Treatment of infective prepubertal vulvovaginitis

Prepubertal vulvovaginitis is usually not caused by infection; dermatitis is a more likely diagnosis. Examine the genital area and consider other causes of vulvovaginitis. Investigation is not required for initial presentations of mild prepubertal vulvovaginitis. However, if vulvovaginitis is severe (eg if there is profuse, bloody or offensive discharge), take a vulval swab or swab of the discharge at the vaginal introitus, and send for microscopy and culture.

Streptococcus pyogenes (Group A streptococcus [GAS]) is the most common bacterial cause in this age group. There is a lack of evidence for the optimal therapy; however, a suitable regimen for prepubertal streptococcal vulvovaginitis is:

phenoxymethylpenicillin 15 mg/kg (up to 500 mg) orally, 12-hourly for 10 days. phenoxymethylpenicillin

For children who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin1, a suitable regimen is:

cefalexin 25 mg/kg (up to 1 g) orally, 12-hourly for 10 days. cefalexin

For children who have had a severe (immediate or delayed)2 hypersensitivity reaction to a penicillin, suitable regimens include:

1trimethoprim+sulfamethoxazole (child 1 month or older) 4+20 mg/kg (up to 160+800 mg) orally, 12-hourly for 10 days trimethoprim + sulfamethoxazole

OR

2clindamycin (child 1 month or older) 10 mg/kg (up to 450 mg) orally, 8-hourly for at least 10 days. clindamycin

Other infective causes of prepubertal vulvovaginitis include other beta-haemolytic streptococci, staphylococci, Haemophilus influenzae and Shigella speciesRomano, 2020. If other bacteria are identified on a swab, treatment should be based on susceptibility results.

If a sexually transmissible infection (STI) is identified in a child, see STIs in children.

If vulvovaginitis recurs following antimicrobial treatment, consider performing a repeat swab in severe cases (eg if there is profuse, bloody or offensive discharge) and consider a longer treatment course. Also reconsider noninfective causes such as a foreign body and referral to a specialist.

1 Cefalexin may be used in patients who have had a nonsevere (immediate or delayed) reaction to amoxicillin or ampicillin. However, because cross-reactivity between these drugs is possible, consideration should be given to the extent of the reaction, patient acceptability, and the suitability of non–beta-lactam options.Return
2 Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse. Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return