). Skin scrapings mixed with KOH can reveal the budding spores and/or pseudohyphae of yeast. Yeast culture can also be done. If the skin is badly macerated, obtain a bacterial culture as well as a fungal culture. Intertrigo is more likely with increased moisture between skin surfaces, increased friction, or lowered immune response. Link to Intertrigo in Atlas.
Anti-fungal treatment	Clotrimazole 2% cream applied twice a day until symptoms resolve OR Miconazole 2% cream applied twice a day until symptoms resolve OR (may also use ketoconazole, econazole, and sertaconazole. May also use topical terbinafine or naftifine; these options are rarely needed.) OR Ciclopirox 0.77% cream applied twice a day until symptoms resolve.	Fluconazole 50-100 mg orally daily or 150 mg orally weekly for 2-6 weeks or until symptoms are gone OR Itraconazole 200 mg orally twice daily for 2-6 weeks or until symptoms are gone	Topical antifungals are the mainstays of treatment, along with preventing skin surfaces from touching. Ciclopirox is an anti-fungal which also has anti-bacterial activity against gram-positive and gram-negative bacteria.Use oral meds only if the patient has failed topical treatment or has a very severe case. Do NOT use oral ketoconazole, which can cause liver toxicity. Do not use oral terbinafine. Drug interactions with oral antifungals are common; check before prescribing. Azole resistance has begun to emerge. Use as little oral anti-fungal medication as possible.
Drying agents	Miconazole, nystatin, undecylenic acid, tolnaftate and 12% benzoic acid come as powders that can be used twice weekly as preventives. OR Domeboro’s solution applied topically twice weekly OR Zeasorb powder (miconazole) applied twice daily or twice weekly OR Corn starch applied topically any time.		Do not use drying agents concomitantly with topical ointments. Best used after skin has cleared up as a preventive action.
Reduction of itching or pain	Topical xylocaine 5%, applied as needed, usually 4-6 times a day (no more than 15 grams a day)	Hydroxyzine 10 to 25 mg orally 1-2 hrs prior to bedtime; (may start at 10 mg and increase nightly to a maximum of 75 mg) (to prevent scratching)OR Benadryl 25-50 mg orally 1-2 hrs prior to bedtime, stopping meds as symptoms subdue.	These are rarely needed.
Anti-inflammatory action	1% to 2.5% hydrocortisone ointment applied once or twice daily for mild inflammation.		Steroid creams or ointments are rarely needed. Avoid moderate and high potency steroids with this condition. A low potency hydrocortisone may help with pain, itching, and burning.
Antibiotics for superimposed infection	Mupirocin ointment (Bactroban) applied topically three times a day until symptoms improved.	Erythromycin 250 mg orally four times a day for 7 days.

Updated 7/11/14 Link to Intertrigo in Atlas.

