Vulval ulcers

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  • See also

    Sexually transmitted infections
    Vulval and vaginal conditions

    Key Points

    1. Most vulval ulcers in children are aphthous or secondary to a systemic infection, rather than due to sexually transmitted infections
    2. Diagnosis on clinical appearance alone is difficult and investigations are often required


    • 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



    Aphthous ulcers

    Common in adolescents
    May be multiple and recurrent
    Associated with systemic symptoms or recent illness


    HSV via autoinoculation, EBV, CMV, VZV, coxsackie virus
    Mycoplasma, Candida albicans

    Other symptoms consistent with infection


    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


    Multiple vesicles progressing to painful or itchy ulcers


    Single painless ulcer

    Lymphogranuloma venereum

    Rare. Single painless ulcer, associated urethritis


    Rare. Exquisitely painful and associated with suppurative inguinal adenopathy


    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


    Trauma or excoriation
    Erosive lichen sclerosus
    Hair removal folliculitis
    Epidermolysis bullosa
    Allergic or irritant contact dermatitis




    • 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


    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



    • 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


    • 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

  • Reference List

    1. Janz-Robinson, E. Differential diagnosis of vulval ulcers. 2017. DermnetNZ, (viewed October 2020)
    2. Laufer, M and Emans S. Overview of vulvovaginal complaints in the prepubertal child. UpToDate (viewed October 2020)
    3. Margesson, L and Haefner, H. Vulvar lesions: differential diagnosis based on morphology. UpToDate (viewed October 2020)
    4. Margesson, L and Haefner, H. Vulvar lesions: Diagnostic evaluation. UpToDate (viewed October 2020)
    5. Oakley, A 2010. Non-sexually acquired genital ulceration. DermnetNZ (viewed October 2020)