Dermatologists: Need help for pediatric genital irritation of unknown cause!?

Question

My prepubescent daughter has had genital irritation for 6 months. She has undergone a myriad of treatments from several doctors without resolution. Some days she can barely stand to sit or wear underwear. There are no visible signs except red vaginal mucosa (hymen is intact), and the redness continues in a straight line up the crack of her hiney at times. No visible vaginal discharge or odor. The only things that help are baths or showers twice daily with no soap and topical steroids which I use sparingly. She has been treated with mebendazole (pinworm) twice with no effect, so that was ruled out. Two cultures showed normal bacteria inhabitance. We applied prescription antifungal creams (Protonix, Vusion, nystatin) to no avail. She has had two doses of oral antifungal (fluconazole) with no difference. We use All Free/Clear detergent, cotton white underwear, and white toilet tissue. She is fully potty trained. What differential diagnosis am I missing? Thank you in advance!

I forgot to mention we've tried Premarin (estrogen) cream but I applied it very sparingly for only about a week and then haphazardly thereafter. I did not see any effect. Any other thoughts you may have would be greatly appreciated.

Also she had a blood test to rule out allergy to common food allergens (eggs soy, milk, corn), all negative.

We've also tried benadryl, claritin, and zyrtec. They reduced the nighttime irritation but not the overall problem. My concern with that is that it only slightly masks the symptoms, but doesnt cure the problem. Plus, at times, the irritation is VERY severe. Again, she can't sit or even stand to wear underwear. Now that the weather is getting colder and I can't put her in dresses I don't know what I'm going to do. She is suffering with this. I'm afraid we can't just relax and ignore it.

Thank you all for your further insights. To answer your questions, she just turned 4 years old. I dont see any foreign body and her hymen is intact. I am as sure as anyone can be that there is no sexual abuse involved as I am with her 24 hours a day when she is not in preschool 2 days per week, and I have ruled out any inappropriate contact at school because at times she's been off from school for a week and a half and her symptoms have stayed the same or exacerbated. There is no bleeding, discharge, blisters, or finite lesions. Just the vaginal mucosa is red and if we do not give her a bath or shower for 48 hours the redness extends as a flat thin line up to the top of her buttocks crack. She has also had a urine sample - negative. Also to desribe the irritation - it is not itching, per se, but rather irritation/ pain. When the symptoms are bad it involves both the vaginal and anal area. She doesn't scratch much but the pressure of sitting or wearing clothes hurts her.

... to the point of her crying. For example, on a bad day, when she's put in her carseat and the weight of her body is focused on her bottom, she will complain and cry. Right now we can keep it in check with once or twice daily showers (no soap), plus/minues a tiny bit of topical triamcinolone on the worst days. Even then she is still very bothered by it. I've also noticed that prior to a bowel movement she will have increased complaints, which makes me suspect that the irritation extends inside the anus, although the anus usually appears normal externally.
Sorry for the lengthy post. I really appreciate all your insights and welcome more. She has a dermatologist appt on Thursday but he has already recommended she take 2 more courses (weekly) of fluconazole, so I would like to go there armed with your expert suggestions. Thank you very much in advance!

Sorry, I meant to say she is in preschool two days a week.

Answer 1

very good thorough history. Its obviously vaginitis so just have to find the cause. Did they do any swabs? if she's having yeast,the fluconazole would've eliminated it so we can rule that out. Do not use too much steroids. and 6 months already means its chronic inflammation. How old is your child? Perhaps she had entered a foreign body into her vagina which has gone undetected? Is there any bleeding or any other multisystem symptoms? whats her WBC count like?
I suggest a cervical/vaginal swab and CT scan if possible. (if bleeding is positive, then an MRI might be necessary to rule out any soft tissue masses) Its quite impossible to make a diagnosis without some interaction.

P.S.
She has to stop scratching it even if its itchy. Scratching will further progress the inflammation and spread of infection. Try to use some aloevera gel to soothe the itch and inflammation.

Answer 2

I suppose you have tried everything under the sun..... Do one thing start her on antihistamines 2 times daily... even benadryl would do. Start applying moisturisers on that areas 3-4 times a day. Stop all the other treatment. When we try out lots of stuff we miss on the most simplest of things. Dont worry... stress itself can cause itching and if your daughte scratches that area it will always look red. so just relax and relax your daughter also. Anti histamines and moisturisers should works.

If you have tried even antihistamines..... The only thing left may be is a punch biopsy... to see what the irritation is... Are there any blisters? Are there any irritation free days? How old is she?

See.. it doesnt seem to be any fungal infection, any worm infestations, No baterial infections, What about viral? Herpes...I know it would not continuously last so long.
Contact dermatitis.... well you have been careful.
Scabies.... other body parts would be involved.
Any urinary tract infections? Is your child a happy child? depression/ anxiety/ sibling rivalry all such aspects need to probed into.... I am just thinking what else it would be. Being a dematologist I am quite intrigued by the complaints and the treatment. I think you should continue the antihistamines. stop steroids for a week or so and if need be meet a dermatologist and consider a skin biopsy. If that is normal then you have nothing to worry about.
http://www.nlm.nih.gov/medlineplus/ency/article/003159.htm
http://www.wrongdiagnosis.com/sym/vaginal_itching.htm

Answer 3

Not a dermatologist, but have you had her estrogen levels checked? If it is abnormal, there is a local estrogen tablet, vagifem, that can help. I know that sounds really weird, but I had similar symptoms and the treatment sounds similar to what I had.