Treatment action	Topical/behavioral	Oral meds	IM or intralesional meds	Vaginal meds	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs. Educate: 1) this is a chronic disease that needs life-long treatment; 2) steroid treatments are safe if used as directed.				Always do pH, wet prep, and yeast culture.Biopsy if unsure of diagnosis. (LINK to biopsy) Steroid medications can enhance development of infectious conditions such as candidiasis, herpes simplex, and condyloma. Link to Lichen Planus in Atlas.
Reduction of pain with intercourse	Topical xylocaine 5%, applied as needed, usually 4-6 times a day or prior to intercourse (avoiding clitoris), then wiped off; (no more than 15 grams a day) (May cause burning when first applied).				Pain with intercourse needs to be fully evaluated (see algorithm).Pain caused by LP can resolve with healing of vestibular erosions and vaginal inflammation. Vulvodynia can arise secondarily.
Anti-inflammatory action for vulva and/or vestibule	Clobetasol or halobetasol 0.05% ointment applied twice a day, in a thin film, for 30 days, followed by once a day application for 14-30 days, OR followed by once a day application three times a week AND that followed by a maintenance dose of twice a week application of ointment.For the peri-anal area or for reduced dose for remission: Betamethasone 17-valerate 0.1% ointment applied twice a day in a thin film until improved x 1 month OR Triamcinolone acetonide 0.1% ointment applied twice a day in a thin film until improved x 1 month	Prednisone or methylprednisolone 40-60 mg every morning for 5 days, or a tapering dose up to 7-10 days (for diffuse inflammation, or for those unresponsive to topical treatment) (Used rarely due to known side effects of oral steroids.)	Triamcinolone acetonide (Kenalog 10), 10 mg/mL diluted 1:1 with saline and using a 30-gauge needle; injected under plaque after application of EMLA (for large, thick areas or those unresponsive to topical treatment)Triamcinolone acetonide 40 mg/ml (Kenalog 40) 1 mg per kg intramuscularly, single dose for diffuse inflammation or for those unresponsive to topical treatment		For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting.Super potent topical steroid ointments are the treatment of choice and usually subdue symptoms or changes in the skin adequately. Only a small amount of ointment is needed. Treatment may be titrated to the individual Treatment is life-long. Occasionally, remission allows reduction to a lower dose ointment or to a reduced frequency of once a week. In the peri-anal area, super-potent steroids are rarely used. Instead, use mid-potency steroid ointment such as Betamethasone valerate 0.1% or Triamcinolone 0.1%. “Flares,” where symptoms recur, are not uncommon and are usually controlled by returning temporarily to more frequent use of steroid ointment. Always look for and culture for yeast during a flare. Steroid rosacea is the most-likely side effect, almost always due to over use of the ointment. (LINK to steroid rosacea).
Anti-inflammatory action for vaginal erosive lichen planus manifesting as mild DIV				Hydrocortisone suppositories 25 mg (use Anusol rectal suppositories vaginally); 1 vaginally at bedtime for 14-30 days, then every other day till seen again in one month.	DIV, in some cases linked to erosive lichen planus in the vagina, is diagnosed through pH and microscopy. (LINK to Annotation P and also microscopy tables). In post menopausal women and those who are breastfeeding, rule out atrophy before assuming DIV since they can look similar under the microscope. Mild DIV may present with a borderline pH, hovering near normal, some parabasal cells, and >1:1 ratio of WBCs to epithelial cells (LINK to microscopy slide with mild DIV)
Anti-inflammatory action for strong evidence of erosive lichen planus manifesting vaginally as DIV				Hydrocortisone compounded suppositories, 100 mg; insert one vaginally nightly x 14-30 nights, then every other night for 14-30 days, then 2-3 times weekly. Re-evaluate at 1 month intervals.	Moderate to severe DIV presents with elevated pH, many parabasal cells and many WBCs. (LINK to microscopy slide with moderate to severe DIV)
Antibiotics for superimposed infection		Dicloxacillin 250-500 mg orally 4 x a day for 10 days OR Cephalexin 250-500 mg orally 4 x a day for 10 daysAND Treat concomitant yeast with Fluconazole 150 mg orally x1 OR x2, days 1 and 3 followed		Clindamycin 2% cream; 5 g intravaginally, nightly x 14 days (used rarely but has anti-inflammatory properties)ANDBecause hydrocortisone has the potential for overgrowth of yeast, consider adding 2% Clotrimazole to the compounded suppositories (Hydrocortisone 100 mg suppositories with 2% Clotrimazole) OR Treat incidental yeast with oral Fluconazole.	If giving antibiotics, consider also treating for potential yeast infection with an anti-fungal.Be aware that Fluconzaole has many potential drug to drug interactions.
Alternative treatments for recalcitrant LS	Calcineurin inhibitors: Topical tacrolimus (Protopic) 0.3% or 0.1% ointmentOR pimecrolimus (Elidel) 1% cream applied once or twice a day can be used as an alternative topical medication or in conjunction with the topical steroid.				These medications may burn and they are expensive. We prescribe the tiniest amount as a trial for the patient.Burning may be ameliorated by applying topical Vaseline first. The burning will sometimes taper off after a few applications. These meds can be used concomitantly with topical steroid ointment.

