NEWS AND FILLER
|Year : 2009 | Volume
| Issue : 2 | Page : 130-133
Vulvovaginal hygiene and care
Pushpa Gupte1, Sharmila Patil2, Rupali Pawaskar2
1 Department of Dermatology, G.S. Medical College and K.E.M. Hospital, Mumbai, India
2 Department of Dermatology, D.Y. Patil Medical College and Hospital, Navi Mumbai, India
|Date of Web Publication||24-Apr-2010|
D.Y. Patil Medical College and Hospital, Navi Mumbai, Mumbai
| Abstract|| |
Homeostasis of the skin is very important, which is achieved by a thin acid film - the acid mantle. Human skin has an acid mantle of pH 4-6. It prevents invasion by pathogenic organisms, acting as a first-line defence and helping in a disease-free existence. The vaginal mucosa has a similar acid mantle. Here, the natural acidic pH is maintained by lactic acid, an integral part of the vaginal ecosystem. This can be easily lost due to the lack of awareness of local care or various aggressive hygiene practices in addition to various diseases. Gentle cleansing along with good moisturization can go a long way in keeping the vulva healthy.
Keywords: Acid mantle, lactic acid, vulvovaginal infections
|How to cite this article:|
Gupte P, Patil S, Pawaskar R. Vulvovaginal hygiene and care. Indian J Sex Transm Dis 2009;30:130-3
| Introduction|| |
Skin protects all the organs from the harmful external environment. For a good healthy life, homeostasis of the skin is very important. This is achieved by a thin acidic film enveloping the skin, called the "acid mantle."
The acid mantle plays a very important role as an integral part of the barrier function of the stratum corneum. Human skin has an acid mantle of pH 4-6, contrasting with the almost neutral pH of the interior body, and implying the existence of a pH gradient over the horny layer that might influence a variety of epidermal processes. 
The optimum skin pH in healthy people is 5.5,  although it varies in different areas of the skin, e.g. the perineal skin pH is between 5 and 5.5. An increase in the skin surface pH has been shown to increase the susceptibility to infections or skin damage and disease. Skin pH is affected by a great number of endogenous factors, e.g. skin moisture, sweat, sebum, anatomic site, genetic predisposition and age. 
The "acid mantle" of the normal skin, which penetrates deep into the stratum corneum, is the combined result of cornification-associated organic acids and back-diffusion of acid material from the surface.  The other components of the acid mantle are various amino acids from sweat and free fatty acids from sebum.
The acidic nature of the mantle prevents invasion by microorganisms,  thus acting as a first-line defence against infection, and also offers direct protection against alkaline substances (alkali-neutralizing capacity). All these properties make the acid mantle indispensable for our disease-free existence.
To stay healthy and avoid infection, hygiene is imperative, especially in women, as they are more susceptible to urinary and reproductive tract infections. Therefore, as a preventive measure, perineal hygiene in women should include the maintenance of the acid mantle in the perineal area.
| Role of Lactobacilli in the Vaginal Ecosystem|| |
The new born vagina is a sterile organ but is soon invaded by numerous micrococci, enterococci and diptheroids within 24 h after birth.  In 1982, Doderlein  described three grades of "vaginal cleanliness" based on a microscopic examination of the unstained vaginal fluid. Grade I indicates a "clean vagina," where lactobacilli predominate. Grade III is "pathological flora," where the discharge is described as "profuse and purulent or, rather, scanty and watery," and therefore appears to describe patients with bacterial vaginosis (BV) or trichomoniasis. Grade II is intermediate between Grades I and III and is associated with a mixed flora including fewer lactobacilli than seen in Grade I.
Maternal estrogen, 2-3 days from birth, induces glycogen deposition in the vaginal epithelium that facilitates growth of lactobacilli. These lactobacilli are the primary source of lactic acid in the vagina. , Lactobacilli have been recognized, as the predominant microflora of the healthy human vagina, to maintain a pH of <4.5.  This low pH reduces the risk of colonization by pathogens. ,,, An increase in vaginal pH is detrimental to the survival of lactobacilli; therefore, local acidification with lactic acid or lactobacilli is useful for restoration of the vaginal ecosystem. 
The microbial flora is diverse and depends on the pH of genital secretions and its enzyme content during different phases of life.
During the reproductive period in a normal woman with adequate levels of estrogen, lactobacilli constitute the predominant organisms in the vaginal flora (>95%) and proliferate well in the acidic environment of the vagina.  Lactic acid produced by lactobacilli acidifies the vagina to a level inhospitable to many other species of bacteria. Other substances produced by lactobacilli that inhibit the invading pathogens include hydrogen peroxide (H 2 O 2 ), lactacin and acidofin. H 2 O 2 may either directly inhibit pathogens, including fungi, or by the myeloperoxidase microbiocidal system.  Thus, vaginal mucosa and perineal skin, through their keratinized epithelium and lactobacilli, together constitute a successful vaginal ecosystem, thereby protecting the vagina from infections like BV, fungal and trichomonial infection.
| Physiological Conditions Responsible for Damaging the Acid Mantle in the Perineal Area|| |
Menstruating women show a lower number of lactobacilli, which in turn can alkalinize the pH of the perineal area. 
During the menopausal years (45-55 years), skin in the perineal area becomes dry and thin, which augments pruritus. Scratching the area affects the acid mantle making it vulnerable to infection. th
The change in the immune system may lead to urinary and reproductive tract infections, damaging the acid mantle. This is aggravated by a protruding abdomen during pregnancy, creating difficulties in maintaining perineal hygiene.
The large abdomen and overhanging folds of obese women pose similar problems of disturbance of the acid mantle due to the inability to maintain perineal hygiene and can lead to chronic maceration and intertrigo of the groins.
