The impact of anxiety on vulvar dermatological diseases: a systematic review.

The impact of anxiety on vulvar dermatological diseases: a systematic review

Abstract

Background:

Vulvar inflammatory dermatoses, including lichen sclerosus, lichen planus, lichen simplex chronicus, and psoriasis, have been shown to impact mental health and quality of life.

Objective:

We aimed to synthesize and evaluate the current literature regarding the association between anxiety and vulvar inflammatory dermatoses.

Data sources:

A comprehensive search was conducted using the Ovid MEDLINE, Embase, Cochrane, PubMed, PsycINFO, and Web of Science databases. Search terms included vulvar conditions (eg, “lichen sclerosus,” “lichen planus,” “lichen simplex chronicus,” and “psoriasis”) combined with anxiety-related terms (“anxiety,” “anxious,” and “mental health”).

Study selection:

We included appropriate studies (eg, clinical trials, case-control studies, cohort studies, cross-sectional studies, or interview studies) directly addressing vulvar inflammatory dermatoses and anxiety. Studies without quantifiable anxiety outcomes or those that were reviews, protocols, commentaries, or abstracts were excluded. Two reviewers independently screened and resolved discrepancies by consensus.

Methods:

A comprehensive search was conducted using the Ovid MEDLINE, Embase, Cochrane, PubMed, PsycINFO, and Web of Science databases. We included appropriate studies (eg, clinical trials, case-control studies, cohort studies, cross-sectional studies, or interview studies) directly addressing vulvar inflammatory dermatoses and anxiety.

Results:

Eighteen studies met inclusion criteria. Up to 52% of patients with vulvar inflammatory disease experience symptoms of anxiety that affect sexual functioning, activities of daily living, and plans for pregnancy. The severity of anxiety may be greater in newly diagnosed patients and younger women, while treatment serves as a protective factor. Treatment modalities, including topical corticosteroids, fat grafting, biologics, and platelet-rich plasma, were associated with reductions in anxiety symptoms concurrent with improvement in vulvar disease severity and quality-of-life measures.

Limitations:

There is a paucity of data reviewing vulvar dermatoses, specifically vulvar involvement of common dermatologic diseases such as lichen simplex chronicus and psoriasis.

Conclusion:

The association between vulvar inflammatory diseases and anxiety may be multifaceted, with emerging evidence suggesting that vulvar disease may increase the risk of anxiety symptoms. Future efforts should focus on establishing targeted interventions that address both the dermatologic and psychological aspects of vulvar disease.

Keywords: Anxiety, mental health, psychodermatology, vulvar dermatitis, vulvar inflammatory dermatoses

What is known about this subject in regard to women and their families?

Vulvar dermatoses can cause significant psychologic impact in a patient’s quality of life.

What is new from this article as messages for women and their families?

We are continuing to further elucidate the role of anxiety in vulvar dermatologic diseases, noting a potential bidirectional framework of worsening anxiety in the setting of increasing dermatologic disease burden, and vice versa.

Introduction

Vulvar inflammatory dermatoses encompass a diverse group of chronic skin conditions affecting the vulva, often causing significant discomfort and negatively impacting quality of life. These include lichen sclerosus, lichen planus, lichen simplex chronicus (LSC), and vulvar psoriasis, among others.1,2 Vulvar lichen sclerosus (VLS) typically presents with porcelain-white atrophic plaques and may lead to scarring and loss of vulvar architecture.1,2 Vulvar lichen planus (VLP) can cause erosive lesions with potential for significant mucosal damage.1,2 Lichen simplex chronicus manifests as lichenified, thickened plaques resulting from chronic pruritus.1,2 Vulvar psoriasis is characterized by fluctuating exacerbations and remissions, presenting as pruritic, poorly demarcated plaques.3 Often difficult to distinguish on physical examination, irritant and allergic contact dermatitis of the vulva both cause pruritus and burning, commonly triggered by external factors such as hygiene products, fabrics, or medications.4

The psychological burden of vulvar inflammatory dermatoses remains underexplored. Patients with vulvar disease frequently experience anxiety, depression, and negative self-image, highlighting the complex interplay between dermatologic and mental health conditions.5,6 Further, studies suggest that such psychiatric comorbidities may be underdiagnosed due to reluctance and embarrassment to seek care.

