In many cases, the PV is a symptom of banal, but in others it is related to preneoplastic or tumor pathology, and in many cases the only warning sign that requires making a careful physical examination and possible interventions for primary and secondary prevention.
The PV can intervene in the epidemiological chain of sexually transmitted diseases (STDs) that sometimes produce no other symptoms. With the treatment of STDs in women than consultation and contacts, we will reduce the frequency of disease in the population context 4. When making a proper diagnosis and treatment in women are prevented fertility problems (tubal obstruction by pelvic inflammatory disease) and transmission to the fetus.
see that it is a prevalent symptom 5 and generates demand for AP. Proper management of this symptom is going to be able to respond to a complaint, which may be the initial manifestation of a serious or process, even of a minor process, if not resolved can make a woman go repeatedly to our clinic
Concept
Pruritus 6 defined as "a particular feeling that moves to scratch", referring to vulvar itching, the sensation is localized in female external genitalia. This is not a syndrome or a disease but a symptom that accompanies many diseases, whether local or systemic.
A brief summary of the anatomy, histology and pathophysiology of the vulva will allow us to understand some of the features that make this symptom
Embryonic development of the vulva is undifferentiated until the third month of pregnancy. The differentiation of the urogenital sinus and external genitalia is of hormonal origin, resulting in the feminization of gradual and spontaneous, in the absence of testicular testosterone secretion that occurs in male fetuses.
The vulva is an anatomical structure with a medial depression, the lobby, which is limited at the top of the Mount of Venus; laterally by two folds skin, labia minora and labia inside out, and in essence are vaginal introitus, urethral meatus and clitoris.
The labia majora have hair on its outer side, formed by the epidermis and dermis rich in sweat and sebaceous glands. The labia minora are folds skin, mucous looking to have the very thinned keratinized outer layer rich in blood vessels, nerves and tactile corpuscles give erectile properties, contains no follicles but many sebaceous glands, its free margin is pigmented .
The lobby is also lined with a multilayered squamous epithelium and lubricated by secretions buccal mucous glands: major, minor and paraurethral. Greater vestibular glands or Bartholin are located deep in the back of the labia, opening a small hole in the third after both sides introitus. Vestibular glands 7 minors are present in 50% of women and are scattered throughout the lobby.
paraurethral glands or Skene open in the back of the urethral meatus.
The vulva is provided with hormone receptors that react to stimuli steroids (androgens, progestogens and estrogen), so that changes in hormone levels have important macro and microscopically. This meant in newborns, the placental estrogen impregnation take a look flushed and lips swollen to major, minor and lobby. The vulva in childhood grows in line with the rest of the body, and upon reaching puberty changes occur that express secondary sexual characteristics: the appearance of pubic hair, the enlargement of labia, because of the activity glandular secretory vulva becomes wet. These characteristics are maintained during the fertile age of women becoming a defense mechanism. At menopause and cessation of hormonal influence, it thins the epidermis, glandular secretion decreases and pilosebaceous follicles disappear.
Pathophysiology of vulvar itching
In the DEJ are polymodal nerve receptors that convey unpleasant feelings through unmyelinated fibers. These fibers run through the spinal cord in the contralateral spinothalamic up to a hub in the thalamus (central pruritus) and from there to the frontal cortex.
The sensations of itching, burning and pain represent a continuum, so that in many cases will be difficult to differentiate itching and vulvodynia. The itching becomes burning pain and then with increasing stimulus intensity. Unmyelinated fibers exhibit the phenomenon of sensitization 8, resulting in the persistence of pruritus giving long after the precipitating cause (eg., Inflammation)
Physiopathologically distinguish two main groups: pruritus of central origin, by action on the cerebral cortex or thalamic center of pruritus, and peripheral origin.
Itching central source
Raised after intracisternal injection in laboratory animals of various substances such as morphine, pilocarpine, etc.. In human practice, it has been observed the relationship of pruritus with various diseases, such as general paresis and epilepsy, and in the course of serious blood disorders and lymphoma (Hodgkin).