Updated 7/11/14 Link to Lichen Planus in the Atlas and in Annotation P

Treatment action	Topical/behavioral	Oral meds	Intramuscular meds	Intralesional meds	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs. Educate: 1) this is a chronic disease that needs life-long treatment; 2) steroid treatments are safe if used as directed. They do not thin the skin. Testosterone has no value in treating LS.				Always do pH, wet prep, and yeast culture. Consider bacterial culture if superimposed infection is suspected. Biopsy if unsure of diagnosis. (LINK to biopsy) White plaques can be squamous cell carcinoma rather than LS. Steroid medications can enhance development of infectious conditions such as candidiasis, herpes simplex, and condyloma. Link to Lichen Sclerosus in Atlas.
Reduction of itching or pain	Topical xylocaine 5%, applied as needed, usually 4-6 times a day (no more than 15 grams a day)	Hydroxyzine 10 to 25 mg orally 1-2 hrs prior to bedtime;OR Benadryl 25-50 mg orally 1-2 hrs prior to bedtime, stopping meds as symptoms subdue.			Anti-pruritics are not used as often in treatment of LS as in lichen simplex chronicus (LSC). Pain is usually caused by erosions from scratching. Pain with intercourse needs to be fully evaluated.
Anti-inflammatory action	Clobetasol or halobetasol 0.05% ointment applied twice a day, in a thin film, for 30 days, followed by once a day application for 14-30 days, OR followed by once a day application three times a week AND that followed by a maintenance dose of twice a week application of ointment. For the peri-anal area or for reduced dose for remission:Betamethasone 17-valerate 0.1% ointment applied twice a day in a thin film until improved x 1 month OR Triamcinolone acetonide 0.1% ointment applied twice a day in a thin film until improved x 1 month	Prednisone or methylprednisolone 40-60 mg every morning for 5 days, or a tapering dose up to 7-10 days (for diffuse inflammation, or for those unresponsive to topical treatment) (Used rarely due to known side effects of oral steroids.)	Triamcinolone acetonide 40 mg/ml (Kenalog 40) 1 mg per kg intramuscularly, single dose for diffuse inflammation or for those unresponsive to topical treatment	Triamcinolone acetonide (Kenalog 10), 10 mg/mL diluted 1:1 with saline and using a 30-gauge needle; injected under plaque after application of EMLA (for large, thick areas or those unresponsive to topical treatment)	For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting. Super potent topical steroid ointments are the treatment of choice and usually subdue symptoms or changes in the skin adequately. Only a small amount of ointment is needed. Treatment may be titrated to the individual Treatment is life-long. Occasionally, remission allows reduction to a lower dose ointment or to a reduced frequency of once a week. In the peri-anal area, super-potent steroids are rarely used. Instead, use mid-potency steroid ointment such as Betamethasone valerate 0.1% or Triamcinolone 0.1%. “Flares,” where symptoms recur, are not uncommon and are usually controlled by returning temporarily to more frequent use of steroid ointment. Always look for and culture for yeast during a flare. Steroid rosacea is the most-likely side effect, almost always due to over use of the ointment. (LINK to steroid rosacea).
Antibiotics for superimposed infection		Dicloxacillin 250-500 mg orally 4 x a day for 10 days OR Cephalexin 250-500 mg orally 4 x a day for 10 daysANDFluconazole 150 mg orally once weekly, if necessary, to control yeast. Use only until yeast has cleared and patient is stable.			If giving antibiotics, consider also treating for potential yeast infection with an anti-fungal.
Alternative treatments for recalcitrant LS	Calcineurin inhibitors: Topical tacrolimus (Protopic) 0.3% or 0.1% ointmentOR pimecrolimus (Elidel)1% cream applied once or twice a day can be used as an alternative topical medication or in conjunction with the topical steroid.				These medications may burn and they are expensive. We prescribe the tiniest amount as a trial for the patient.Burning may be ameliorated by applying topical Vaseline first. The burning will sometimes taper off after a few applications. These meds can be used concomitantly with topical steroid ointment.