While substantial evidence suggests that vulvar inflammatory dermatoses can exacerbate symptoms of anxiety, we suspect a potential bidirectional relationship – where anxiety itself may contribute to the severity and progression of vulvar disease, and vulvar disease may exacerbate preexisting anxiety. In this systematic review, we reviewed and assessed the literature reporting on anxiety in patients with vulvar inflammatory dermatoses, exploring how psychological factors may influence disease outcomes. By synthesizing existing literature, we seek to provide a more comprehensive understanding of this relationship and its implications for patient care.

Methods

A comprehensive search was conducted using the Ovid MEDLINE, Embase, Cochrane, PubMed, PsycINFO, and Web of Science databases. We used the terms “vulva,” “vulvar,” “vulvas,” “vulvae,” or the MeSH term Vulva/, in combination with dermatologic conditions such as “dermatosis,” “dermatitis,” “lichen sclerosus,” “kraurosis,” “lichen planus,” “lichen ruber planus,” “lichen rubra planus,” “lichen planopilaris,” “lichen simplex chronicus,” “neurodermatitis,” “neurodermatitides,” “psoriasis,” or the MeSH terms Dermatitis/, Dermatitis, Atopic/, Dermatitis, Contact/, Dermatitis, Allergic Contact/, Dermatitis, Photoallergic/, Dermatitis, Toxicodendron/, Dermatitis, Irritant/, Dermatitis, Phototoxic/, Lichen Planus/, Neurodermatitis/, Psoriasis/, and Vulvar Lichen Sclerosus/. These were combined with anxiety-related terms including “anxiety,” “anxious,” “mental health,” and the MeSH terms Anxiety/, Anxiety Disorders/, Generalized Anxiety Disorder/, Anti-Anxiety Agents/, and Mental Health/. After removing duplicate articles, the remaining articles were independently screened and assessed for eligibility by 2 reviewers (S. Sharifi and O. Katamanin/R. Moraga). Abstracts that lacked sufficient information to include or exclude were further assessed using full-text evaluation to determine eligibility. Discrepancies between reviewers were resolved through discussion to reach consensus. Inclusion criteria for this study were: (a) studies must directly address vulvar disease and anxiety, (b) be of an appropriate study type (eg, clinical trials, case-control studies, cohort studies, cross-sectional studies, or interview studies), and (c) be published in peer-reviewed journals in English. Studies were excluded if they were irrelevant to the topic, used an incorrect study type (eg, letters to the editor, commentaries, reviews, conference abstracts, or protocols), were not published in English, or were not published in peer-reviewed journals. Studies lacking quantifiable data regarding anxiety prevalence and characteristics were excluded.

The screening process is outlined in our Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram (Fig. 1). Following abstract and title screening of 95 studies, 33 underwent full-text review. Fifteen articles were excluded upon full-text review due to study designs that did not meet our search criteria or outcomes that were not relevant to our analysis. Ultimately, 18 studies met the inclusion criteria for this review, with 8 cohort studies, 2 pilot clinical trials, 2 observational studies, 1 case-control study, and 5 cross-sectional studies. The included articles underwent formal quality assessment procedures, using the Joanna Briggs Institute Critical Appraisal Checklists, selected according to study design. Data extraction involved 2 independent reviewers (S. Sharifi and O. Katamanin/R. Moraga) extracting pertinent information from eligible studies and organizing and summarizing the findings, using the online platform, Covidence. A narrative synthesis was conducted to summarize findings (Supplementary Table S1, https://links.lww.com/IJWD/A101).