On the other hand, continuity of transmitting the itch fibers in the frontal cortex could explain the great importance of psychological factors in the onset and / or exacerbation of pruritus (individuals who when they see or think of parasites notice itching).
There are substances that act on the central nervous system (CNS) or enhancing (drugs caffeine and Benzedrine Group) or decreasing the central perception of pruritus (CNS depressant drugs except morphine, opiates and barbiturates .)
Itching of peripheral origin
Any stimulus, however slight, can be triggered. On the one hand, there is a physiological itching produced by light rubbing and small changes in pressure and temperature, but when its low-intensity stimuli are imperceptible, except in situations where our attention is more concentrated (forced immobilization, fatigue, worry, etc.).
On the other hand, endopeptidases, histamine and prostaglandins, substances released by a wide range of insults, selectively stimulate itching, pain receptors, causing itching sensation and, at high concentration, burning pain.
physiology is closely related vulvar vaginal changes the anatomical proximity. Normally, the balance of the vaginal ecosystem is a protection for the genital region and on the Conversely, changes in the ecosystem impact negatively on vulval symptoms. In the vagina of women of childbearing age are usually a mixed bacterial flora and lactobacilli (Doderlein) responsible for splitting the glycogen vaginal epithelial cells in lactic acid, determining an acidic vaginal pH (3.5 to 4.5). The normal vaginal discharge is colorless and odorless and the amount varies with the menstrual cycle phase.
Etiological Classification
Pruritus is the most common dermatological symptoms. It can be a symptom of skin disease 9.10 located, but may also occur in the vulvar area accompanying a systemic disease 11.12. This paper will address the PV of local origin without entering the systemic causes. Table 1 shows the various causes of pruritus in response to systemic or only vulvar location.
Conditions limited to the vulva
response with increased incidence should be considered infectious etiology: fungi (candidiasis, Tinea cruris , pityriasis versicolor), viruses (herpes simplex 2 , papilloma virus, poxvirus ), Bacteria (Gardnerella , Corynebacterium minutissimun ), protozoa (Trichomonas) and parasites (pinworms, Sarcoptes scabiei).
continue, in order of frequency, dermatological processes: contact dermatitis, lichen sclerosus, squamous cell hyperplasia, psoriasis inverted plasma cell vulvitis.
Among neoplastic lesions present with localized pruritus of vulva squamous intraepithelial neoplasia (VIN I, II and III) and non-squamous intraepithelial neoplasia (Paget's disease, pigmented lesions).
should consider other situations that may lead to PV: excess or lack of hygiene, insect bites, psychogenic pruritus, irritation by continuity (cystitis, diarrhea), idiopathic pruritus, etc.
systemic pruritus
The systemic skin diseases with vulvar affectation is one of the most frequent causes of PV: psoriasis, lichen planus, atopic dermatitis, seborrheic dermatitis, urticaria, angioedema.
Other causes of PV can be very different situations such as pregnancy, endocrine-metabolic diseases (hyper or hypothyroidism, hyperparathyroidism, renal failure, hyperuricemia, diabetes) and cholestasis, central nervous system diseases like multiple sclerosis, epilepsy, cortical lesions, hematologic malignancies (lymphoma and myeloproliferative disorders) and genital carcinoma are also causes of PV.
Anamnesis
Following are the main variables to keep in mind when taking the history:
Temporal relationship vulvar pruritus
A recent itching can indicate an infection, the most common in women of childbearing age is candidiasis (20-30%). Contact dermatitis 13 also associated with acute presentations.
will value the circadian rhythm: Is it more intense or wakes you up at night? If so, can indicate a possible oxiurasis in the case of girls, a scabies or candidiasis in a woman or a lichen sclerosus in a woman.
intermittent developments associated with the second phase of the cycle again makes us think Candida which thrives best in an acidic pH, or intermittent presentation always confined to the same location, and followed by burning, involving the presence of a recurrent herpes.