In other words, even during normal physiological conditions, the acid mantle in the perineal area can be damaged, resulting in various complications.
| Pathological Conditions Responsible for Damaging the Acid Mantle in the Perineal Area|| |
Vulvar skin diseases are often multifactorial, with subtle clinical abnormalities. They are often accompanied and driven by secondary yeast infection or bacterial colonization. Irritant contact dermatitis from various topical preparations may further aggravate the diseases.
Various dermatological conditions are responsible for damaging the acid mantle, especially atopic dermatitis, senile vaginitis, Lichen sclerousus (LS), Lichen planus (erosive) and vulvovaginal infections (VVIs).
In atopic dermatitis, the skin shows a reduction in filaggrin proteolysis and sweat secretion. This results in an impaired release of proton donors such as amino acids, urocanic acid and lactic acid to the stratum corneum hence augmenting bacterial infections.
In adults, contact dermatitis of the vulva and vagina is frequently due to contact with menstrual pads, condoms, medicated douches, vaginal spermicides, depilators and vaginal creams. An impaired formation of free fatty acids from sebaceous lipids and epidermal phospholipids seems to be involved. All these factors disturb the acid mantle over the perineal area, the pH of which becomes alkaline.
Senile vaginitis is very common in postmenopausal women or those who have undergone oophorectomy. The vagina and the adjacent skin and glandular structures show atrophic changes and render the skin dry and itchy.
LS causes vulvar atrophy. The vulvar skin and mucosa become dry, ivory white and atrophic. The perianal skin is also rarely affected, causing an "hour glass" deformity that lacks acid mantle.
| Vvis|| |
The World Health Organization estimated that there are 333 million new cases of curable VVIs per year. A study in India has shown that the prevalence of reproductive tract infections was 37.0% based on symptoms and 36.7% by laboratory investigations, including 31% candidiasis, 3% gonorrhea, 2% Trichomoniasis and 45% BV. 
BV occurs most commonly during the reproductive years, affecting the vagina, bladder and skin in the genital area.  In the common population, its prevalence was shown to be 10-20%,  while in STI clinics, it appears to be much higher (20-36%).  It is usually caused by anaerobic bacteria such as Gardenella vaginalis, Bacteriodes species, Mobiluncus species and Mycoplasma hominis. Multiple sexual partners, frequent vaginal douches, lack of H 2 O 2 -producing strains of Lactobacilli in the vagina and use of intrauterine devices increase the incidence of BV. ,
Yeast infections are commonly caused by Candida albicans. It is often associated with recent use of antibiotics, pregnancy, obesity, diabetes mellitus and the use of undergarments of nylon or lycra that trap heat and moisture. 
Trichomoniasis, caused by Trichomonas vaginalis, is one of the common causes of soreness of the vagina, vulva and vestibule, dysuria and dyspareunia.
These VVIs can present with intense itching, maceration, malodor and burning sensation in the perineal area, which is extremely distressing. These symptoms can cause disruption of the perineal skin acid mantle, thereby breaching the skin barrier function. When there are more than four episodes of VVIs in a year, it is called recurrent VVI. It is often a relapse or reinfection of endogenous pathogens. Recurrent VVIs are more common with multiple sexual partners, frequent penovaginal and orogenital intercourse and oral contraceptive pills.
Systemic diseases such as diabetes mellitus also contribute to disturbed acid mantle.
Diabetes and acid skin mantle
Patients with diabetes mellitus secrete a lower amount of lactic acid on the skin surface, especially in the intertriginous areas. Higher skin pH favors the hyphal forms of the dimorphic Candida albicans. Hence, there is an increased incidence of yeast infection in these patients.
Poor perineal hygiene, low socioeconomic status and comorbid conditions like diabetes have been considered to be important risk factors associated with genital infections in women. ,, Of these risk factors, poor perineal hygiene is an easily modifiable risk factor and therefore addressing it would be a feasible and prudent decision to reduce the incidences of itching and infections in the perineum. The current options available for perineal hygiene are water, soap, talc, toiletries and antiseptics.
Role of soap, talc, toiletries and antiseptics in acid skin mantle
Many women are convinced that that their genital area is "dirty" and so requires strong soaps, wipes, sponges and douches. Soaps with an alkaline pH disturb the delicate ecological balance and thus the pH of the vagina and the perineum. It removes the protective acid mantle thus increasing the risk of local infection and irritation. Overzealous cleansing is one of the most common causes of irritant contact dermatitis. Cleansing with mild soap and water is adequate to maintain essential hygiene. After cleansing, the area should be patted dry and should not be rubbed.
Talcum powder, antiperspirants, deodorants and antiseptics used for better perineal hygiene can/may block the sweat glands and may result in contact sensitization and irritant action and strip the vulva and perineum off its moisture, causing extreme dryness.
An ideal perineal wash
The perineal wash must preserve the acid skin mantle, symbiotic normal flora and barrier function. Its natural antiseptic and moisturizing action should restore the normal vulval pH even in the presence of infection and render the vulva and perineum symptom free.
The correct use of moisturizers and cleansers is an integral component of the skin care regimen for any patient with dermatologic disease. 
Of the currently available options in the market, Chlorhexidine gluconate 0.4% vaginal wash does not reduce the incidence of infectious morbidity in parturients compared with the use of a sterile water wash useful in treating vaginitis during pregnancy.  Similarly, 10% Povidone-iodine does not provide for a better vaginal wash and is inferior to Chlorhexidine.  
Lactic acid and lactoserum may act as a perineal wash as they provide an acidic pH and maintain the moisture of the perineal area, improving barrier function. Clinical trials in various groups are essential to asses the essential role of such medications in normal and diseased individuals.
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