26420 Vulvar pain and pruritus secondary to dermatographism: An underrecognized etiology

Abstract

Vulvar manifestations of dermatographism, which include itching, swelling, burning, and irritation, are not well-documented. Dermatographism is entirely excluded from current vulvar disease guidelines. We present a 23-patient series identified via retrospective chart review, alongside an illustrative case. From 2008-2020, 23 women presenting to a single provider for vulvovaginal complaints were dermatographic on physical examination. Presenting age averaged 42.76 years (range 17-75), with symptom duration of 32.53 months (range 10-72). Among eleven returning patients (M = 11.85 months follow-up; range 0.5-38), 91% (n = 10) reported symptomatic improvement with hydroxyzine treatment. A 35-year-old female presented with 10-month history of severe vulvar pruritus unresponsive to repeated antibiotic and topical steroid therapy. Symptoms impaired her concentration, daily activities, and sleep. Prior biopsies demonstrated mild dermal telangiectasias and attenuation of collagen possibly representing steroid atrophy but no evidence of active inflammatory process or atypia; periodic acid–Schiff stain was negative. Physical examination revealed no vulvar atrophy, erythema, or other dermatologic changes. Notably, the patient demonstrated marked dermatographism with wheal and flare response on her back. She reported improvement of vulvar symptoms within 1 week of initiating hydroxyzine treatment. Three years later, the patient maintains excellent control with hydroxyzine 10 mg nightly. Dermatologists and gynecologists alike should include dermatographism in the differential for vulvar complaints. The simple screening test (tic-tac-toe board drawn on the back) and high responsiveness to antihistamine treatment can prove gratifying to both patients and clinicians. Given the complexity of vulvar pain and itch, an etiology so easily screened and treated warrants consideration.