A chronic PV forced to think of a dystrophic process, such as lichen sclerosus or a neoplastic process.
Location 
When the itching is only located in the vulva may indicate dystrophic cases, the infections tend to spread to adjacent areas such as vagina and anal region.
If you are located in the area of \u200b\u200bpubic hair lice oriented towards pubis.
If the itching is systemic, the range of possibilities is much wider, ranging from skin diseases to endocrine-metabolic diseases and myeloproliferative processes (Table 1).
Age
The woman's age may also focus on the etiology. In prepubertal girls the main reasons are the oxiurasis pruritus and contact dermatitis, in women of childbearing age are infectious causes, and in older women is due to degenerative benign and malignant. Vulvar atrophy presenting some women after menopause, with thinning and dryness of the skin may cause itching.
coital activity
vulva in a pruritic lesion of unknown etiology, we always appreciate the presence of symptoms in the couple.
women in sexual relationships will not have to rule out STDs, as though their relationship is stable and monogamous now, does not exclude other contacts in the two previous sexual partners.
The current vulvovaginal candidiasis is not considered an STD 14 , And also in women who have had sex, and although one of the most common mechanisms of transmission is sexual transmission, is not unique.
We assess whether increases itching after intercourse, which is likely to occur in the vaginosis.
Contraception
Some women with latex allergy can present severe itching after use of the diaphragm or the male condom (for that reason, also made of polyurethane condom as both females). The use of oral contraceptives (AHO) produce changes in vaginal pH may facilitate the development of candidiasis and lead to itching.
care habits
A poor hygiene, either by default or by excess, can lead to PV. On many occasions maneuvers cleaning after defecation can approach germs vulva and anal area remains, which give rise to irritation and PV. The use of hygiene products "intimate" may be irritating to present pH extremes and be another reason for PV. Underwear bit too tight and breathable PV also cause some women. The use of safe-slip or pads treated with cosmetic products to avoid the smell can sensitize the skin and cause contact dermatitis. We will also investigate the recent use of soaps and antiseptic solutions as a cause of contact dermatitis.
Background pathological
immunosuppressive diseases or treatments can facilitate colonization by opportunistic pathogens. In the case of diabetes mellitus is more common Candida infection , a situation that is also having received treatment with broad spectrum antibiotics.
Accompanying symptoms
If in addition to PV refers women voiding symptoms and / or dyspareunia, these symptoms are attributable to Trichomonas Candida and herpes simplex.
In women with leucorrhoea we investigate the characteristics. In a first diagnostic is found that Candida produces little white clumpy flow, infection with Gardnerella -anaerobic (vaginosis) secretion is also accompanied by abundant white-gray fluid with a characteristic odor of "fish", which increases after intercourse, and trichomonas flow is abundant and green-yellow.
Exploration
Physical
The examination should be performed systematically starting with the inspection of the skin of the vulva and the groin. We need a suitable source of light that allows us to evaluate pubic hair and the labia majora to rule pediculosis pubis; continue to display in the lobby, stopping at the inside of the labia and to assess the interlabial fold skin lesions and their characteristics, and then explore the introitus, to investigate the presence of vaginal discharge 15.
We must not forget to make a general inspection to rule out a systemic dermatosis.
palpation of skin lesions will allow us to assess their consistency, depth and texture. It should palpation of the vestibular glands and the inguinal region for the detection of lymphadenopathy.
then will place the speculum to visualize the walls and the vaginal fornix and ectocervix looking to assess the skin lesions and abnormal discharge. 
Investigations
Material Required. For proper management of PV in AP box does not require a sophisticated technology. We have first an optical microscope accessible to most health centers, a good light source to facilitate the inspection and a gynecological examination table, but failing that we can use a normal examination table. The rest is expendable material (Fig. 1) common to other activities:
single-use gloves.
specula.
Portas-cover.
saline.
potassium hydroxide (KOH) to 10%.
swabs and wooden tongue depressors.
cytology fixative (hair spray can be used).
colorimetric strips pH.