Results

Prevalence and impact of anxiety

Of the 18 studies that met the criteria, 16 included cases of VLS, 6 of VLP, and 3 of LSC. Common validated scales used to assess anxiety were the Hospital Anxiety and Depression Scale, Anxiety (HADS-A), Hamilton Anxiety Rating Scale, Beck Anxiety Inventory, and Vulvar Quality of Life Index. Notably, these tools measure anxiety symptoms and are not diagnostic for generalized anxiety disorder or other anxiety disorders.

A total of 17 of the 18 studies endorsed an association between a diagnosis of vulvar inflammatory disease and anxiety.7–23 Recent data has shown that up to 52% of patients with vulvar inflammatory disease had clinically significant anxiety, with multiple studies indicating a higher risk compared to the general population.13–15 An electronic health record-based retrospective cohort study of 16,696 patients with VLS compared to matched controls with lichen sclerosus sparing the vulva demonstrated that VLS was associated with an approximately 2-times greater risk of anxiety disorder (3.77% vs 1.96%, relative risk [RR] = 1.93 [1.69–2.20]).11 Anxiety is also prevalent in pediatric patients; among 12 pediatric patients with anogenital lichen sclerosus, 75% met the criteria for very high levels of anxiety.18

Anxiety secondary to vulvar conditions has been shown to have profound impacts on various aspects of life, including sexual functioning, activities of daily living, and plans for pregnancy.19,21 A prospective observational study of 178 patients with VLP and VLS revealed a negative correlation between anxiety and sexual functioning scores, demonstrating increased anxiety associated with worsening sexual functioning, such as a decrease in arousal, desire, orgasm, satisfaction, as well as increased pain.22

Research suggests that the time since diagnosis and treatment initiation may play a significant role in the psychological burden experienced by patients. According to a retrospective cohort study of 77 patients with erosive vulvovaginal lichen planus, 29% of women with newly diagnosed disease experienced anxiety, compared to 6% of those with prolonged time since initial diagnosis or treatment with a provider.10 Choi et al. corroborated these results, demonstrating that VLS patients who received treatment had a decreased risk of anxiety disorder compared to those who were not treated (3.08% vs 4.27%, RR = 0.72 [0.59−0.89]).11 Overall, research suggests that over time and with appropriate treatment, anxiety symptoms may ameliorate.

Impact of disease treatment on anxiety

Several treatment options have been evaluated for their efficacy in reducing anxiety, including topical medications and novel treatments such as lipotransfer and platelet-rich plasma (PRP). Wijaya et al. demonstrated in a cross-sectional study of 204 patients with VLS treated with long-term topical corticosteroids that anxiety scores were significantly lower on the VLQI compared with pretreatment levels (median = 0 [interquartile range {IQR} = 0.0–0.3] vs 0.8 [IQR = 1.1–2.0]; P < 0.001).21 The same research group found that patients who reported a poorer quality of life during long-term topical corticosteroid treatment tended to have higher levels of anxiety, as well as concerns related to sexuality and body image (1.3 [IQR = 1.0–1.5]).23 Notably, these patients with elevated anxiety scores also demonstrated lower adherence to topical corticosteroids and had more active disease, including scarring progression (mean rank = 94.8 vs 66.6; P = 0.02), unstable disease (mean rank = 94.3 vs 65.5; P = 0.005), and urinary incontinence (mean rank = 82.0 vs 65.5; P = 0.04), suggesting that treatment adherence may influence both disease severity and associated anxiety.21

