Treatment of Vaginal Ulcers
The treatment of vaginal ulcers should be based on the specific etiology, with antimicrobial therapy directed at the most common infectious causes including herpes simplex virus (HSV), syphilis, and chancroid, while also providing appropriate wound care. 1
Diagnostic Approach Before Treatment
Before initiating treatment, the following diagnostic tests should be performed:
- Serologic tests for syphilis
- Darkfield examination or direct immunofluorescence for Treponema pallidum
- Culture, PCR, or antigen test for HSV
- Culture for Haemophilus ducreyi (in settings where chancroid is prevalent)
- HIV testing (mandatory for patients with syphilis or chancroid, recommended for all) 1, 2
Treatment Based on Specific Causes
1. Herpes Simplex Virus (Most common in US)
- First episode: Oral acyclovir for 7-10 days
- Recurrent episodes: Oral acyclovir for 5 days
- Alternatives: Famciclovir or valacyclovir 1, 2
2. Syphilis
- Single dose of intramuscular penicillin G benzathine
- Follow-up examination to ensure healing 1
3. Chancroid (H. ducreyi)
- Options include:
- Azithromycin 1 g orally in a single dose
- Ceftriaxone 250 mg IM in a single dose
- Ciprofloxacin 500 mg orally twice daily for 3 days (contraindicated in pregnancy)
- Erythromycin base 500 mg orally four times daily for 7 days 1
4. Lymphogranuloma Venereum
- Doxycycline 100mg orally twice daily for 21 days
- Alternative for pregnant patients: Erythromycin base 500mg orally four times daily for 21 days 1
5. Granuloma Inguinale (Donovanosis)
- Doxycycline 100mg orally twice daily for at least 3 weeks and until all lesions have completely healed 1, 2
6. Non-infectious Causes
- Sexual trauma: Topical wound care
- Psoriasis: Topical corticosteroids
- Behçet syndrome: Consider subcutaneous pegylated interferon alfa-2a
- Fixed drug eruptions: Discontinuation of causative medication 2, 3
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 protective bandage that doesn't apply excessive pressure
- Maintain a moist wound environment to facilitate healing 1
Special Considerations
- Up to 25% of patients with genital ulcers may have no laboratory-confirmed diagnosis even after complete evaluation 1, 2, 4
- Healing time varies depending on:
- Etiology
- Size (ulcers ≥3.1 cm may require >2 weeks to heal)
- HIV status (HIV-positive patients heal more slowly)
- Circumcision status in male partners 1
Follow-up and Treatment Failure
- Re-examination 3-7 days after treatment initiation
- 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
Important Caveats
- Ciprofloxacin should be avoided in pregnancy
- HIV co-infection may require longer courses of therapy and closer monitoring
- Sexual partners should be examined and treated appropriately
- Consider referral for ulcers that:
The most recent evidence from the CDC guidelines emphasizes the importance of identifying the specific cause of vaginal ulcers to guide appropriate treatment, as treatment approaches differ significantly based on etiology 1, 5.