Transport microbiology.
methylene blue dye.
acetic acid 1% solution.
vaginal pH measurement with colorimetric strip
strip is inserted into the vagina away from the ectocervix and cervical fluid that has an alkaline pH can alter the measurement. In the normal vagina is to find an acidic pH between 3 and 4.5. Variations in pH can guide us on the etiology of vulvovaginal pruritus: in the case of candidiasis <> find an acid pH 5, in the case of vaginosis (Gardnerella) the pH is always higher than 4.5 (Table 2). 
Valuation of fresh vaginal
is a simple test. We just need to have an optical microscope, two slides, two covers, a swab, KOH solution at 10% and 16 saline. In one of the slides, a drop of KOH, is taken with swabs of vaginal discharge and it is diluted in the holder, before placing the cover should smell, since infection with Gardnerella will detect the characteristic odor of "fish" which is considered a positive amine test (the smell is produced after the reaction between KOH and amines present in the vaginal discharge produced vaginosis), and then put the cover and you're the ready for the test preparation in the microscope. KOH and breaks the cell walls will allow us to observe the hyphae and yeast in the case of candidiasis.
another slide in the place a drop of saline, warm if possible, so that in the case of trichomoniasis not inhibit the motility characteristic of these protozoa that move in the field with spiral movements. In adverse conditions but do not move we can see the vibrations of the membrane and flagella.
We will also detect the "hairy cells" or "clue cells" are cells covered with coccobacilli vaginal peeling attached to the membrane, the case of Gardnerella vaginosis by . The presence of clue cells, positive amine test, vaginal discharge gray abundant and pH> 4.5 AMSEL criteria are useful for the diagnosis of vaginosis.
We also assess menstrual cycle phase according to which predominate in epithelial cells of fresh air. Observe in the follicular phase mainly polygonal cells and the second phase will navicular or folded.
cervicovaginal cytology
The performance of cytology by making triple (vagina, ectocervix, endocervix) will allow us to detect sometimes typical cellular changes, such as papilloma virus (HPV), with this result we investigate the presence of subclinical in the vulva. Cytology also guides us in the case of vaginosis, candidiasis or other vaginal infection as possible causes of PV.
Test toluidine blue 17
This test, used for the biopsy to be performed in the specialized area in AP can be used in suspected skin lesions on the vulva, allowing plates narrow and excluding dysplastic areas of possible malignancy. The test consists of applying a solution of toluidine blue 1% on the vulvar surface for 3 min and washed the area with 1% acetic acid, the dye remains in those areas of the skin where abnormally nucleated cells are abundant in contrast to normal skin stratum corneum which lacks nuclei. A test is a positive indication for referral for biopsy.
acetic acid 18
acetic acid, 1-3% solution, applied to the vulva for 3 min reaction in skin areas with surface nuclear activity (parakeratosis) or more cell density, resulting in white patches or "aceto" that are associated with subclinical or clinical infection by papillomavirus. This simple technique allows us to select those women can be referred for a vulvoscopia. Although inflammatory conditions or infectious may give positive reactions, given the carcinogenic risk from human papillomavirus, should lead to complete its study in the vagina and cervix in all cases acetowhite epithelium and in the presence of STDs.
Differential Diagnosis
To facilitate the initial diagnosis and treatment of PV AP local source, once the history and examination, differential diagnosis (DD), according to color and type of cutaneous lesion (Table 2).
erythematous macules
accompanying erythema infectious processes. In most cases these are caused vaginal candidiasis or trichomoniasis as they usually give a pruritic rash across the vulva, the differential diagnosis between these two germs are carried out with the help of fresh vaginal pH measurement and valuation leukorrhea (Table 2). The realization of the fresco also allows us to DD with vaginosis, Gardnerella because although given little tissue reaction the presence of leukorrhea irritation with erythema and pruritus.