Novel therapies for vulvar inflammatory dermatoses are emerging, though evidence is limited to small cohort studies. Almadori et al. examined fat grafting in their prospective cohort of 33 patients with VLS not responsive to topical corticosteroids and reported statistically significant improvements in anxiety scores following fat grafting (P < 0.0001).7 Boero et al. supported these findings in a larger retrospective cohort study of 71 patients, reporting that at follow-up (2–11 years) after fat grafting for vulvar VLS, patients had improved HADS-A scores (P < 0.029).8 In both studies, fat grafting was associated with reported improvement in vulvar disease features, including fibrosis and scarring, with concurrent reductions in anxiety scores; however, these findings were derived from relatively small cohorts.7,8 Patients treated with tildrakizumab, a biologic inhibiting the interleukin-23 (IL-23) receptor, had statistically significantly decreased VLQI scores in the anxiety domain (4.04, 95% confidence interval [CI] = 2.38–5.78) compared to patients treated with traditional topical (6.69, 95% CI = 5.02–8.38; P = 0.006) or systemic (6.58, 95% CI = 4.81–8.35; P < 0.001) modalities.16 Finally, autologous PRP was examined in a pilot study of 50 patients, with median anxiety scores significantly decreasing after 3 monthly vulvar injections (P < 0.001).9 It is worth noting that these therapies also demonstrated clinical improvement, which may contribute to the observed reductions in anxiety.9,16

According to a prospective observational study of 186 female patients with nonneoplastic epithelial disorders of the vulva (including VLS, VLP, and LSC), anxiety was a negative prognostic factor for treatment outcomes with the use of high-intensity focused ultrasound, a novel physiotherapy technique.12 Hence, while conventional and emerging therapies have demonstrated the potential to improve clinical symptoms and disease-related anxiety, anxiety itself may correlate with treatment outcomes.13

Discussion

Our results indicate a significant association between vulvar inflammatory dermatoses and anxiety, with implications regarding comorbid disease progression and severity. While causality cannot be established, it is plausible that these effects exist in a bidirectional relationship, in which vulvar disease may increase the risk of anxiety, while preexisting anxiety may, in turn, contribute to symptom amplification, delayed clinical improvement, or persistent symptom burden despite appropriate therapy. Similar bidirectional patterns have been observed in other inflammatory dermatoses, such as chronic urticaria.24 Conversely, the unpredictable nature and visibility of the disease may contribute to psychological distress.24 Psoriasis demonstrates a comparable cycle, in which the disease is associated with increased rates of anxiety and depression, independent of disease severity. At the same time, psychological stress is also a known trigger for psoriasis flares, likely mediated via the HPA axis and proinflammatory cytokines such as tumor necrosis factor alpha and IL-17, perpetuating a vicious cycle between psoriasis and mental health burden.25

Importantly, worsening patient-reported symptoms in vulvar disease may not uniformly reflect objective progression of inflammatory disease. Anxiety has been shown to heighten symptom perception through mechanisms such as central sensitization, attentional bias, and an overlap between anxiety and somatic symptom reporting.26,27 In this context, symptoms may feel more severe without corresponding changes in clinical disease activity. This distinction underscores the need to interpret anxiety-associated symptom burden not solely as disease worsening, but as an interaction between peripheral inflammation and central perceptual processing.

Anxiety may be particularly elevated in patients with newly diagnosed vulvar conditions.10 These psychological effects may be more pronounced in certain populations, such as premenopausal women.11 Not only does anxiety peak in the young adult years, but also, younger women may have greater concerns over fertility, body image, and sexual functioning, heightening the psychological burden of vulvar disease.17,28 Moreover, fluctuations in anxiety symptoms throughout the female lifespan are also postulated to be secondary to hormonal changes.29 Future research should explore the interplay between hormonal factors, vulvar disease severity, and psychological risks throughout varied age groups.

