In this month's Did You Know? series, Chief Science Officer Beth DuPriest, PhD discusses the controversial topic of vulvar washes, including how research shows that vulvar washes may, in fact, support vulvovaginal health. Have a question about vaginal biome science? Submit yours here and your answer may be featured in an upcoming newsletter.
Q: How can vulvar washes support vulvovaginal health?
The vagina has been described as a “self-cleaning oven” which rids itself of any kind of foreign material through its natural exfoliation processes and fluid flow. This means that the vagina does not need any assistance to be cleaned. In fact, vaginal douching is strongly discouraged due to its associations with ectopic pregnancy, pelvic inflammatory disease, bacterial vaginosis (BV) and many other conditions. Worldwide, the consensus of all professional OB/GYN societies is that douching for routine hygiene should be avoided.
But the vulva is not the vagina – they are different organs, yet the advice regarding not using vaginal cleansers has often been extended to the vulva. This has been supported by the fact that alkaline soaps and harsh anionic detergents have been shown to be harmful to other types of skin. These products can elevate the skin’s pH, denature proteins, and strip natural oils, causing a decrease in the barrier effectiveness and an increase in transepidermal water loss1. This has led to another worldwide consensus regarding avoidance of these harsh products, especially bar soaps, on the vulva.
However, professional societies differ on recommendations regarding other types of washes for the vulva. While the American College of Obstetrics and Gynecology is conservative and recommends avoidance of all vulvar cleansers, the Federation of Obstetrics and Gynecology Societies of Brazil, the Royal College of Obstetrics and Gynecology of the UK, and a Middle East and Central Asia committee formed to examine vulvovaginal hygiene all concluded that soap substitutes are appropriate and even encouraged as vulvar washes2,3. One report noted that water alone can be drying to vulvar skin; it is also possible that women using only water would scrub more vigorously to try to clean, which would be damaging to the vulva.
The vulva is exposed to many substances: vaginal discharge (which may be irritating if unhealthy), mucus, menstrual blood/tissue, female ejaculate, semen, saliva, urine, feces, sweat, and oils, not to mention medications or other products like lubricants and moisturizers. Additionally, these irritants may lead to vaginal itching, a common occurrence among women. When you consider that the vulva contains a wide variety of glands, including sebaceous glands and apocrine glands similar to those found in the armpit, it is apparent that water alone is not sufficient to remove vulvar secretions. After all, few would argue that water by itself can effectively wash underarms! Unlike the vagina, the vulva has no directional fluid flow and outlet for these secretions to be naturally removed.
Soap substitutes usually consist of blends of amphoteric and/or nonionic surfactants, which compared to soap have a lower pH, are less drying to skin, and often even have emollient properties. These provide a gentle cleansing effect and have been shown to be safe for the vulva. Studies of at least three different vulvar washes have shown that they are well tolerated, and that they do not change the pH or microbiome of the vulva2,4–7. One gel wash was shown to improve the moisture of vulvar skin both in a single day of use, and over a full month of use8. The vulvar microbiome, like the vaginal biome, is important for maintaining health of the tissue; both typically have high levels of lactobacilli. Lactic acid, a primary metabolic byproduct of lactobacilli, can help maintain the vulvar and vaginal biomes by suppressing potential pathogens. Of course, not all products are created equal. Vulvar washes with good ingredients can help maintain vulvovaginal health.
Of course, there will always be some women who are very sensitive and who really should be encouraged to avoid use of all products. These are a small minority - though they may form the majority of patients in some specialized women’s healthcare practices. Recommendations for these women should not be the same as for others who can benefit from good vulvar washes. The general public can confidently use a well-formulated vulvar wash that has a low pH, lactic acid, and gentle cleansing agents without perfumes or toxic chemicals. Not all brands are formulated this way, so women need to choose products carefully.
1. Ananthapadmanabhan KP, Moore DJ, Subramanyan K, Misra M, Meyer F. Cleansing without compromise: the impact of cleansers on the skin barrier and the technology of mild cleansing. Dermatol Ther. 2004;17(s1):16-25. doi:10.1111/j.1396-0296.2004.04S1002.x
2. Chen Y, Bruning E, Rubino J, Eder SE. Role of female intimate hygiene in vulvovaginal health: Global hygiene practices and product usage. Womens Health. 2017;13(3):58-67. doi:10.1177/1745505717731011
3. FEBRASGO. Practical Guide to Conducts on Female Genital Hygiene. Brazilian Federation of Gynecology and Obstetrics Associations; 2009.
4. Jacquet A, Roussilhes R, Anoufa S, Marteau C, Mallet F, Audebert A. [Study of a new lactic acid and pH 5.2 lactoserum emulsion for feminine hygiene. Results of a clinical study]. Contracept Fertil Sex 1992. 1995;23(7-8):457-459.
5. García F, Rodríguez CA, Palomo ML, et al. Efficacy, acceptability and tolerability of Zelesse® for the treatment of non-specific vulvovaginitis in paediatric patients: The NINESSE Study. J Int Med Res. 2018;46(9):3583-3595. doi:10.1177/0300060518775566
6. Guinot M, Blanco JE, Delgado JL, et al. Acceptability, tolerability, and effects on symptoms and signs of vulvovaginitis of a non-soap, herbal-based intimate hygiene solution (Zelesse®). J Int Med Res. 2019;47(6):2626-2636. doi:10.1177/0300060519837820
7. Tansupasiri A, Puangsricharern A, Itti-arwachakul A, Asavapiriyanont S. Satisfaction and tolerability of combination of lactoserum and lactic acid on the external genitalia in Thai women. J Med Assoc Thail Chotmaihet Thangphaet. 2005;88(12):1753-1757.
8. Bruning E, Chen Y, McCue KA, Rubino JR, Wilkinson JE, Brown ADG. A 28 Day Clinical Assessment of a Lactic Acid-containing Antimicrobial Intimate Gel Wash Formulation on Skin Tolerance and Impact on the Vulvar Microbiome. Antibiot Basel Switz. 2020;9(2):E55. doi:10.3390/antibiotics9020055