Burning Sensation in Vaginal Area with Multiple Cut-Like Lesions
The most likely diagnosis is herpes simplex virus (HSV) infection, which requires immediate viral culture or PCR testing and prompt initiation of antiviral therapy with famciclovir 500 mg twice daily for 7 days if confirmed. 1
Primary Differential Diagnosis
Herpes Simplex Virus (Most Likely)
- Ulcers found on the external genitalia and vagina are most commonly caused by herpes simplex virus (HSV) in the United States. 1
- The sensation of "multiple cuts" is pathognomonic for herpetic ulceration, which presents as painful vesicles that rupture into shallow ulcers with erythematous bases. 1
- Burning pain is a hallmark symptom of HSV, often preceding visible lesions by 24-48 hours. 1
- A viral culture for HSV and serologic tests for syphilis should be performed for suspicious lesions. 1
Other Sexually Transmitted Causes
- Syphilis can present with painless ulcers (chancres) but is less likely given the burning sensation and multiple lesions. 1
- Chancroid causes painful ulcers but is uncommon in the United States. 1
- Lymphogranuloma venereum can present with ulcers but is rare domestically. 1
Non-Sexually Transmitted Causes
- Aphthous spectrum ulcers can cause painful vulvar lesions without sexual transmission. 1
- Epstein-Barr virus infection may cause genital ulceration. 1
- Vulvovaginal candidiasis typically presents with fissures rather than ulcers, accompanied by thick white discharge and normal vaginal pH ≤4.5. 2
Immediate Diagnostic Workup
Essential Physical Examination Findings
- Inspect for papules, vesicles, pustules, ulcers, fissures, and warts on the external genitalia and vaginal walls. 1
- Note any erythema, edema, excoriation, or bleeding. 1
- Palpate inguinal lymph nodes for size, tenderness, and consistency—enlarged painful nodes suggest HSV or syphilis. 1
- Assess vaginal discharge for amount, color, and odor. 1
- Check perianal area for evidence of trauma, discharge, or warts. 1
Laboratory Testing Algorithm
- Obtain viral culture for HSV from the base of fresh ulcers (highest yield within 48-72 hours of lesion onset). 1
- Perform serologic testing for syphilis (RPR or VDRL with confirmatory treponemal test). 1
- Measure vaginal pH with narrow-range pH paper: pH ≤4.5 supports candidiasis; pH >4.5 suggests bacterial vaginosis or trichomoniasis. 2
- Perform wet-mount microscopy with 10% KOH to visualize yeast, pseudohyphae, clue cells, or trichomonads. 2
- Consider culture/antigen testing for chlamydia and gonorrhea if cervicitis is suspected. 1
Treatment Recommendations
For Confirmed HSV Infection
- In HIV-infected or immunocompromised patients: Famciclovir 500 mg orally twice daily for 7 days. 3
- In immunocompetent patients with first episode: Famciclovir 250 mg orally three times daily for 7-10 days. 3
- For recurrent episodes in immunocompetent patients: Famciclovir 1000 mg twice daily for 1 day, initiated at first sign of prodrome (tingling, itching, burning). 3
- Therapy should be initiated at the first sign or symptom of a recurrent episode (e.g., tingling, itching, burning, pain, or lesion). 3
If Candidiasis is Confirmed (Less Likely Given Ulceration)
- For uncomplicated vulvovaginal candidiasis: Fluconazole 150 mg orally as a single dose OR topical azole therapy for 7 days. 2
- For severe vulvar inflammation with marked erythema, edema, or fissures: Extend topical azole therapy to 7-14 days rather than single-dose treatment. 2
- Clotrimazole 1% cream 5 g intravaginally daily for 7-14 days is an effective topical option. 2
Symptomatic Relief During Diagnostic Workup
- Apply water-based vaginal moisturizers 3-5 times per week to alleviate dryness and irritation. 2
- Offer topical lidocaine for persistent introital pain. 2
- Recommend over-the-counter analgesics such as acetaminophen or ibuprofen for discomfort. 4
Critical Pitfalls to Avoid
Diagnostic Errors
- Do not assume all vaginal burning and lesions are due to yeast infection—HSV, syphilis, and other STIs require different management. 2, 5
- Do not treat empirically without microscopic or viral culture confirmation; self-diagnosis is accurate in only 30-50% of cases. 2
- Do not overlook the possibility of concurrent infections—vulvovaginal candidiasis can occur simultaneously with sexually transmitted diseases. 2
Treatment Mistakes
- Do not use short-course (1-3 day) antifungal regimens if severe vulvar inflammation is present; these require 7-14 day therapy. 2
- Do not treat asymptomatic Candida colonization (present in 10-20% of women). 2
- Forcing a patient to undergo pelvic examination is always contraindicated. 1
Follow-Up Failures
- Patients should seek further medical evaluation if symptoms persist after completing therapy, recur within 2 months, or if ≥3 episodes occur within a 12-month period. 2
- If symptoms persist despite appropriate azole therapy, obtain vaginal culture to detect non-albicans Candida species (e.g., C. glabrata), which require alternative treatment with boric acid 600 mg vaginal capsules daily for 14 days. 2
When to Consider Alternative Diagnoses
Lichen Sclerosus
- Consider in postmenopausal women with depigmented, burning, and painful vulvovaginal areas characterized by porcelain-white plaques, fragile atrophic skin, and fissures in a figure-eight pattern around the vulva and anus. 6
- Biopsy is mandatory if diagnosis is uncertain, disease fails to respond to treatment, or there is suspicion of neoplastic change. 6
Vulvodynia
- Consider if burning pain persists without visible depigmentation, structural changes, or identifiable infectious cause. 6, 7
Desquamative Inflammatory Vaginitis
- Consider if patients do not respond to initial treatment for presumed candidiasis or bacterial vaginosis. 8