Desquamative inflammatory vaginitis is a rare inflammatory condition of the vagina without evidence of an infectious etiology. It is occurs most commonly in perimenopausal and postmenopausal women or in other hypoestrogenic states. Symptoms include a purulent vaginal discharge, vaginal irritation, dyspareunia, and dysuria. Diagnosis is with pelvic examination, vaginal pH, and microscopy. Treatment is with vaginal clindamycin or hydrocortisone.
Desquamative inflammatory vaginitis (DIV) occurs and recurs most commonly in patients who become hypoestrogenic due to menopause or primary ovarian insufficiency. The etiology may be autoimmune.
Symptoms and Signs of Inflammatory Vaginitis
Purulent vaginal discharge, dyspareunia, dysuria, and vaginal irritation are common. Vaginal pruritus and erythema may occur. Burning, pain, or mild bleeding occurs less frequently. Vaginal tissue may appear thin and dry. Vaginitis may be chronic or recurrent.
Patients who are postmenopausal or those with premature ovarian insufficiency may also have signs and symptoms of genitourinary syndrome of menopause (eg, vulvovaginal atrophy, urinary urgency, dysuria).
Diagnosis of Inflammatory Vaginitis
Vaginal pH and microscopy
Symptoms of DIV overlap with other forms of vaginitis, and a general evaluation for vaginitis (eg, vaginal fluid pH measurement, microscopy, whiff test) should be performed.
DIV is diagnosed if:
Vaginal fluid pH is > 6.
Whiff test is negative.
Microscopic evaluation of a saline wet mount shows predominantly sheets of white blood cells and parabasal cells.
The pelvic examination should include evaluation for characteristic findings of vulvovaginal atrophy (eg, labia minora resorption or fusion, tissue fragility, pallor, loss of vaginal rugae).
Treatment of Inflammatory Vaginitis
Vaginal clindamycin
Vaginal hydrocortisone
Mild DIV can be treated with 0.5% hydrocortisone cream or hydrocortisone 5 mg suppository (suppositories for rectal use are available and can be used intravaginally) intravaginally once a day for 2 to 4 weeks. For severe or persistent disease, treatment options include 2% clindamycin cream (5 g daily) or 10% hydrocortisone cream (3 to 5 g daily) intravaginally at bedtime for 4 to 6 weeks (1, 2, 3).
Vulvovaginal atrophy, if present, can be treated with vaginal hormone therapy.
Treatment references
1. Reichman O, Sobel J. Desquamative inflammatory vaginitis. Best Pract Res Clin Obstet Gynaecol. 2014;28(7):1042-1050. doi:10.1016/j.bpobgyn.2014.07.003
2. Paavonen J, Brunham RC. Bacterial Vaginosis and Desquamative Inflammatory Vaginitis. N Engl J Med. 2018;379(23):2246-2254. doi:10.1056/NEJMra1808418
3. Sobel JD, Reichman O, Misra D, et al. Prognosis and treatment of desquamative inflammatory vaginitis. Obstet Gynecol. 2011;117(4):850-855. doi:10.1097/AOG.0b013e3182117c9e
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