What causes vulvar ulceration?

Causes of Vulvar Ulceration

Herpes simplex virus (HSV) and syphilis are the most common infectious causes of vulvar ulceration in the United States, while non-infectious etiologies including trauma, dermatologic conditions, and drug reactions must also be considered. 1, 2

Infectious Causes

Sexually Transmitted Infections

• HSV (most common): Presents as vesicles that burst to form shallow ulcers on the vulva, labia, and surrounding genital area, with lesions progressing from papules to vesicles to ulcers that crust and heal within less than 10 days 3, 2
• Syphilis: Causes painless ulcers (chancres) and is the second most common cause of genital ulcers in the United States 1, 2
• Chancroid (Haemophilus ducreyi): Presents with painful ulcers, often accompanied by tender inguinal adenopathy; when suppurative adenopathy is present, this combination is almost pathognomonic 1, 2
• Lymphogranuloma venereum (LGV): Caused by invasive serovars L1, L2, or L3 of Chlamydia trachomatis; rare in the United States but can cause genital ulcers at the inoculation site 1, 2
• Granuloma inguinale (donovanosis): Uncommon in the United States but causes progressive ulcerative lesions 1, 2

Non-Sexually Transmitted Infections

• Epstein-Barr virus: Can cause aphthous spectrum ulcers that are not sexually acquired 1, 4
• Lipschütz ulceration: Non-sexually acquired condition affecting mainly sexually inactive subjects ≤20 years of age, presenting with ≤3 painful vulvar ulcers that resolve within 3 weeks, most frequently associated with infectious mononucleosis syndrome or flu-like illness 4
• Mycoplasma species: Associated with acute vulvar ulceration, particularly in younger patients 4
• Secondary bacterial infections: Can complicate existing ulcers 2, 5
• Fungal infections: Including candidiasis and dermatophytosis 5

Non-Infectious Causes

Dermatologic Conditions

• Behçet syndrome: Autoimmune condition causing recurrent oral and genital ulcers 3, 2
• Crohn disease: Can present with vulvar ulceration as an extraintestinal manifestation 3
• Psoriasis: Can affect the vulvar area and cause ulceration 2
• Autoimmune bullous disorders: Can present with vulvar ulcers 6

Other Non-Infectious Causes

• Sexual trauma: Direct mechanical injury causing ulceration 1, 2
• Fixed drug eruption: Medication-induced ulceration 3, 2
• Neoplasms: Vulvar malignancies can present as ulcerative lesions 7
• Hormonally induced ulcers: Related to hormonal changes 7

Critical Diagnostic Considerations

Co-infections Are Common

• Up to 10% of patients with genital ulcers have HSV co-infected with Treponema pallidum 3
• Patients with chancroid may be coinfected with T. pallidum or HSV in up to 10% of cases 1

Diagnostic Uncertainty

• Even after complete diagnostic evaluation, at least 25% of patients with genital ulcers have no laboratory-confirmed diagnosis 1, 3, 2
• Clinical diagnosis alone is often inaccurate, requiring laboratory confirmation 3

Essential Testing

• Viral culture or antigen test for HSV from the ulcer base or vesicular fluid 1, 3
• Serologic test for syphilis (mandatory in all cases) 1, 3
• Darkfield microscopy or direct fluorescent antibody testing for Treponema pallidum 1, 2
• Culture for Haemophilus ducreyi in settings with high chancroid prevalence 1, 2
• Testing for other STIs including Chlamydia trachomatis and Neisseria gonorrhoeae 3
• HIV testing should be considered, especially in patients with syphilis or chancroid 1

Key Clinical Pitfalls

• Atypical presentations are common due to secondary conditions, making clinical diagnosis unreliable 7
• The combination of painful ulcer with tender inguinal adenopathy suggests chancroid, particularly when adenopathy is suppurative 1
• Acyclovir-resistant HSV can occur even in immunocompetent patients, causing chronic non-healing ulcers 6