Treatment of Vaginal Aphthous Ulcers
For vaginal aphthous ulcers in adolescents and young women, initiate supportive care with high-potency topical corticosteroids (clobetasol 0.05% ointment 4 times daily) and topical anesthetics for pain relief, as these lesions are typically self-limited and resolve within days to weeks. 1, 2
Initial Diagnostic Approach
Before treating as aphthous ulcers, you must exclude sexually transmitted infections, which are far more common causes of genital ulcers in the United States:
- Obtain serologic testing for syphilis in all patients with genital ulcers 3, 4
- Perform HSV culture or PCR testing to rule out herpes simplex virus, the most common cause of genital ulcers in the U.S. 3, 4
- Test for Haemophilus ducreyi if chancroid is prevalent in your area 3, 4
- Consider HIV testing, especially given the association between genital ulcers and HIV transmission 3
The American Academy of Pediatrics notes that non-sexually acquired ulcers, including aphthous spectrum ulcers, can occur on external genitalia and vagina, distinguishing them from the more common sexually transmitted causes like HSV and syphilis 3.
Clinical Recognition of Aphthous Ulcers
Aphthous ulcers present with distinctive features that help differentiate them from infectious causes:
- Exquisitely painful ulcerations that are disproportionate to their size 1
- Typically occur in peri-menarchal adolescents (around the time of first menstruation) 1
- Often preceded by viral prodrome including fever, flu-like symptoms, or upper respiratory infection 2, 5
- Negative testing for HSV, syphilis, and other STIs 2
- Self-limited course with spontaneous resolution 1
First-Line Treatment Protocol
Once infectious causes are excluded, implement the following treatment approach:
Topical Corticosteroids:
- Clobetasol 0.05% ointment applied 4 times daily provides rapid symptomatic improvement, typically within 3-4 days 2
- Taper application over several days as ulcers heal to prevent rebound 2
Pain Management:
- Viscous lidocaine gel or lidocaine 2% gel applied as needed for immediate symptomatic relief 2
- This provides temporary anesthesia to allow eating, drinking, and urination 2
Systemic Therapy for Severe Cases
For extensive or recurrent aphthous ulcers:
- Oral prednisone for 2 weeks can produce complete resolution with no scarring in severe cases 5
- Consider systemic corticosteroids when topical therapy alone is insufficient 5
Expected Clinical Course
- Marked symptomatic improvement within 3-4 days of initiating topical corticosteroids 2
- Complete healing typically occurs within 1-2 weeks 1, 2
- Recurrence is possible with subsequent viral illnesses, but episodes generally become less severe 2
Critical Pitfalls to Avoid
Do not empirically treat with acyclovir without confirming HSV infection, as this delays appropriate diagnosis and wastes resources 2. The case report demonstrates a patient who received unnecessary acyclovir before proper diagnosis 2.
Do not assume sexual transmission in adolescents with genital ulcers—aphthous ulcers are non-sexually acquired and can cause significant distress if misdiagnosed as an STI 1, 5.
Do not overlook systemic associations: While most aphthous ulcers are benign, ulcers occurring with uveitis, arthritis, fever, or adenopathy require evaluation for Behçet syndrome or other systemic conditions 6.
Recognize that up to 25% of genital ulcers have no identifiable pathogen even after complete testing, making clinical diagnosis essential 3, 4.
Follow-Up Recommendations
- Re-evaluate in 3-7 days to confirm clinical improvement 2
- If no improvement occurs, reconsider the diagnosis and evaluate for resistant infections, HIV co-infection, or systemic disease 3, 4
- Counsel patients and families that recurrence may occur with future viral illnesses but typically responds to the same treatment 1, 2