Desquamative inflammatory vaginitis: differential diagnosis and alternate diagnostic criteria

To describe alternate diagnostic protocols and describe the differential diagnosis for desquamative inflammatory vaginitis (DIV).

One hundred one cases of DIV were audited retrospectively. All patients were seen exclusively by the authors in their private practices using diagnostic criteria applicable to local practice limitations. Other potential etiologies (infection, contact irritant vaginitis, fixed drug eruptions, immunobullous diseases, estrogen hypersensitivity vulvovaginitis, and graft-vs-host disease) were excluded by history, examination, and focused trials of treatment. Historical triggers in the study cohort and a control group of 75 women with lichen planus also drawn from the authors' private practice were compared. Patients were treated with 4 to 6 weeks of topical vaginal antibiotics, 94% with clindamycin, and response to treatment was recorded at subsequent follow-up.

All patients were white. Of 101 patients, 57 (56%) had historical triggers, most frequently diarrhea or antibiotic treatment. Of the 75 women in the control group with vaginal lichen planus, 11 had historical triggers (15%, p <.0001). Of 101 patients, examination revealed classic ecchymotic findings in 55 (54%), confluent erythema in 36 (36%), involvement of the upper vagina in 8 (8%), and heavy discharge in only 2 (2%). Of 101 patients, 54 (54%) had no significant abnormality on laboratory microbiological testing. Moreover, 20 (20%) had a pure growth of a commensal organism on culture, of which 13 were group B streptococci. Of 101 patients, 96 (95%) were symptomatically and objectively improved at initial review. On the other hand, 45 (45%) required maintenance treatment. Of this group, 10 patients who had triggers for their vaginitis, which were ongoing, were cured when their triggers were finally controlled or cured, leaving 35 patients who required long-term maintenance therapy.

Desquamative inflammatory vaginitis seems to be a distinct entity of vaginitis that, in an office setting, can be distinguished from other diagnostic possibilities by careful clinical evaluation and focused trials of treatment. The majority of women responded promptly to intravaginal antibiotics, with approximately 35% of cases requiring maintenance therapy. More than half the cases have an historical trigger. We postulate that DIV occurs when a trigger causes shifts in vaginal homeostasis, resulting in an inflammatory response associated with increased epithelial cell turnover.