Vaginal itching: what calms it and what makes it worse

Itching down there is most often caused by what has been applied to treat it. The first forty-eight hours, the four causes that actually account for almost all of it, and the patches that need a biopsy rather than another wash.

Which part is itching, because it changes the answer

The vulva is the outer skin: the labia, the opening, the perineum. The vagina is the canal inside, and it has almost no itch receptors. Genuine internal itching with a discharge is usually coming from the vagina. Itching of the outer skin, worse with urine, with a wash, or at night, is a skin problem of the vulva, and putting an antifungal pessary into the canal will not help it. Most women describe both, and most treatment failures come from treating the wrong one.

The four causes that account for nearly all of it

• Thrush. Intense itch, soreness, swelling of the labia, white curdy discharge with no strong smell, and often a burning sting when urine touches the skin. Common after antibiotics, in pregnancy, and with poorly controlled sugar. The vulval skin looks raw rather than patched.
• Bacterial vaginosis. Thin grey or milky discharge, a fishy smell that is strongest after intercourse or a period, and more irritation than true itch. It is an imbalance of the flora, not an infection caught from anyone, and it needs a different medicine from thrush.
• Contact and irritant dermatitis. This is the one we see most often in Delhi, and it is caused by the washing. Antiseptic liquid diluted and used as a daily wash, deodorant sprays, scented sanitary pads and liners worn every day, a strongly alkaline soap, hot water, a rough towel, tight synthetic underwear worn through a sweaty day, and douching of any kind. The vulva becomes dry, red, fissured at the back and itches exactly because the protective layer has been stripped away.
• A skin condition rather than an infection. Lichen sclerosus causes white, thin, crinkled patches spreading in a figure-of-eight around the vulva and anus, with night itching and splits; it needs prescription treatment and long-term follow-up, not a pessary. Eczema and psoriasis affect the vulva like anywhere else. Lichen planus, herpes, pubic lice, scabies and threadworms each have their own pattern, and threadworms are worth remembering in any child with night itching and nothing else.

The first forty-eight hours

Whatever the cause, this calms the skin, and it is the part most people skip while trying a fifth product.

• Stop every wash, spray, oil, paste and rinse on the vulva. Clean with lukewarm water only, or an emollient substitute instead of soap, and pat dry with a soft cotton cloth.
• Apply a thin layer of plain petroleum jelly or a simple zinc barrier afterwards. It protects split skin from urine, which is where the stinging comes from.
• A cool compress, or a clean cloth soaked in cool water, for ten minutes, two or three times a day, settles the itch better than any cream in the first hours.
• Cotton underwear, loose trousers or a nightgown without underwear at home, and no panty liner unless there is bleeding. Change out of sweaty gym or travel clothes as soon as you can.
• A non-drowsy antihistamine in the day and a sedating one at night, both available over the counter, so the sleep is not destroyed by scratching. Cut the nails short; scratching is what turns a two-day irritation into a two-week one.
• Avoid intercourse until it has settled. Friction on inflamed skin prolongs it, and semen changes the vaginal pH.

When an over-the-counter antifungal is reasonable

If you have had confirmed thrush before, are not pregnant, have the classic symptoms with no smell and no ulcers, and this is not your fourth episode this year, a clotrimazole pessary with the matching cream, or a single oral fluconazole capsule where it is sold, is reasonable and usually works within three days. Insert the pessary at night, lying down, and expect it to leak. If there is no clear improvement by the third day, stop and be examined, because the diagnosis was probably wrong. Recurrent thrush, four or more episodes a year, is a different problem needing induction and maintenance treatment and a sugar test, not a monthly capsule bought as required.

What to stop doing

Douching, in any form, including the classical preparations. It removes the lactobacilli that keep the vagina acidic and is associated with bacterial vaginosis, not with its prevention. Garlic, curd, honey, turmeric paste, neem washes and tea tree oil placed on or in the vagina: tea tree and neem are well-documented contact irritants and the others are unproven. A topical steroid meant for hands or feet, used for weeks on vulval skin, thins it and causes stretch marks. Wet wipes and pH-balanced intimate washes, which are marketing rather than medicine. And hot water, which feels like relief for about two minutes and then itches harder.

The internal causes that keep it coming back

Diabetes and prediabetes, where recurrent thrush is often the first visible sign and the sugar test is the whole answer. Low oestrogen after menopause, or while on certain contraceptives, which thins the vulval and vaginal skin and produces dryness, stinging, itching and post-urinary burning; the treatment is local oestrogen, and it works well. Anaemia and iron deficiency. Recent antibiotics. Pregnancy, where thrush is common and needs treatment. Stress and sleep deprivation do not cause itching directly but do worsen the itch-scratch cycle of any underlying dermatitis.

When to be seen rather than self-treated

Any ulcer, blister, wart, or a patch that is white, thickened, shiny or numb. Bleeding from the vulva that is not menstrual, or a lump. Severe pain, fever, lower abdominal pain or a foul discharge, which can mean a pelvic infection and needs assessment the same day. Itching in a child. Symptoms in pregnancy. No improvement after a week of the routine above, or a relapse as soon as it stops. Painful intercourse. New sexual partner or any possibility of a sexually transmitted infection, where both partners need discussing. And weight loss, thirst or passing lots of urine alongside recurrent infection.

How we look at it at Aksa

Inspection of the skin in good light, which is where most of the diagnosis lives, plus a swab for the discharge rather than empirical treatment, microscopy for yeast and clue cells, a vaginal pH, urine, and a blood sugar or HbA1c in anyone with recurrent episodes. STI testing when the history asks for it. A persistent white patch, a lesion that will not heal, or itching that has run for years without an explanation needs a vulval specialist and often a small biopsy, and that is not an alarm, it is how lichen sclerosus and vulval intraepithelial neoplasia get caught. From the Ayurvedic side we work on the skin barrier, the recurrent-infection tendency and the sleep, and on the metabolic picture that keeps bringing it back. We will also tell you plainly, in the first sitting, that the wash is the problem.