Treatment stands as a protective factor, with a greater risk of anxiety in those left untreated.11 First-line management with topical steroids remains the cornerstone of therapy and is essential not only for disease control, but also to mitigate psychosocial distress as higher anxiety levels are associated with inadequate or suboptimal management. Several alternative treatment modalities, including fat grafting, biologics, and PRP, have shown improvement in reducing anxiety symptoms, with fat grafting reporting robust results within small participant studies.7,8,30 Nonetheless, some women continue to experience mood changes and sexual dysfunction despite vulvar symptom improvement, indicating the long-term emotional impact of the disease.23,31

Beyond symptomatic improvement, emerging evidence suggests that inflammatory modulation may influence anxiety-related pathways. Biologic agents such as tildrakizumab, which target the IL-23 axis, have been associated with improvements in anxiety-related quality-of-life domains among patients with vulvar inflammatory disease.16 These observations align with broader psychoneuroimmunology literature demonstrating associations between peripheral inflammatory cytokines and anxiety symptoms.32 While these agents are currently not indicated for the treatment of anxiety, these findings underscore the interconnectedness of immune signaling, chronic inflammation, and psychological distress, particularly in inflammatory dermatoses affecting sensitive anatomical sites.

Patients often express concern about long-term health implications and sexual functioning, underscoring the benefit of physician counseling and integrative treatment approaches.21 Further, anxiety relating to the risk of cancer in cases of VLS emphasizes the importance of education at the time of diagnosis.21 Holistic treatment may improve outcomes, including pelvic floor therapy, cognitive behavioral therapy, and social support groups.33 The utility of these treatment modalities, as well as anti-anxiety medications, remains underexplored and warrants further investigation. Importantly, the vulvar dermatologic education of dermatology and obstetrics and gynecology trainees remains limited, suggesting an opportunity to improve care delivery through increased interdisciplinary collaboration.34

Our review is subject to several limitations that necessitate consideration. First, the reported prevalence of anxiety varied across studies, potentially due to differences in diagnostic criteria. Furthermore, geographic and demographic influences were not directly addressed in our analysis, potentially impacting the generalizability of results. Notably, our review included only 3 articles addressing LSC, and none for vulvar psoriasis. This paucity of data limits our ability to fully characterize the relationship between specific vulvar conditions and anxiety. Finally, individual factors such as cultural preferences and socioeconomic status must be considered when assessing psychological impact. Future studies should use larger, more diverse cohorts and longitudinal designs with standardized screening tools to better quantify the relationship between vulvar inflammatory dermatoses and anxiety.

Conclusion

This systematic review purports the increasingly evident bidirectional relationship between anxiety and vulvar inflammatory dermatoses, highlighting the prevalence of anxiety in inflammatory dermatoses and, therefore, the role for a multidisciplinary approach to patient care for patients with vulvar conditions. Anxiety may not only exacerbate disease symptoms but also influence treatment outcomes and overall quality of life. Given the psychological burden associated with vulvar disease, there is benefit in integrating mental health support alongside dermatologic and gynecologic care. Future research could focus on refining long-term treatment approaches, exploring the role of hormonal influences, and identifying targeted interventions that address both the dermatologic and psychological aspects of vulvar disease.

Conflicts of interest

The authors made the following disclosures: KSF is an investigator for Abbvie, Moonlake, and Novartis. She is a consultant for Leo Pharma. She is on the board of directors for the Vulvar Disease Research Consortium. She previously received fellowship funding from Abbvie, the National Psoriasis Foundation, and Janssen Biotech, Inc, which was paid directly to her institution. EE is a consultant for Leo Pharma. She is on the board of directors for the Vulvar Disease Research Consortium.

Funding

None.

Study Approval

Because this systematic review utilizes existing literature and does not collect primary data from human participants, it did not require institutional review board approval.

Author contributions

SS: Participated in conceptualization, data extraction, writing, and editing. OK: Participated in data extraction, writing, and editing. RM: Participated in data extraction, writing, and editing. KSF: Participated in supervision, writing, and editing. EE: Participated in supervision, writing, and editing.

Supplementary data

Supplementary material associated with this article can be found at https://links.lww.com/IJWD/A101.

Acknowledgements

We thank C. Scott Dorris at the Georgetown University Library for his contributions to the manuscript preparation.

Supplementary Material

Footnotes

Published online 26 August 2026

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Associated Data

Supplementary Materials