Updated 7/11/14 Link to Lichen Sclerosus in the Atlas

Treatment action	Topical/behavioral	Oral meds	Intramuscular meds	Intralesional meds	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs				Always do pH, wet prep, and yeast culture. Consider bacterial culture if superimposed infection is suspected. Biopsy if unsure of diagnosis. (LINK to biopsy) Steroid medications can enhance development of infectious conditions such as candidiasis, herpes simplex, and condyloma. Consider obtaining North American Series patch testing to learn more about possible irritants. Link to Lichen Simplex Chronicus in Atlas
Reduction of itching or pain	Topical xylocaine 5%, applied as needed, usually 4-6 times a day (no more than 15 grams a day)	Hydroxyzine 10 to 25 mg orally 1-2 hrs prior to bedtime; (may start at 10 mg and increase nightly to a maximum of 75 mg) OR Benadryl 25-50 mg orally 1-2 hrs prior to bedtime, stopping meds as symptoms subdue.
Anti-inflammatory action	1% to 2.5% hydrocortisone or desonide 0.05% ointment applied once or twice daily for mild inflammation. This dose may be used once more potent steroids have improved the condition. Betamethasone 17-valerate 0.1% ointment applied twice a day in a thin film until improved x 1 monthOR Triamcinolone acetonide 0.1% ointment applied twice a day in a thin film until improved x 1 month OR Clobetasol or halobetasol 0.05% ointment applied twice a day, in a thin film, tapering with improvement or reducing to one of the mid-low potency steroid ointments	Prednisone or methylprednisolone 40-60 mg every morning for 5 days, or a tapering dose up to 7-10 days (for diffuse inflammation, or for those unresponsive to topical treatment)	Triamcinolone acetonide 40 mg/ml (Kenalog 40) 1 mg per kg intramuscularly, single dose for diffuse inflammation or for those unresponsive to topical treatment	Triamcinolone acetonide (Kenalog 10), 10 mg/mL diluted 1:1 with saline and using a 30-gauge needle; injected under plaque after application of EMLA (for large, thick areas or those unresponsive to topical treatment)	For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting.
Treatment for concomitant candidiasis		Fluconazole 150 mg orally every 72 hrs x 3, then weekly until symptoms are gone; for LSC, use in conjunction with steroid treatment.
Antibiotics for superimposed infection		Dicloxacillin 250-500 mg orally 4 x a day for 10 days OR Cephalexin 250-500 mg orally 4 x a day for 10 days
Reduction of the habit of scratching	Counsel to bring importance of this to patient’s awareness.	SSRIs may be helpful; dosing should start low and slowly build; tapering off the medication should be done very slowly:Fluoxetine (Prozac) 10-20 mg orally, dailyOR Citalopram (Celexa) 10-20 mg orally daily OR Other SSRIs

