Question
Posted on: April 19 2013A gynecologist asks me for a cream for a difficult to treat vaginal itching.
He has already prescribed all sorts of medications (anti-fungal, cortisone,..) but nothing proves to help. Now this woman has been told by an American doctor that the following recipes will help. Now he asked what our opinion was because he did not know this use. So now our question has someone experience with it and these products have a working in an ointment because the Act prod must be obtained from crushed tablets. The recipes are as follows: R/doxepin 5% in cream and R/topical Amitriptylline 2% and R/gabapentin 3% in cream
Answer
Beforehand I have to say that there are pages about "vaginal itching" on the internet. The problem is not simple and apparently can be treated in a multidisciplinary manner in difficult situations. Maybe the gynecologist can see what he can read about this ailment on the internet.
With regard to the creams, I must point out that doxepine cream has already been treated on the question box. But I now read that vaginal use is not permitted. Can also be found on the internet.
I know the two remaining ones as creams that are used, possibly with more components, for the treatment of neuropathic pains eg trigeminal.
Because of their vaginal use, I thought
1. Vulvodynia: An often-overlooked cause of dyspareunia in the menopausal population by Nancy Phillips, MD, Clinical Associate Professor, Department of ObGyn and Reproductive Services, UMDNJ—Robert Wood Johnson Medical School, New Brunswick, New Jersey
Topical formulations of both gabapentin (2%-6%, formulated by a compounding pharmacy) and amitriptyline 2%/baclofen 2% have shown moderate success in small numbers of patients.(10,11) These are appealing as a potential means of decreasing systemic drug levels and subsequently decreasing unwanted side effects. More clinical experience and controlled trials are needed to establish efficacy.
2. Prescription for gabapentin 4g in cetomacrogol cream 100g for a 20-year-old girl, prescribed gynecologist. What would the function of this preparation be ??? (copied from IPSA)
More than likely this preparation is intended for the treatment of vulvodynia. In one study, 51 women with vulvodynia were treated with gabapentin cream. 35 women were found to have experienced significant pain relief. 28 women experienced more than 50% pain reduction.
More than likely this preparation is intended for the treatment of vulvodynia.
Vulvodynia is a little known, but particularly annoying chronic pain syndrome that primarily affects women between 20 and 40 years old. It is a collective term characterized by itching, a burning sensation, redness, pain or irritation in and around the vagina, labia and clitoris. Vulvodynia is referred to if no direct other cause (including infection, inflammation, etc.) is found. Some patients only suffer during intercourse, in other patients the pain is so severe that even the slightest touch can cause irritation or pain. Well-being is sometimes severely reduced [1].
A first choice treatment against vulvodynia does not exist. In addition to local creams for skin irritation and pelvic floor exercises, antidepressants are used with varying degrees of success to reduce pain symptoms. The anti-epileptic drugs gabapentin or pregabalin are used in a supporting role. A surgical procedure in which the vagina is enlarged and / or the irritated skin is removed is considered the last resort.
The role of tricyclic antidepressants and anti-epileptics in the treatment of chronic nerve pains has been established. [2]. Hence perhaps the inspiration to try this medicine in the treatment of vulvodynia.
Oral gabapentin has been shown to be effective in reducing pain symptoms in patients suffering from generalized vulvodynia [3]. In 64% of 152 included patients, at least 80% of the pain symptoms disappeared during the study period. The treatment was insufficiently effective in 32%.
In one study, 51 women with vulvodynia were treated with 2%, 4% or 6% gabapentin cream [4]. They were instructed to smear 0.5 ml (pea size) 3 times a day in the vagina. After 8 weeks the pain was evaluated on a pain score and 35 women were found to have experienced significant pain relief. 28 women experienced more than 50% pain reduction.
The global experience is therefore limited. Local treatment with gabapentin, however, is not (yet?) A standard treatment [5,6], which is part of fixed treatment guidelines.
I received two proposals from abroad.
The first is a cream with Nacromoglycate or -glicate 4% but the raw material appears to be unavailable in Belgium, although Fagron, this product sells in other countries! Unfortunately !
The second is Amphotericin 5%; Nystatin 100,000 units / gram in an ointment or safflower oil, sweet almond oil, beeswax, goldenseal root, myrrh gum and vitamins E, A, and D.
According to the source, both drugs are added to an existing specialty. Goldenseal root = hydrastis canadensis. But this too is not available with us.
This is of course an antimycotic preparation. But I think the doctor already tried this therapy.
We can therefore conclude that the effect of creams with gabapentin and amitriptyline can be tested. A simple cetomacrogol cream can be used as an excipient.
Hopefully it will benefit the patient more.