Chronic vulvar irritation: could toilet paper be the culprit?

It is estimated that half of all women older than 24 years of age will experience at least 1 episode of vulvovaginitis discomfort; however, some say that this number is an underestimate.1-3 Although vulvar discomfort or pain encompasses a number of conditions, vulvovaginitis is perhaps the most common cause.4 Vulvovaginitis can result from bacterial, viral, or yeast infections,5-8 or from contact irritation or allergy.9 Douches, feminine hygiene sprays, cleansers, and medications used on the vulva and in the vagina can all cause contact vulvitis.9 Vulvovaginitis is characterized by vaginal discomfort and might present with abnormal vaginal discharge, pruritis, dyspareunia, or dysuria; the vulva is often swollen and erythematous.5,6,10-12 Vulvar skin is more readily irritated than skin elsewhere.13 Often, low-grade erythema of the vulva is not readily apparent because of the pigmentation of the skin of the vulva. Symptoms of vulvovaginitis, such as itching, burning, and stinging, can be debilitating. Physical activities such as running or cycling can be difficult. Women might avoid sexual intercourse because of dyspareunia and some might find it difficult to use tampons during their menstrual cycle. Almost half of vulvar problems in women presenting to family physicians have no clear cause.14,15 When accurately diagnosed, however, vulvovaginitis can be treated effectively with topical or oral azoles, antibiotics, and boric acid propolis.2,4,6,12 When women present to physicians, yeast vaginitis is often diagnosed solely based on self-diagnosis or the patient’s history—even though an accurate diagnosis requires clinical assessment, a positive fungal culture result, and a vaginal pH assessment.10,16 For many women, any vulvovaginitis-type symptoms have become synonymous with yeast infections. Readily available over-the-counter (OTC) antifungal medications help lead to this conclusion. Studies have shown that 50% of women who use OTC antifungal medications do not have yeast infections.17 Since the introduction of OTC antifungal medications in the early 1990s, their use has increased substantially.18 In the United States, it is estimated that women spend $250 million annually on OTC antifungal medications.19 As a result of self-diagnosis and self-treatment, the prevalence and incidence rates of vulvovaginitis might be grossly underestimated.10,20 Case description* A 51-year-old white female office worker complained of a 4-year history of vulvar “rawness,” itchiness, and mild dyspareunia. She did not have symptoms of unusual or malodorous vaginal discharge, and she did not experience any perianal symptoms. She was a nonsmoker with a history of hypertension, which was treated with ramipril and metoprolol. She had no drug allergies and no previous history of either atopic or contact dermatitis. Vulvovaginal symptoms initially occurred every 3 or 4 months. Given the easy accessibility of OTC antifungal medications, the patient self-treated with clotrimazole vaginal ovules and topical cream. She experienced relief of her symptoms for a few months after each treatment; however, her symptom-free intervals gradually shortened until her symptoms became difficult to control with OTC antifungal medications. She noted some symptom relief from a barrier cream. She did not use other OTC products. The effects of these symptoms on the patient’s life was substantial. Frequent purchases of OTC medication became costly. When her symptoms were at their worst, she experienced difficulty walking and became anxious about traveling anywhere outside her home town. Before a trip abroad, she sought medical opinion at a local walk-in clinic where she was given a prescription for oral fluconazole. The vaginal and cervical cultures taken at that time were negative. Two days after her visit to the walk-in clinic, the patient traveled to her home country in Europe; while there, she experienced complete relief of her symptoms, which she attributed to the fluconazole. Immediately upon her return to Canada her symptoms recurred. After 1 week, owing to illness of a family member, she returned to her home country. Again, in her home country the patient experienced complete remission of her symptoms. Upon return to Canada, her symptoms returned. This set of events led the patient to begin a search for an external irritant and to a discovery of the culprit: bleached toilet paper. Although unbleached toilet paper is commonly used in her home country, most of the toilet paper in Canada is bleached. Now the patient only uses cheap