Updated 7/11/14 Link to Lichen Simplex Chronicus in Atlas

Treatment action	Topical/behavioral	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs	Molluscum is transmitted skin to skin or by auto-innoculation. Incubation averages 2-6 weeks. Diagnosis is usually made clinically. Immunocompetent patients may have spontaneous resolution (without treatment) within three months. Genital molluscum should be treated in sexually active women. Link to Molluscum Contagiosum in Atlas.
Reduction of pain	Topical xylocaine 5%, applied as needed, usually 4-6 times a day (no more than 15 grams a day)
Mechanical removal of lesions	Curettage: Manually remove the lesions with a curette, pre-treating with EMLA (Lidocaine/Prilocaine) to numb the areas if necessary	Some feel this is the most effective, though time consuming, method. Clinician-only treatment.
Freezing of lesions	Cryotherapy: Liquid nitrogen applied to each lesion for 6-10 seconds to achieve a white frosted 1 mm border, every 1 to 2 weeks till lesions are gone, is usually effective. Pre-treat with EMLA (Lidocaine/Prilocaine) to numb the areas if necessary.	Most common treatment used in clinician offices. Pain associated with the procedure can be a problem, as can scarring afterward, including hypopigmentation in those with dark skin. The procedure is well tolerated by adults but may not be by children. Clinician-only treatment.
Medical treatment of lesions	Blistering agent: Topical cantharidin 0.7% (Cantharone, a blistering agent that must be compounded) is applied in a thin film to the lesions and dried. The lesions are taped for two to four hours, and then washed off. This is repeated as needed every 2 to 3 weeks. Anti-mitotic podophyllotoxin: Podofilox 0.5% in a solution, gel or cream applied twice a day on three consecutive days in a week for up to four weeks.	Using one drop can make a nasty blister. Erythema, burning pain, and pruritus may occur after treatment although the liquid is painless when first applied. Scarring may also occur. Clinician-only treatment. May be self-applied by older adolescents or adults. Safety in children is not established. Erythema, burning pain and pruritus may occur after treatment. Patient-applied treatment.
Electrodesiccation of lesions	Light electrodesiccation with or without local anesthesia pre-treatment.	Clinician-only treatment.

Updated 7/11/14 Link to Molluscum Contagiosum in Atlas.

For the most up to date information on treatment, go to http://www.cdc.gov/std/trichomonas/treatment.htm

Treatment action	Topical/behavioral	Oral meds	Testing/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants (e.g. daily panty liners) or tight clothing		Trichomonads are usually easily seen on microscopy. Make sure you get to the microscope as soon as you take the sample because motility of the protozoa slows down with cooling, making them harder to identify. Inflammation may cause a large number of WBCs on the slide, which may obscure trich. If unsure, use the Affirm test or culture. Link to trichomoniasis, Annotation P.
Anti-protozoal for treatment of non-pregnant women		Metronidazole 2 g orally in a single doseOR Tinidazole 2 g orally in a single dose OR, alternatively: Metronidazole 500 mg orally twice a day for 7 days
Anti-protozoal for treatment of symptomatic trichomoniasis in pregnant women		Metronidazole 500 mg orally twice a day for 7 days (preferable due to nausea associated with pregnancy),OR Metronidazole 2 g orally in a single dose
Anti-protozoal for treatment with breastfeeding		After a 2 g dose of metronidazole, pumping and discarding breast milk for 24 hours is recommended.⁸
CDC recommended treatment regimens⁹ in imidazole-resistant Trichomonas vaginalis		Tinidazole orally in a single 2 g dose, OR Metronidazole 500 mg orally twice daily for seven days (total dose 7 g), OR Tinidazole or metronidazole 2 g orally a day for five days (total dose 10 g) for failure of the other two options.
For failure of the 10 gram dose regimen		Therapeutic options include maximum tolerated doses of metronidazole, or preferably tinidazole (2 to 4 g daily in divided doses) for 14 days. Patients with high-level metronidazole resistance are usually successfully treated by prolonged and high-level tinidazole therapy, although cross-resistance to tinidazole is frequently reported.¹⁰ The optimal dose has not been established	CDC recommends trichomonas culture and drug susceptibility testing (drug susceptibility available from the CDC, telephone 770-488-4115) and referral to a specialist.
*Treatment for candidiasis* related to antibiotic use**		Keep in mind that oral use of Metronidazole may cause secondary yeast and be prepared to offer treatment if the patient develops vulvar pruritus.

Updated 7/14/14 Link to Trichomoniasis Annotation P.

References

Sobel JD, UptoDate, 2010.
CDC 2006.
Schwebke JR, Barrientes FJ. Prevalence of Trichomonas vaginalis isolates with resistance to metronidazole and tinidazole. Antimicrob Agents Chemother. 2006; 50:4209.

