See also
Sexually transmitted infections
Vulval and vaginal conditions
Key Points
- Most vulval ulcers in children are aphthous or secondary to a systemic infection, rather than due to sexually transmitted infections
- Diagnosis on clinical appearance alone is difficult and investigations are often required
Background
- Vulval ulcers are uncommon, particularly in children who are not yet sexually active
- Ulcers are often very painful and can cause anxiety and emotional distress for the child and family
- In children, vulval ulcers are not usually due to sexually transmitted infections (STIs)
- Using clinical appearance alone to diagnose the cause of vulval ulcers is misleading due to overlap and variable disease presentation
Differential diagnosis
| Diagnosis |
Features |
|
Aphthous ulcers |
Common in adolescents
May be multiple and recurrent
Associated with systemic symptoms or recent illness |
|
Infectious |
|
HSV via autoinoculation, EBV, CMV, VZV, coxsackie virus
Mycoplasma, Candida albicans |
Other symptoms consistent with infection |
|
Impetigo |
Spreading blisters and redness with yellow crust |
|
Group A streptococci |
Often associated with bright red perianal rash, itching and rectal pain |
|
Molluscum contagiosum |
Firm papules with central dimple, may ulcerate if core removed |
|
Sexually transmitted infections |
|
HSV |
Common
Multiple vesicles progressing to painful or itchy ulcers |
|
Syphilis |
Single painless ulcer |
|
Lymphogranuloma venereum |
Rare. Single painless ulcer, associated urethritis |
|
Chancroid |
Rare. Exquisitely painful and associated with suppurative inguinal adenopathy |
|
Autoimmune |
|
Crohn’s disease |
Mixed linear inflammatory lesions and fissures
Vulvar oedema
GI symptoms |
|
Behcet disease |
Recurrent oral ulcers and systemic symptoms,
Aphthous genital ulcers, painful and heal with scarring
Eye and skin involvement |
|
Drug reactions |
|
NSAIDs, metronidazole, paracetamol, sulfonamides, tetracycline, phenytoin, oral contraceptives, barbiturate, phenolphthalein |
No definitive features
Exposure to medication |
|
Stevens-Johnson syndrome/ toxic epidermal necrolysis |
Flu-like illness
Ulcers across mucous membranes and skin
Conjunctivitis |
|
Other |
|
Trauma or excoriation
Erosive lichen sclerosus
Hair removal folliculitis
Epidermolysis bullosa
Allergic or irritant contact dermatitis
Malignancy |
|
Assessment
History
- Single or multiple lesions
- First episode or recurrent
- Painful or painless
- Evolution of ulcer(s)
- Difficulty passing urine
- Review of systems:
- Systemic symptoms: fever, malaise, headache, myalgia
- Gastrointestinal symptoms
- Respiratory symptoms
- Oral ulcers, skin lesions, eye and joint symptoms
- Family history autoimmune disorders and family ethnicity (Behcet disease is more common in families from Mediterranean countries and South East Asia)
- Normal skin care and hygiene routines
- Sexual history
- Medication and topical product (washing detergent, soaps etc) exposure
Examination
See Vulval and vaginal conditions for considerations relating to performing a perineal examination
Assess for
- Size, shape, colour, location of vulval ulcers
- Presence of secondary skin changes (excoriation, lichenification, oedema, crust, bleeding, pigmentation, scar)
- Oral ulcers
- Joint and eye examination when autoimmune causes being considered
- Skin inspection for eczema, rash, other ulcers or bullae
- Lymphadenopathy
Management
Investigations
- Swab ulcer(s):
- Viral: HSV-1 and 2, VZV PCR
- Bacterial: Gram stain and culture, syphilis PCR
- Fungal: wet prep and culture
- Consider blood tests:
- Serology for HSV-1 and 2, EBV (plus monospot), CMV, Syphilis and Mycoplasma
- CRP, ESR, FBE, ANA ± HLA-B51 (Behcet)
- Also see
Sexually transmitted infections
- If non-healing lesion, may need biopsy
Treatment
- Symptom relief
- Analgesia – simple oral, topical (xylocaine viscous, lidocaine gel 2%)
- Minimise irritants (no soaps, pads, tight underwear or clothing)
- Pass urine while using a spray bottle or in a bath to reduce dysuria
- Salt baths
- Cool compresses
- Barrier cream
- If unable to void, admission for a urinary catheter may be required
- Antiviral: consider aciclovir if primary HSV is likely diagnosis
- Steroids: consider topical corticosteroids if aphthous ulcers most likely
- Antibiotics: if bacterial infection suspected
- Treat
sexually transmitted infections
Consider consultation with local paediatric team when
Admission for urinary catheter is required
Consider specialist consultation when
Appropriate specialist consultation with gynaecology, dermatology, rheumatology or infectious diseases is required when the diagnosis is unclear or there is concern for a more serious cause
If sexual assault is suspected, please refer to local guidelines. Early consultation with specialist services is vital
Consider transfer when
Child requires care above the level of comfort of the local hospital
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
Consider discharge when:
Adequate symptom relief and clear follow up plan in place
Parent information
Vulval skin care for children
Last updated November 2022