Erythrasma (red macules tinted brown, well defined) mainly affects the groin, although the man never affects the scrotum in women can lead to plaques on the vulva. Is produced by Corynebacterium minutissimun and little itchy. The DD would be established with Tinea cruris Strand marginalized or eczema, the table that is present difference Tinea lesions in concentric circles with a raised edge, more itching and skin scrapings do in the case of erythrasma not find hyphae .
When the rash is limited and women covered by its fixed location, we think of a recurrent herpes whose lesions begin with pruritus and erythema. Once the blisters appear, the diagnosis of genital herpes and is clear and also present the sting.
Erythema is also in atopic dermatitis and seborrheic dermatitis. Although it is rare that only lesions in the vulva, in these cases will help in diagnosing the presence of typical lesions elsewhere in the body and history of previous episodes. In contact dermatitis is common to find the erythema confined to the area of \u200b\u200bcontact with the trigger agent (underwear, towels) respecting surrounding areas.
The inverse psoriasis, erythema was mainly located in folds and has a pink tone, while the classical psoriasis occupies the hairy areas of pubis and labia majora, the coloration is more intense and is accompanied by desquamation.
In the first stage of HPV infection, the initial lesion may be erythema, acetic acid application is going to designate areas acetowhite. 
hypopigmented macules
Vitiligo, which is the hypopigmented lesion par excellence, not itching. Pityriasis versicolor can be started with itchy hypopigmented lesions, but rarely is only vulvar presentation.
In older women vulva skin loses thickness and becomes pale or white, but feel we found that retaining the flexibility, in contrast to lichen sclerosus and other hyperplastic lesions, which have texture rigid.
erythematous papules (Table 3)
find them, especially in inflammatory vestibulitis surrounding holes of the vestibular glands. The Fox-Fordyce disease exhibit it. The bumps are formed around the outlet duct of the sweat gland that is blocked by a plug of keratin.
Tinea cruris Strand marginalized or eczema usually presents no difficulty for diagnosis by the nature of their injuries, rounded, concentric, elevated halo and central clearing of the lesion, to perform skin scrapings and after adding KOH and detected optical microscope to observe the hyphae.
Molluscum occurs forming small pruritic papules with central dimpling.
Just keep in mind that start forms warts can present as small pruritic papules.
Lichenification, proliferation of keratinocytes, appears as a bright erythematous, well demarcated on a grid, is usually secondary to chronic scratching 19 that induce some skin diseases.
Once discarded benign processes referred to above, and with a single red papule that expands precise edges slowly peeling eccematiforme, symptoms may correspond with Paget's disease, as its derivation need for biopsy.
The presence of itchy red bumps, irregular surface with areas of dark pigmentation, will guide us towards a neoplastic process as carcinoma in situ. invasive squamous cell carcinoma is also characterized by ulcerated surface. Erythroplakia inflammatory or plasma cell vulvitis also attends as chronic erythematous papule with a tendency to erode, making it necessary to biopsy for squamous cell carcinoma of the DD
Hypopigmented papules
If a distribution plate with reticular hypopigmented or white spots may be due to lichen planus. It is not only common vulvar presentation, often associated with other locations in the buccal mucosa, lips and extremities, where it acquires a violet tint
white boards, shiny, itchy, dry surface, finely wrinkled and that try to pinch are rigid are pathognomonic of lichen sclerosus.
20 In 1976, the Committee on Terminology of the International Society for the Study of Vulvar Disease (ISSVD) proposed to delete the terms of leukoplakia, vulvitis leukoplakia, hyperplastic vulvitis, Leukokeratosis, kraurosis vulvar atrophic vulvitis, neurodermatitis, and adopt the term 21 dystrophy to designate a group of lesions that share a common characteristic, the white. This classification was revised again in 1986 by the ISSVD, establishing the following classification, which is used today:
hypoplastic dystrophy or lichen sclerosus 22. Formerly known kraurosis or vulvitis atrophic lesion, which is a hypopigmented plaque, itchy, leathery, atrophic orificial stenosis. Can occur at any age but is most common in postmenopausal women. DD with senile vulva what can be done by palpation, in the case of lichen sclerosus is impossible to pinch the skin, which is rigid, similar to the plaques of morphea, whereas in senile vulva skin remains flexible. In the same patient may match areas of lichen sclerosus or Duchenne dystrophy hypoplastic and hyperplastic. Should lead to complete histopathologic study.
