What is the recommended treatment for a gay man with a penis ulcer suspected to be Lymphogranuloma Venereum (LGV)?

From the Guidelines

The recommended treatment for a gay man with a penis ulcer suspected to be Lymphogranuloma Venereum (LGV) is doxycycline 100 mg taken orally twice daily for 21 days. This extended course is necessary because LGV, caused by specific serovars of Chlamydia trachomatis (L1, L2, or L3), involves deeper tissue invasion than non-LGV chlamydial infections, as noted in the guidelines for treatment of sexually transmitted diseases 1. While awaiting confirmation of LGV diagnosis through laboratory testing, treatment should begin promptly to prevent complications such as lymphatic obstruction, genital elephantiasis, or rectal strictures.

Key Considerations

• Alternative regimens for patients who cannot take doxycycline include erythromycin base 500 mg orally four times daily for 21 days.
• Sexual partners from the previous 60 days should also be evaluated, tested, and treated for chlamydial infection, as suggested by the treatment guidelines 1.
• The patient should abstain from sexual activity until treatment is completed and symptoms have resolved.
• Additionally, testing for other sexually transmitted infections including HIV, syphilis, gonorrhea, and hepatitis B is recommended, as co-infections are common.
• Follow-up evaluation should occur within 1-2 weeks to ensure symptom improvement and treatment adherence, and buboes may require aspiration through intact skin or incision and drainage to prevent the formation of inguinal/femoral ulcerations, with doxycycline being the preferred treatment 1.

From the FDA Drug Label

Lymphogranuloma venereum caused by Chlamydia trachomatis. The recommended treatment for a gay man with a penis ulcer suspected to be Lymphogranuloma Venereum (LGV) is doxycycline 2.

• The treatment is aimed at targeting the causative agent, Chlamydia trachomatis.
• Doxycycline is indicated for the treatment of LGV, as stated in the drug label.

From the Research

Diagnosis of LGV

• The diagnosis of Lymphogranuloma Venereum (LGV) can be confirmed with an LGV discriminatory nucleic acid amplification test (NAAT) in a sample that has tested positive for Chlamydia trachomatis with a commercial NAAT platform 3.
• A high index of clinical suspicion is necessary for the early diagnosis of LGV, as the clinical presentation can be unspecific 4.

Treatment of LGV

• The recommended treatment for LGV is doxycycline 100 mg twice a day orally for 21 days 3, 5.
• However, recent evidence suggests that a 7-day course of doxycycline may be as effective as the traditional 21-day course for asymptomatic or clinically mild C. trachomatis infections, and contacts of LGV infection 6.
• In cases of inguinal LGV, prolonged courses of doxycycline, exceeding the currently advised 21 days regimen, may be necessary 7.
• Azithromycin is not recommended as a treatment for LGV, as it may be insufficient to prevent established infections and has been associated with treatment failure 5, 7.

Considerations for Gay Men with Penis Ulcer

• Gay men with a penis ulcer suspected to be LGV should be tested for Chlamydia trachomatis and LGV-specific DNA 3.
• If LGV is confirmed, treatment with doxycycline should be initiated as soon as possible, and the patient should be monitored for response to treatment and potential complications 4, 5.
• It is essential to consider the patient's HIV status, as LGV infections are more common among men who have sex with men (MSM) living with HIV, and the treatment approach may need to be adjusted accordingly 4.