What is the diagnosis and treatment for a young woman presenting with Lipschutz ulcers, potentially associated with infectious mononucleosis or other viral infections?

Lipschütz Ulcers: Diagnosis and Management

Clinical Recognition

Lipschütz ulcers are acute, painful, non-sexually transmitted vulvar ulcerations that primarily affect young, sexually inactive women and resolve spontaneously within 3 weeks, most commonly triggered by Epstein-Barr virus or other viral infections. 1

Key Diagnostic Features

• Patient demographics: Approximately 90% of cases occur in women ≤20 years of age who are sexually inactive 1
• Ulcer characteristics: Typically 1-3 painful ulcers, ≥10 mm in size, well-delimited with fibrinous and necrotic centers and symmetric distribution 1
• Associated symptoms: Prodromal flu-like illness or infectious mononucleosis syndrome precedes ulcer development, with voiding disorders and enlarged inguinal lymph nodes frequently present 1, 2
• Oral involvement: Canker sores noted in 10% of patients 1

Essential Diagnostic Workup

Despite the clinical presentation suggesting non-sexually transmitted etiology, comprehensive STI testing remains mandatory to exclude life-threatening sexually transmitted infections.

Required Laboratory Testing

• Serologic testing for syphilis in all patients with genital ulcers, as diagnosis based on history and physical examination alone is often inaccurate 3, 4
• HSV culture or PCR from ulcer base, as HSV remains the most common cause of genital ulcers in the United States (49% prevalence) 3, 5, 6
• HIV testing should be considered given the association between genital ulcers and HIV transmission 3, 5, 6
• Haemophilus ducreyi culture if chancroid is endemic in your geographic area 3, 4

Specific Testing for Lipschütz Ulcers

• Epstein-Barr virus serology and PCR is the highest yield test, as EBV-associated infectious mononucleosis is the most frequently detected infection (40 of 139 infectious cases) 1, 2, 7
• Mycoplasma and Ureaplasma testing should be performed, as these are the second most common identified pathogens (11 cases in systematic review) 8, 1
• Cytomegalovirus testing can be considered as CMV has been documented as a causative agent 9

Critical Management Pitfall

Up to 25% of genital ulcers have no identifiable pathogen even after complete testing, and up to 10% have co-infections (HSV with T. pallidum), so never rely on a single positive test to exclude other pathogens. 5, 6

Treatment Approach

Supportive Care (Primary Treatment)

• Reassurance and supportive measures are the mainstay of treatment, as the condition resolves spontaneously within ≤3 weeks without recurrence 1, 2
• Pain management with analgesics and gentle hygiene with mild, unscented cleansers 6
• Avoidance of sexual activity until ulcers heal completely 5, 6

Corticosteroids (Severe Cases Only)

• Systemic corticosteroids may be considered in severe cases, though evidence shows they do not reduce disease duration 1
• Topical clobetasol can be used but requires monitoring for secondary infections 6

When to Treat Empirically for STIs

If test results are not immediately available and the patient has risk factors for STIs, empiric treatment should cover syphilis and HSV while awaiting results. 3, 5

• Benzathine penicillin G 2.4 million units IM single dose for syphilis coverage 5
• Acyclovir 400 mg orally 5 times daily for 10 days for HSV coverage 5
• Azithromycin 1 g orally single dose or ceftriaxone 250 mg IM if chancroid is endemic 5

Follow-Up Protocol

• Re-examine at 48-72 hours if no clinical improvement occurs, and reconsider alternate diagnoses including Behçet syndrome, Crohn disease, fixed drug eruption, or sexual trauma 6
• Repeat HIV and syphilis testing at 3 months if initial results are negative 5
• Large ulcers may require >2 weeks for complete healing even with appropriate therapy 5

Patient Counseling

• Emphasize the non-sexually transmitted nature of Lipschütz ulcers to avoid unnecessary distress and embarrassing questioning about sexual history, particularly in sexually inactive young women 8, 2
• Explain the association with viral illnesses like influenza, EBV, or other infections that trigger the immune response 6, 1
• Reassure about spontaneous resolution within 3 weeks and lack of recurrence 1