What are the causes and treatment options for genital ulceration in pediatric patients?

Causes of Genital Ulceration in Pediatric Patients

The most common causes of genital ulceration in pediatric patients include infectious etiologies such as herpes simplex virus (HSV), syphilis, and chancroid, with HSV being the predominant cause in most settings. 1

Infectious Causes

Viral Causes

1. Herpes Simplex Virus (HSV)

   • Most common cause of genital ulcers in the United States 1, 2
   • Presents as painful vesicles that rupture to form shallow ulcers
   • Lesions typically heal within 10 days without scarring but may be prolonged with secondary bacterial infection or immunosuppression 1
   • Diagnosis: Culture or antigen test for HSV; PCR testing is most sensitive 1
   • Treatment: Acyclovir 20 mg/kg 4 times daily (up to 3,200 mg per day) for 5-7 days for primary infection in children 3

2. Epstein-Barr Virus (EBV)

   • Rare cause of genital ulcers in pediatric patients 2, 4

Bacterial Causes

1. Syphilis (Treponema pallidum)

   • Presents as painless, indurated ulcer (chancre)
   • Diagnosis: Darkfield examination or direct immunofluorescence test for T. pallidum; serologic testing 1
   • Treatment: Intramuscular penicillin G benzathine in a single dose 5

2. Chancroid (Haemophilus ducreyi)

   • Painful genital ulcer often with tender inguinal adenopathy
   • Suppurative inguinal adenopathy is almost pathognomonic 1
   • Diagnosis: Culture for H. ducreyi (sensitivity ≤80%) 1
   • Treatment options for pediatric patients:
     • Azithromycin 1 g orally in a single dose
     • Ceftriaxone 250 mg IM in a single dose
     • Erythromycin base 500 mg orally four times a day for 7 days 1

3. Lymphogranuloma Venereum (LGV)

   • Caused by specific serovars of Chlamydia trachomatis
   • Treatment: Oral doxycycline for 21 days (for post-pubertal patients) 5

4. Granuloma Inguinale (Donovanosis)

   • Caused by Klebsiella granulomatis
   • Treatment: Oral doxycycline for 21 days (for post-pubertal patients) 5

Non-Infectious Causes

1. Inflammatory Conditions

   • Behçet syndrome
   • Inflammatory bowel disease (Crohn disease)
   • Psoriasis 1, 5

2. Traumatic Causes

   • Sexual trauma
   • Accidental trauma 5, 4

3. Drug-Related

   • Fixed drug eruptions 5, 2

Diagnostic Approach

For all pediatric patients with genital ulcers, the following tests should be considered:

1. Serologic tests for syphilis
2. Darkfield microscopy or direct fluorescent antibody testing for T. pallidum
3. Culture or PCR test for herpes simplex virus
4. Culture for H. ducreyi in settings with high prevalence of chancroid 5, 2

Important note: In up to 25% of patients with genital ulcers, no pathogen is identified despite diagnostic efforts 1, 5, 6

Management Considerations

1. Laboratory confirmation is essential

   • Clinical diagnosis alone is often inaccurate 1
   • Multiple pathogens may be present in 3-10% of cases 1

2. HIV testing

   • Should be performed in patients with genital ulcers caused by T. pallidum or H. ducreyi
   • Should be considered for those with ulcers caused by HSV 1

3. Treatment before test results

   • If diagnosis is unclear, treat for the most likely cause based on clinical presentation
   • In areas with notable chancroid prevalence, consider treating for both syphilis and chancroid 1

4. Special considerations for pediatric patients

   • Genital ulcers in children may raise concerns about sexual abuse
   • Management requires referral to or close consultation with physicians familiar with pediatric infections 1
   • Dosing of medications should be adjusted based on age and weight

Common Pitfalls and Caveats

1. Relying solely on clinical appearance for diagnosis can lead to misdiagnosis
2. Failing to consider non-infectious causes when infectious testing is negative
3. Not testing for multiple pathogens, as co-infections can occur
4. Overlooking the possibility of sexual abuse in pediatric patients with STIs
5. Not adjusting medication dosages appropriately for pediatric patients

By following a systematic approach to diagnosis and treatment, clinicians can effectively manage genital ulcers in pediatric patients while minimizing complications and preventing transmission.