Terminology	Age, frequency	Appearance of skin	Risk factors	Symptoms & Exam
VIN 1: no longer considered pre-cancerous (usually HPV 6 and 11)
VIN, USUAL TYPE (encompasses VIN 2 and 3) Former VIN warty type Former VIN baseloid type Former VIN mixed (warty and baseloid) type	Younger, pre-menopausal women75% of VIN cases are in young women	Often multi-focal, multicentric (different ebryologically similar areas) Colors: red, pink, grey, brown, white Textures: slightly raised or flat or verrucous Warty type: condylomatous appearance Baseloid type: thick epithelium with flat, smooth surface	HPV infection (often 16, 18, 31) (may be associated with CIN or VAIN) Cigarette smoking Immunodeficiency (HIV) Immunosuppression	50% asymptomatic Pruritus, palpable or visible lesion, perineal pain or burning, dysuria EXAM: Must check entire vulva and groin; use colposcope or magnifying glass; use acetic acid; BIOPSY suspicious lesions.
VIN, DIFFERENTIATED TYPE (encompasses VIN 2 and 3) Former simplex type	<5% of VIN cases are differentiated type and are usually in postmenopausal women	Often unifocal, unicentric Epithelium is thickened and parakeratotic (with thick scale formation, cracking and fissuring and underlying raw, red surface)	History of lichen sclerosus (or lichen planus)	50% asymptomatic Pruritus, palpable or visible lesion, perineal pain or burning, dysuria EXAM: Must check entire vulva and groin; use colposcope or magnifying glass; use acetic acid; BIOPSY suspicious lesions.
VIN, UNCLASSIFIED TYPE(rare)				BIOPSY suspicious lesions.

TREATMENT OF VULVAR INTRAEPITHELIAL NEOPLASIA (2004 terminology)
See Atlas Topic or UpToDate for more information.

Treatment action	Topical/behavioral	Type of lesion	Procedure	Advantage/disadvantage/Notes
Comfort measures, general care	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs		When VIN, VAIN, CIN, or AIN are found, the patient needs to have a complete colposcopic evaluation of the vulva, vagina, cervix, and anus, including anoscopy. Treatment goal: Prevention of development of invasive cancer, relief of symptoms, preservation of normal anatomy and function.	If untreated, VIN may persist, progress, or resolve. Recurrence is common: 1/3 of women utilizing any treatment.
Wide local excision		VIN, most commonly differentiated type: unifocal	Wide local excision (knife, electrosurgery, CO2 laser) with a 1 cm margin and removal of the epidermis and a small section of dermis.	Allows for histopathological examination of the sample.
Laser ablation		VIN, most commonly usual type: multifocal or extensive	Laser vaporization treats the whole area, with depth to 1 mm (in hair-free areas) to 3 mm (in hair-bearing areas).	Must evaluate with colposcope and biopsy for cancer prior to ablative treatment;Superficial laser treatment is comestically more satisfactory than skinning vulvectomy. Deep laser may cause scarring.
Simple vulvectomy		VIN, most commonly usual type: multifocal or extensive	Removal of the entire vulva usually including some subcutaneous tissue.	Tissue available for pathological evaluation.
Skinning vulvectomy		VIN, usually usual type: multifocal or large and confluent	Removal of the vulvar skin along an avascular plane beneath the epidermis, leaving the subcutaneous tissue.	Rarely used unless other treatments have failed. May need skin graft.
Topical medical treatment		VIN, usually usual type	Application of Imiquimod cream (Aldara) to individual lesions: 1 x a week x 2 weeks, then 2 x a week x 2 weeks, then 3 x a week till lesions are gone or up to 16 weeks	Must evaluate with colposcope and biopsy for cancer prior to topical treatment. Response rate varies.

Updated 7/11/14 Link to VIN in Atlas

General Information:

Etiologies of Vulvovaginal Disorders: This section will give you a way to frame your approach to treatment. Ask yourself: Is it fungal? Is it viral or bacterial? Is it a dermatosis? Is it a benign lump, bump, or discharge? Is it related to systemic disease? Is it related to the musculoskeletal system/pelvic floor? Is it purely neuropathic?

