Background
Vulvar ulcers are rare in
girls and young women, especially when they are not sexually
active.Most lesions are exquisitely
painful and result in considerable anxiety and emotional distress
for both the patient and family, not to mention the physician's
frustration in trying to expediently diagnose and treat a lesion
which is rarely seen in general practice.Parents and physicians may also suspect sexual abuse,
which can be very disconcerting. Most ulcers in the
paediatric population however are NOT sexually transmitted
infections.
The differential diagnosis
of non-sexually transmitted vulvar ulcers
is as follows (most common in bold)
- Aphthous
ulcers(synonyms include
aphthosis, canker sores, Lipschutz ulcers, ulcus vulvae
acutum)
- Infectious
- HSV via autoinoculation
- EBV (self limited genital
ulcers)
- CMV
- VZV (varicella or herpes zoster)
- Group A Strep
- Mycoplasma
- Molluscum contagiosum
- Autoimmune
- Crohn's disease (ulcers + GI
symptoms)
- Behçet's disease (Aphtous genital ulcers
that last for weeks and heal with scarring)
- Vaculitis (LUPUS)
- Pemphigus and Pemphigoid (lesions may mimic
lichen sclerosus with extensive scarring)
- Drug reactions
- Fixed drug eruptions(NAIDs, metronidazole,
Acetaminophen, Sulfonamides, Tetracycline, Phenitoyn, oral
contraceptives, Barbiturates, Phenolphthaten)
- Stevens Johnson's syndrome/ toxic epidermal
necrolysis
- Other
- Erosive Lichen Sclerosus
- Hair removal folliculitis
- Epidermolysis bullosa
- Allergic contact dermatitis
In sexually active
young women, or in cases of sexual abuse, the differential
diagnosis also includes:
- HSV (most common, multiple vesicles
progressing to pustules over 10-14 days)
- Syphilis (painless ulcer)
- Rarely- Lymphogranuloma venereum and
Chancroid ( Ulcer is exquisitely painful and is associated with
suppurative inguinal adenopathy)
Assessment
History:
The history should
determine whether these are primary or recurrent lesions and the
evolution of it. A review of systems should
include:
Systemic symptoms (fever,
malaise, headache, GI symptoms, respiratory symptoms,
myalgia)
Oral ulcers, skin lesions,
ocular symptoms.
A family history of
autoimmune disorders should be determined. Behçet's disease
is more common in families from Mediterranean countries, Turkey and
the Middle East, and South East Asia.
Social history should be
obtained confidentially, especially if there is a possibility of
sexual activity.
Examination:
Assess for the
following:
- General
appearance
- Oral ulcers
- Uveitis
(Behçet's)
- Skin inspection (eczema,
rash, other ulcers or bullae)
- Lymphadenopathy
(cervical, inguinal/femoral)
- Size, shape, location of
vulvar ulcer(s): Physical examination of the external genitalia can
be accomplished in the frog leg or knee chest
position.
Investigations:
(send results to
GP)
Non-sexually
active:
- Swabs:
- HSV 1 and 2, VZV
- PCR
- OR immunofluorescence
- OR culture
- Gram stain and bacterial culture
- Yeast Culture
- Consider the following
- Serology:
- Herpes simplex (HSV-1/HSV-2)
- EBV (IgM and IgG) and/ or
monotest
- CMV and Mycoplasma
- CRP and ESR
- FBE
- ANA and Consider HLA-B51 if Behçet's disease
is a possibility
Sexually
active:
- All of the above plus:
- Urine:
- Pregnancy test
- PCR for Chlamydia (First pass urine
test)
- PCR for Gonorrhea (First pass urine
test)
- Serology:
- RPR (Rapid Plasma Reagin)
- HIV
If non healing refer the
patient for biopsy of lesion.
Management
Because of the delay in
results from most of the investigations, treatment is often
supportive, directed to pain relief, prevention of scarring and
specific treatment based on diagnosis. In severe cases where
micturition is impossible secondary to pain, an in-dwelling
catheter may be required.
Provide reassurance to
parents and the patient that ulcers in young girls and women are
often not sexually transmitted, and that recurrence rates are
low.
- Remove all irritants
- No pads, underwear, tight
clothes
- Pain relief:
- Salt baths and general vulvar hygiene are
recommended (see vulvar care handout).
- Spray bottles or voiding in the bath to
reduce external dysuria
- Petrolatum or zinc oxide barrier after
soak
- Topical anaesthetics (ie. Viscous Xylocaine,
Lignocaine gel 2%)
- Oral Analgesics ( NSAIDs)
- Antiviral:
- Consider Aciclovir if primary HSV likely
diagnosis
- Steroids:
- Consider topical corticosteroids (Advantan
fatty ointment) if aphthous ulcers or Behçhet's disease most
likely
- Antibiotics: if bacterial infection
suspected
- Treatment of Sexually Transmited Infections
(Refer to CPGs on STIs)
- Immunosuppressants: (Discuss with
Reumathology Consultant if Behchet's disease and aphtous ulcers is
likely the diagnosis)
Referral
Most ulcers are
self-limiting and can be followed up by the GP. If the ulcers
are recurrent or there are associated abnormalities to the
underlying skin, then a referral to Gynaecology for follow-up
should be organized. If Behçet's disease is suspected, a
referral to Rheumatology may be useful. Dermatology or
Infectious Diseases could also be consulted.