What is a Lipschutz ulcer?

Lipschütz Ulcer: A Non-Sexually Transmitted Genital Ulceration

Lipschütz ulcer is a rare, non-sexually transmitted condition characterized by painful, necrotic genital ulcerations that occur suddenly in young females, typically associated with systemic infections, and resolves spontaneously within 2-3 weeks without specific treatment.

Clinical Presentation

• Demographics: Primarily affects females ≤20 years of age 1
• Sexual history: Most commonly occurs in sexually inactive females, though can affect sexually active individuals 1, 2
• Onset: Sudden appearance of painful genital ulcers
• Ulcer characteristics:
  • Usually 1-3 ulcers 1
  • Well-demarcated with necrotic centers
  • Painful
  • ≥10mm in size
  • Symmetric distribution 1
  • May have a "kissing pattern" (bilateral ulcers on opposing surfaces)

Associated Symptoms and Findings

• Vulvar edema preceding ulceration
• Voiding difficulties in many cases
• Enlarged inguinal lymph nodes
• Oral aphthous ulcers in approximately 10% of cases 1
• Often accompanied by systemic symptoms:
  • Fever
  • Malaise
  • Myalgia
  • Lymphadenopathy

Etiology

Lipschütz ulcers are associated with various infectious triggers:

• Epstein-Barr virus (most common identified cause) 3, 1
• Other infectious agents:
  • Cytomegalovirus
  • Mycoplasma species
  • Ureaplasma 2
  • Mumps
  • Salmonella species
  • Toxoplasmosis 2
  • Other viral or bacterial infections causing flu-like illness

Diagnosis

Lipschütz ulcer is a diagnosis of exclusion 4. The diagnostic approach should include:

1. Clinical evaluation:

   • Detailed history (including sexual history)
   • Physical examination of genital ulcers
   • Assessment for systemic symptoms

2. Laboratory testing to exclude other causes:

   • Serologic tests for sexually transmitted infections:
     • Herpes simplex virus (HSV)
     • Syphilis
     • HIV
   • Testing for EBV, CMV, mycoplasma
   • Complete blood count
   • Inflammatory markers

3. Diagnostic criteria 5:

   • Age <20 years (though can occur at any age)
   • First episode of acute genital ulceration
   • Sudden onset of painful ulcers
   • Absence of sexual contact (traditional criterion, though now recognized in sexually active individuals)
   • Absence of immunodeficiency

Differential Diagnosis

Several conditions must be excluded:

• Sexually transmitted infections:

  • Genital herpes
  • Syphilis
  • Chancroid 6
  • Lymphogranuloma venereum

• Non-infectious causes:

  • Behçet's syndrome 6
  • Fixed drug eruptions
  • Crohn's disease 6
  • Trauma
  • Stevens-Johnson syndrome
  • Pemphigus

Management

Treatment is primarily supportive as the condition is self-limiting:

1. Pain management:

   • Topical anesthetics
   • Oral analgesics
   • Sitz baths

2. Wound care:

   • Keep area clean and dry
   • Avoid tight clothing
   • Consider topical antiseptics

3. Specific treatments:

   • Treat identified underlying infection if present
   • Systemic corticosteroids have not been shown to reduce disease duration 1
   • Antibiotics only if secondary bacterial infection occurs

Prognosis

• Self-limiting: Resolves spontaneously within 2-3 weeks 1
• Recurrence: Uncommon
• Scarring: Minimal in most cases

Important Considerations

• Despite being described as rare, studies suggest Lipschütz ulcers may account for 4-36% of acute genital ulcer cases in females, indicating it is likely underdiagnosed 5
• Misdiagnosis as sexually transmitted infection is common and can cause significant psychological distress, especially in adolescents 3
• Persistent questioning about sexual history when the patient denies sexual activity can be harmful and embarrassing 3
• Consider this diagnosis in young females with acute painful genital ulcers, particularly when accompanied by systemic symptoms and negative STI testing

Clinical Pitfalls to Avoid

• Assuming all genital ulcers are sexually transmitted
• Initiating unnecessary antiviral or antibiotic therapy without confirmed diagnosis
• Failing to consider non-sexually transmitted etiologies in adolescents
• Overlooking potential systemic infectious triggers
• Excessive and repeated questioning about sexual activity when the patient consistently denies it

By maintaining awareness of this uncommon but important diagnosis, clinicians can provide appropriate care and avoid unnecessary treatments and psychological distress for patients with Lipschütz ulcers.