Education of the patient and general vulvar care: Prevention and supportive vulvar care concepts apply in all situations and details are found in the patient handouts “General Vulvar Care” and “Guidelines for sex when you are having discomfort or pain” under Education of the Patient.

Overviews: General and specific approaches to treatment are also addressed in Overview of Treatment of Vulvar Skin Disorders and Pruritus and in Overview of Treatment of Vulvovaginal Pain.

Treatment Plan Tables: Detailed treatment plans accompany the texts that describe each disorder, both in the Annotations and in the Atlas. Only the most common disorders are found here and the treatment plans are in abbreviated format for quick reference. If the disease you wish to treat is not listed to the left, look it up through the search function.

Sexually transmitted disease treatments are best found on the CDC website: https://www.cdc.gov/std/treatment-guidelines/default.htm

Remember: mixed conditions are common and treat accordingly

Lubricants and moisturizers are not the answer most of the time, but information about them is included here for easy reference.

WATER BASED	OIL BASED	SILICONE BASED
Thickening agents in a water-soluble base differ by: consistency, feel, duration of action	Oil: mineral, olive, almond, coconut, other	Silicon Dimethicone
Dry quickly; reapplication necessary. Osmolality determines irritation	Slippery Messy/greasy	Slippery; “coating” effect
Compatible with latex condoms	Break condoms, diaphragms	Not compatible with silicone rubber sex toys
Sticky	Possible odor	Bad taste
May contain preservatives: parabens, propylene glycol or antiseptics: chlorhexidine-glycerin	Non-irritating	Non-irritating
Wash away easily	Water-resistant, difficult to wash off body; stain clothes or sheets.	Water-resistant, difficult to wash off body, clothes or sheets. Need soap for removal.
Astroglide Free, Slippery stuff, Just Like Me, KY Jelly, Pre-seed, Liquid Silk, Good Clean Love, YES personal lubricant	Elegance Women’s lubricants Mineral oil, olive oil, almond oil, coconut oil, corn or canola oil	Uberlube, Astroglide X, Pjur, Eros, Pink ID Millenium, Wet Platinum, KY Intrigue

OSMOLALITY	MUCOSAL INFLUENCE	PRODUCTS
Iso-osmotic 314 mOsm/kg	No irritation	Pre-seed
Hypo-osmotic 13-32 mOsm/kg	Negative mucus production	FemGlide, Slippery Stuff
Hyper-osmotic 1491-5848 mOsm/kg	Mild to severe irritation	Replens, KY jelly, Astroglide

PRODUCT	pH TOO LOW	PHYSIOLOGIC 7.2-8.5	pH TOO HIGH	OSMOLALITY TOO LOW	OSMOLALITY PHYSIOLOGIC	OSMOLALITY TOO HIGH
Pre-Seed		7.25			314
Replens	2.8					2610
FemGlide		7.22		162
KY Jelly	4.52					2052
KY Liquid	3.62					5492
Astroglide	3.45					5848
Moist Again	5.29			187
Saliva	7.08		151
Water		8.01		98
Mineral oil			10.5			1735
Baby oil	7.16				1565

PRODUCT	INGREDIENTS	USE	MEDICAL STUDY
Replens	Polycarbophil, glycerin, mineral oil	Every 3 days	Yes
Me again	Hyaluronic acid, propylene glycol, parabens	7 days>2/wk	Yes- hyaluronic acid
KY Liquibeads (ovules)	Dimethicone, gelatin, glycerin, dimethiconol	Varies	No
KY long-lasting	Polymers, glycerin mineral oil	Varies	No
Emerita personal moisturizer	Aloe vera gel, calendula, vitamin E, ginseng, chamomile, allantoin	As needed	No
Moist Again	Carbomer, aloe vera, glycerin, chlorhexidine	As needed	No
Hyalofemme	Hyaluronic acid	7 days > 2/wk	Yes- hyaluronic acid
Pre-seed	Hydroxyethylcellulose pluronic, arabinogalactan	As needed	Yes