Workup and Treatment for Vulvar Ulcers
The comprehensive workup for vulvar ulcers should include serologic testing for syphilis, HSV culture or PCR, and consideration of H. ducreyi culture in high-prevalence settings, with treatment directed at the specific etiology identified. 1, 2
Initial Diagnostic Workup
Required Testing
- Serologic test for syphilis (all patients)
- Darkfield examination or direct immunofluorescence for Treponema pallidum
- Culture or antigen test for HSV
- Culture for Haemophilus ducreyi (in settings where chancroid is prevalent)
- HIV testing (especially for patients with syphilis or chancroid)
Additional Workup Based on Clinical Presentation
- Consider testing for:
- Lymphogranuloma venereum (LGV)
- Granuloma inguinale (donovanosis)
- Non-infectious causes (biopsy may be needed)
Differential Diagnosis
Infectious Causes
- Herpes Simplex Virus (HSV) - Most common cause in the US 2
- Syphilis - Second most common cause in the US 2
- Chancroid (H. ducreyi)
- Lymphogranuloma venereum (LGV)
- Granuloma inguinale (donovanosis)
- Secondary bacterial infections
- Fungal infections
Non-Infectious Causes
- Sexual trauma
- Psoriasis
- Behçet syndrome
- Fixed drug eruptions
- Vulvar aphthous ulcers (non-sexually acquired) 3
Treatment Algorithm
1. Herpes Simplex Virus
- First episode:
- Recurrent episodes:
- Same medications for 5 days 1
2. Syphilis
- Primary syphilis:
- Follow-up: Re-examination to ensure healing
3. Chancroid
- Recommended regimens:
- Azithromycin 1 g orally in a single dose, OR
- Ceftriaxone 250 mg IM in a single dose, OR
- Ciprofloxacin 500 mg orally twice daily for 3 days (contraindicated in pregnancy, lactation, and persons <18 years), OR
- Erythromycin base 500 mg orally four times daily for 7 days 1
- Expected healing time: 7-14 days for small ulcers, >2 weeks for large ulcers
4. Lymphogranuloma Venereum
- Doxycycline 100 mg orally twice daily for 21 days
- Alternative for pregnant patients: Erythromycin base 500 mg orally four times daily for 21 days 1
5. Granuloma Inguinale (Donovanosis)
- Doxycycline 100 mg orally twice daily for at least 3 weeks and until all lesions have completely healed 1, 2
6. Non-Infectious Vulvar Ulcers
- Vulvar aphthous ulcers:
- Topical corticosteroids (e.g., clobetasol 0.05% ointment 4 times daily) 4
- Topical anesthetics for pain relief (lidocaine gel/ointment)
- Behçet syndrome:
- Consider referral to specialist for systemic therapy 2
Wound Care
- Gentle cleansing with sterile saline solution
- Application of plain petrolatum ointment directly to the ulcer
- Cover with non-adherent dressing or petrolatum-impregnated gauze
- Secure with a bandage that provides protection without excessive pressure 1
Follow-Up and Monitoring
- Re-examination 3-7 days after treatment initiation 1
- Signs of treatment failure:
- No symptomatic improvement within 3 days
- No objective improvement within 7 days
- Worsening symptoms despite appropriate therapy
- Development of new lesions during treatment 1
Special Considerations
HIV Co-infection
- May require longer courses of therapy
- Closer monitoring recommended 1
- Higher risk of treatment failure
Pregnancy
- Avoid ciprofloxacin
- Azithromycin safety not established in pregnancy 1
- Use erythromycin or penicillin-based regimens when appropriate
When to Refer
- Ulcers that do not respond to appropriate therapy
- Extensive or rapidly spreading lesions
- Suspected malignancy
- Recurrent ulcerations despite appropriate treatment 1
Important Caveats
- No pathogen is identified in up to 25% of patients with genital ulcers 2
- Consider non-infectious causes when infectious workup is negative
- Sexual partners should be examined and treated appropriately 1
- In adolescents, consider non-sexually acquired genital ulcers, which are typically self-limited but exquisitely painful 3
- Acyclovir-resistant HSV can occur even in immunocompetent patients and may require alternative treatments like foscarnet 5