TREATMENT FOR DESQUAMATIVE INFLAMMATORY VAGINITIS

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.