What is the treatment for a vaginal ulcer?

Treatment of Vaginal Ulcers

The treatment of vaginal ulcers should be directed at the underlying cause, with herpes simplex virus (HSV), syphilis, and chancroid being the most common infectious etiologies requiring specific antimicrobial or antiviral therapy. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Required testing:

  • Serologic test for syphilis
  • Darkfield examination or direct immunofluorescence for Treponema pallidum
  • Culture or antigen test for HSV
  • Culture for Haemophilus ducreyi (in settings where chancroid is prevalent) 1, 2
  • HIV testing (particularly important for patients with syphilis or chancroid) 1

• Important note: Up to 25% of patients with genital ulcers have no laboratory-confirmed diagnosis despite complete testing 1, 3

Treatment Based on Specific Etiology

1. Herpes Simplex Virus (Most common in the US)

• First episode:
  • Acyclovir 400 mg orally three times daily for 7-10 days 2, 3
  • Alternatives: Famciclovir or valacyclovir 3
• Recurrent episodes:
  • Acyclovir for 5 days 2

2. Syphilis

• Primary syphilis:
  • Benzathine penicillin G 2.4 million units IM in a single dose 2, 3
  • Follow-up examination to ensure healing 2

3. Chancroid

• Recommended regimens (choose one):

  • Azithromycin 1 g orally in a single dose 1, 4
  • Ceftriaxone 250 mg IM in a single dose 1
  • Ciprofloxacin 500 mg orally twice daily for 3 days 1
  • Erythromycin base 500 mg orally four times daily for 7 days 1

  Note: Ciprofloxacin is contraindicated in pregnant women, lactating women, and persons under 18 years of age 1

4. Lymphogranuloma Venereum

• Doxycycline 100 mg orally twice daily for 21 days 2, 3

5. Granuloma Inguinale (Donovanosis)

• Doxycycline 100 mg orally twice daily for at least 3 weeks and until all lesions have completely healed 2

6. Candidiasis (if present)

• Intravaginal options:
  • Clotrimazole 1% cream 5 g intravaginally for 7-14 days 1
  • Miconazole 2% cream 5 g intravaginally for 7 days 1
  • Various other intravaginal azole preparations 1
• Oral option:
  • Fluconazole 150 mg oral tablet, single dose 1, 5

Wound Care for Ulcers

• Gentle cleansing with sterile saline solution 2
• Avoid harsh antiseptics that may delay healing 2
• Apply plain petrolatum ointment directly to the ulcer 2
• Cover with non-adherent dressing 2
• Regular dressing changes to maintain cleanliness 2

Special Considerations

When Diagnosis is Unclear

If treatment must be initiated before test results are available:

• Treat for the diagnosis considered most likely 1
• Many experts recommend treatment for syphilis, or for both syphilis and chancroid if the patient resides in a community where chancroid is prevalent 1

HIV Co-infection

• HIV testing should be performed for all patients with genital ulcers, especially those with syphilis or chancroid 1, 2
• Patients with HIV may require more aggressive or prolonged therapy 1
• Uncircumcised and HIV-infected patients with chancroid might not respond as well to treatment 1

Follow-up

• For chancroid: Re-examination 3-7 days after treatment initiation 1
• For all ulcers: Monitor until complete healing occurs 2
• Consider treatment failure if no improvement after 3-7 days 1
• If treatment fails, consider: incorrect diagnosis, co-infection with another STD, HIV infection, non-adherence to treatment, or antimicrobial resistance 1

Common Pitfalls to Avoid

1. Misdiagnosis: Up to 25% of genital ulcers have no identifiable pathogen despite testing 3
2. Overlooking non-infectious causes: Consider conditions like Behçet's syndrome, pemphigus, Crohn's disease, and erosive lichen planus 6
3. Inadequate testing: Failure to perform all recommended diagnostic tests can lead to missed diagnoses 1
4. Treating empirically without follow-up: Always re-examine patients to ensure healing 1, 2
5. Ignoring HIV risk: Genital ulcers increase HIV transmission risk 6
6. Neglecting partner treatment: Sexual partners should be examined and treated appropriately 2

By following this structured approach to diagnosis and treatment, most vaginal ulcers can be effectively managed with resolution of symptoms and prevention of complications.