What is desquamative inflammatory vaginitis (DIV)?

DIV is a cause of abnormal vaginal discharge and vulvovaginal discomfort.  The cause is not known but might be an overactive local immune system response.  About half of people with DIV recall an event that triggered the problem.  Potential triggers include medications used on the vulvovaginal skin, new hormonal medication, vulvovaginal infection, gastroenteritis, severe medical illness, prolonged antibiotics, surgery, childbirth, and travel to the bush or overseas.  Symptoms include yellow to green discharge with variable odour, and irritation where the discharge contacts the skin.  Sex is uncomfortable so people often avoid it.

How do you diagnose DIV?

Diagnosis usually requires a look inside the vagina with a speculum.  This shows increased discharge and inflamed vaginal skin.  There might be red-brown spots on the vagina and cervix.  If vinegar solution is applied, there might be a ‘leopard skin’ appearance.  Red spots sometimes occur at the vestibule (see Vulval anatomy) – this may be an overlap with plasma cell vulvitis (see below).

Some doctors or nurses look at a smear of the discharge under a microscope.  This shows many white blood cells – these are the cells that fight infection and cause inflammation.  Also, vaginal skin cells are smaller and rounder than usual because they shed off too early.  If there is another reason seen for inflammation, like parasites or yeast, that should be treated instead.  Vaginal swab is usually normal, or just shows increased white blood cells.  Biopsy is not required to make a diagnosis but may be taken to check for other disorders (see Biopsy).  Under the microscope there are white blood cells sitting under the skin, swollen tiny blood vessels, and sometimes red blood cells that have leaked into the tissues.  The overlying skin reacts to the inflammation but is not directly attacked by the white blood cells.

What is plasma cell vulvitis (PCV)?

PCV, also called Zoon’s vulvitis, is an uncommon skin disorder affecting the inner labia minora and vestibule.  The cause is unknown but may involve an overactive local immune response.  The main symptom is pain or burning.  Some people have constant pain, others feel it during urination, wiping, and touch.  There may be increased red-tinged discharge.  Most people cannot have sex due to pain.

How do you diagnose PCV?

On the vulva, there are flat red-orange speckles or spots.  These are tender to touch.  The skin can look shiny and sometimes the top layer of the skin is missing – this is called an erosion.  A biopsy of these ‘rust’ or ‘brick’-coloured areas is often needed to tell PCV apart from other conditions like erosive lichen planus (see Lichen planus).  Under the microscope, PCV shows many white blood cells, especially the ‘plasma cells’ that are seen in chronic infections or inflammatory conditions.  Inflammation of tiny blood vessels allows red blood cells to leak into the tissues.  The end product of red blood cell breakdown (haemosiderin) remains in the tissue and makes the skin look orange-red.  The overlying skin reacts to the inflammation but is not directly attacked by the white blood cells.

How do you treat PCV and DIV?

There are few studies about treatment of DIV and PCV.  The main options are topical steroid ointments and a topical antibiotic cream called clindamycin.  Clindamycin works especially well for DIV.  Dosing varies from one quarter of an applicator nightly for a month, to 1 applicator vaginally nightly for 2 weeks.  After stopping treatment, some people have return of symptoms straightaway.  They can then repeat the treatment regimen and go on a long-term schedule of twice a week clindamycin to prevent recurrence.

Steroid ointment must go where the problem is, so for DIV this includes vaginal application.  It is safe to place steroid ointment on a vaginal trainer / dilator or on an applicator (even if the package says ‘not for internal use’).  Your doctor may prescribe a cream to be mixed up at the chemist – this might contain steroids, antibiotics, and/or hormones.  The compounding chemist prepares it in a cream base suitable for use in a vaginal applicator.  Another option is a steroid product packaged for use in the bowel – these can also be safely used in the vagina to treat DIV.

Good vulval care helps with these conditions (see Vulval care advice).  People with abnormal discharge often hope that extra showers or baths will improve things.  Unfortunately, this does not work and dries out the skin.  Instead, use a soothing barrier ointment or oil to wash and to apply it throughout the day.  Liners and pads can make skin irritation worse, so it is best to avoid them or use hypoallergenic products.  Another alternative is ‘period’ underwear that is washed in ‘sensitive skin’ laundry products.  Loose breathable clothing is important for people with PCV.

Can I expect these disorders to go away after treatment?

Some people just have DIV once and it never returns.  Others have recurrent episodes and need long-term medications to avoid flare-ups.  PCV tends to last longer and be more difficult to treat.  However, with regular use of treatments, most people have a major improvement in their quality of life.  Some people find PCV eventually goes away and does not require ongoing treatment.

It is common to develop nerve and muscle pain after experiencing a painful disorder like PCV (see Vulvodynia).  In this situation, the pain continues even after the original problem has been successfully treated.  Nerve and muscle pain requires other treatment strategies, but eventually most people recover and get back to normal activities.