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Desquamative inflammatory vaginitis | Aerobic | Idiopathic


Desquamative inflammatory vaginitis is a newly recognized clinical syndrome characterized by persistent purulent vaginal discharge and vaginal erythema, often with submucosal cervicovaginal petechiae. Inflammation is the cardinal feature of this disorder, which has also been called idiopathic inflammatory vaginitis.
Vaginitis is common among women of reproductive age


Donders and colleagues have recently reviewed the literature on this inflammatory vaginitis, which they call “aerobic vaginitis.” However, the term “desquamative inflammatory vaginitis” holds priority and was first introduced in 1965 by Gray and Barnes. The term “aerobic vaginitis” was introduced in 2002 in reference to a disease entity caused by an abnormal vaginal microbiome genomically defined as CST IV.



Vaginal Environment

The vagina is a dynamic ecosystem that normally contains approximately 109 bacterial colony-forming units per gram of vaginal fluid. The normal vaginal discharge is clear to white, odorless, and of high viscosity. The normal bacterial flora is dominated by lactobacilli, but a variety of other bacteria are also present at lower levels. Lactobacilli convert glycogen to lactic acid, which helps to maintain a normal acidic vaginal pH of 3.8 to 4.5. Some lactobacilli produce H2O2 (hydrogen peroxide), which serves as a host defense mechanism and kills bacteria and viruses.

Vaginitis

Vaginitis is common among women of reproductive age and is usually characterized by a vaginal discharge, vulvar itching and irritation, and a vaginal odor. In a retrospective review of studies published between 1966 and 2003, the three most common conditions diagnosed among women with vaginal symptoms presenting in the primary care setting were bacterial vaginosis (22% to 50%), vulvovaginal candidiasis (17 to 39%), and trichomoniasis (4% to 35%). In some cases, the etiology may be mixed, and there may be more than one disease present; in approximately 30% of symptomatic women, no etiologic agent is identified.

Other causes of vaginal discharge or irritation include the following:
Normal physiologic variation, Allergic reactions (e.g., spermicides, deodorants), Genital herpes, Mucopurulent cervicitis, Atrophic vaginitis, Vulvar vestibulitis, Lichen simplex chronicus, Lichen sclerosis, Foreign bodies (e.g., retained tampons), Desquamative inflammatory vaginitis.

Desqamative Inflammatory Vaginitis (DIV) is an inflammatory skin condition of the vagina. It is called a vaginitis because of the strong inflammatory reaction of the vaginal skin but it is not a true infection caused by a specific organism like yeast. This reaction often leads to symptoms of pain, discharge, irritation and itching. Intercourse can become quite uncomfortable and some women report a scratchy, raw sensation. It is unclear what causes DIV but it is not contagious or hereditary. The inflammation can lead to a disruption of the bacterial ecosystem which also likely contributes to the symptoms.

Causes
The exact cause of desquamative inflammatory vaginitis is unknown but appears to be a dysbiosis of the normal vaginal microbiome associated with inflammation. In desquamative inflammatory vaginitis, the vagina is colonized with facultative bacteria, not the obligate anaerobic bacteria that colonize the vagina in bacterial vaginosis.

The microflora in desquamative inflammatory vaginitis typically consist of Escherichia coli, Staphylococcus aureus, group B streptococcus, or Enterococcus faecalis. The microbiome associated with desquamative inflammatory vaginitis is less well understood than the bacterial vaginosis microbiome.

Desquamative inflammatory vaginitis may also represent a systemic inflammatory syndrome that produces vaginal inflammation, resulting in abnormal vaginal flora. As with bacterial vaginosis, understanding the mechanism underlying the loss of vaginal lactobacilli should shed light on the pathogenesis of desquamative inflammatory vaginitis.

Signs and symptoms

Clinical manifestations of desquamative inflammatory vaginitis include purulent vaginal discharge and a strong inflammatory reaction. The vaginal discharge is homogeneous and yellowish, with no fishy smell. Vulvar irritation and vaginal mucosal erythema with ecchymotic lesions or erosions are present in severe cases. Symptoms may last for a long time and fluctuate, suggesting a chronic or recurrent natural history.

Treatment
2% clindamycin cream (i applicator) per vagina six hourly x 14 (could use suppositories) versus
25 mg hydrocortisone suppository per vagina six hourly x 14 (could use foam)
• Repeat successful regimen after verifying diagnosis
• May require long term hydrocortisone suppository (25 mg) twice weekly or greater
• May need to add estrogen and/or clindamycin, or alternate treatments



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