hyperplastic dystrophy or 23 cell hyperplasia carcinoma. Formerly known leukoplakia leukoplakia or vulvitis. Pruritic plaque, dense and white, which occurs in women between 40 and 50 years of age. DD with carcinoma in situ is microscopic and is done when major cellular atypia identified as hyperplastic dystrophy without atypia attends, but sometimes has minor atypia.
mixed dystrophy. combines the two types of lesions.
vesiculobullous
vesicles and blisters occur as a result of peel the layers of the skin. Can break apart easily, so most times what we find in the exploration area is eroded. The most common forms that occur with PV are contact dermatitis and atopic dermatitis, which can be made DD by the extent and location of lesions, limited to contact area in one case and extension throughout the body in dermatitis AD.
Although less frequent, bullous pemphigus that occurs in older women presents with blisters on skin itch of the vulva. Dermatitis herpetiformis, most common in young women, preferably has mucosal areas, such as pruritic erythematous plaques found in the blisters. In girls, the chronic bullous dermatosis linear IgA child produces a similar clinical picture. Herpes gestationi, with characteristics similar to dermatitis herpetiformis, differs from it by not affect the vulva.
Erosions-ulcers
tend to be associated with itchy processes as a result of scratching. Some of the pictures that present with vesicles and blisters appear and at this stage, so when do the DD should be taken into account.
is frequently associated with infectious processes that occur with large tissue reaction, as is the case of vulvitis moniliásicas or trichomonas. In dystrophy, as with lichen sclerosus may commence as hypopigmented plaque eroded and, of course, in patients with malignant and invasive squamous cell carcinoma and Paget's disease, which when they come to our clinic have erosions and ulcers on the initial injury.
Treatment
Treatment of vulvar pruritus, understood as a symptom, should be focused to eradicate their causes 24. When you discover the cause production (candidiasis, trichomoniasis, etc..) Produce good results. Sometimes the treatment is not totally effective, as in dystrophies and in some dermatoses. Symptomatic drugs are merely aids in emergency situations and in cases where you do not find a clear etiology.
Symptomatic
General measures
mention mainly two:
decreasing appropriate Diet carbohydrates, which help the skin edema, also avoid spicy foods, chocolate, alcohol and all sorts of exciting, especially coffee and tea, which increases the itching sensation.
Avoid occlusive clothing, removing wool and synthetic fibers that irritate mechanically. Wear loose clothing of natural fiber (cotton), non-irritating and easily breathable.
Hygiene vulva
Avoid deodorants, perfumes, soaps, antiseptics, artificial fiber napkins, contraceptives chemical (gel, eggs), and perform washed simple soap and water dilution.
systemic antipruritic drugs
These include three types:
antihistamines. They are useful in cases where histamine acts as a mediator (urticaria). In the itching due to other causes, its benefit lies in the sedative action. Is preferred, for its remarkable sedative effect of hydroxyzine, 25-100 mg/6-8 h (Atarax ® ).
tranquilizers: benzodiazepines (diazepam). No direct influence on the itch, but modify the vicious cycle that perpetuates it. They are especially indicated in the first days of treatment.
analgesics. Paracetamol or metamizol if the sensation of pain prevails over that of pruritus.
topical pharmacological treatment mention three basic options:
is not advisable to local employment to be highly sensitizing antihistamines. In a clinical trial has shown efficacy and good tolerability of oxatomide 25, antihistamine H 1 , topically, in women with vulvar itching of varied nature, although in our country is not yet marketed the drug.
alcohol subcutaneous infiltrations in the affected tissue have been used to control symptoms with good results. However, the process requires local or general anesthesia, so it is reserved for cases resistant to other treatments.
