A 3-year-old girl is brought to the office by her mother for evaluation of vulvar pruritus. For the past month, the girl has been scratching her vulvar region through her clothes day and night. There have been no changes in soap or laundry detergent, and the patient does not have pruritus over any other areas. She has been toilet-trained for the past year and has had no accidents, hematuria, or abnormal vaginal discharge. The patient has no chronic medical conditions and has met all developmental milestones. Vital signs are normal. Height and weight are at the 40th percentile for age. On pelvic examination, the vulva is excoriated and there is an adhesive ridge fusing the posterior labia minora in the midline. There is no labial or vulvar atrophy and no plaque formation. The vagina appears pale, and a speculum examination is deferred. Urinalysis is normal. Which of the following is the best next step in management of this patient?
Show Explanatory Sources
This girl has vulvar pruritus and fusing of the posterior labia minora consistent with labial adhesion. Labial adhesions, or fused labia minora, typically affect prepubertal girls (with a peak incidence at age 2-3) due to low estrogen production. Other contributing factors may include chronic inflammation due to poor hygiene, skin irritation (eg, diaper dermatitis), and trauma (eg, straddle injury, sexual abuse).
Labial adhesions can be partial (involving only a small portion of the labia) or complete (with a small orifice for urine to come out). Partial adhesions, as seen in this patient, are often asymptomatic; however, some children develop pain or pruritus, which can lead to secondary excoriations and exacerbate adhesion development. Adhesions covering the urethral meatus can also cause an abnormal urinary stream and an increased risk for recurrent urinary tract infections.
Mild, asymptomatic labial adhesions require no treatment because up to 80% of labial adhesions resolve spontaneously. However, in patients with complete adhesions or symptomatic partial adhesions (such as this patient), first-line therapy is with topical estrogen cream.
(Choice A) Antifungal cream is used to treat Candida dermatitis, a common cause of vulvar pruritus in children; however, patients typically have beefy red plaques with satellite lesions.
(Choice C) Gonorrhea and chlamydia testing is indicated in girls with abnormal (eg, purulent, bloody) vaginal discharge and/or signs of genital trauma (eg, edema, lacerations), which are not seen in this patient.
(Choice D) Karyotype testing is used in the evaluation of ambiguous genitalia in newborns, such as clitoromegaly or palpable gonads in the labioscrotal folds. This patient's onset of vulvar pruritus and posterior labia fusion at age 3 is more consistent with labial adhesions.
(Choice E) Trichloroacetic acid is commonly used to treat condyloma acuminata (ie, genital warts), which are typically raised, soft, and have a cauliflower-like appearance.
(Choice F) Vulvar biopsy may be indicated for lichen sclerosus, which can present with vulvar pruritus in prepubertal girls or postmenopausal women. However, in contrast to this patient, those with lichen sclerosus typically have labial or vulvar atrophy and/or vulvar plaques. In addition, biopsy is typically reserved for adults due to an association with vulvar cancer.
Educational objective:
Labial adhesions, or fused labia minora, typically affect prepubertal girls due to low estrogen production. Topical estrogen cream is first-line therapy for symptomatic lesions.