As an alternative to previous treatments, is under investigation subcutaneous injection of triamcinolone acetonide (Trigon Depot ®) 15-20 mg as treatment chronic vulvar pruritus 26 (more than 6 months duration), provided advance ruling that is caused by infection or tumor. In the study by Kelly (1993) referred to in this point, 78% of women in the intervention group experienced a significant improvement effect persisted for approximately the same 6 months.
as undesirable effect in some cases, may cause local tissue necrosis after injection, which, when rare subcutaneous.
Surgical
vulvectomy and removal the tissues where the itch is located provides unsatisfactory results. It is considered a therapeutic action in some cases extremely difficult to treat.
Psychotherapy
is important to reassure the patient, give explanations about the kindness and chronicity of the process that suffers, emphasizing the importance of stress and lack of rest as aggravating itching sensation.
etiologic treatment in primary care
rashes and dermatitis Contact
oral corticosteroids are given, related to antihistamines, for its anti-inflammatory. These act on the inflammation secondary to scratching and have no direct action on pruritus.
The low potency topical steroids (hydrocortisone topical at 1 or 2%, fluocortina clobetasona 0.75% or 0.05%) are usually sufficient to achieve the improvement, but sometimes a rebound effect stopping treatment. It is not advisable for long-term use adverse effects: irritation, itching and dryness in the area of \u200b\u200bapplication.
Vulvar atrophy
topical estrogens are useful in postmenopausal women fast losing collagen. The drawback is that they are absorbed through the mucosa and induce endometrial hyperplasia in women with a uterus, if applied for a long time and without attaching a progestin to counteract its effect.
topical vaginal estriol (Ovestinon ®), a óvulo/24 h for 2-3 weeks, after which an egg every 3 days at bedtime.
Promestrieno (Colpotrofin ® 1% cream), 1-3 applications / day for 20 days.
Vulvovaginitis caused by infection
Candidiasis. The clotrimazole is the treatment of choice in mild and sporadic cases (500 mg single dose vaginal). It is effectively a single dose of 150 mg of fluconazole orally 27.
During pregnancy and indicated moderate cases topical treatment with clotrimazole, 100 mg/12 h for 3 days or 100 mg/24 h for 7 days
If vulvovaginitis recurrent (more than of 4 episodes / year) is indicated the use of fluconazole (Sobel, 1997), 150 mg orally / posmenstruación for 3-6 months. It is also indicated treatment with 500 mg clotrimazole vaginal single-dose, after menstruation for 6 months 28.
Women suffering from Candida, asymptomatic, not requiring treatment 29.
sexual partner requires treatment only if you have clinical balanitis 30.31.
bacterial vaginosis. The use of clindamycin vaginally has proved as effective as oral metronidazole 32 , although the former implies a greater cost.
The regimen is: clindamycin 2% cream, one application at bedtime for 7 days or oral metronidazole, 500 mg every 12 hours for 7 days.
The asymptomatic patients require no treatment except pregnant women and prior to the implementation urogenital 33.
In pregnant women, the treatment of choice is the pattern of topical clindamycin.
sexual partner requires treatment only if clinical features of balanitis.
Trichomonas Vulvovaginitis. The treatment of choice is oral imidazoles 34 (metronidazole, tinidazole). Treatment regimens are: metronidazole 2 g orally single dose, metronidazole 500 mg/12 h for 7 days or tinidazole 1 g/12 h during a day
If pregnancy the treatment of choice is clotrimazole vaginal, at doses of 100 mg / day for 14 days. The oral imidazoles have teratogenic potential at the beginning of pregnancy, acceptable in the third trimester of pregnancy.
The asymptomatic patients should be treated with single dose of 2 g of metronidazole or tinidazole 2 g orally.
sexual partner always require treatment, the same pattern described. 
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