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Ulcus vulvae (vulvar ulcer)

What is Ulcus vulvae (vulvar ulcer)?

A vulvar ulcer, medically termed ulcus vulvae, is an open sore or lesion that develops on the external female genitalia (the labia, clitoral hood, vestibule, or perineum). The ulcer may be shallow or deep, painful or painless, and can appear suddenly or gradually. Because the vulva is richly supplied with nerves and blood vessels, ulcers often cause significant discomfort, irritation, and risk of secondary infection.

Vulvar ulcers are a symptom rather than a disease in themselves; they signal an underlying condition that must be identified and treated. In many cases the ulcer heals once the cause is addressed, but without proper care the lesion can become chronic, scar, or lead to complications such as urinary obstruction or dyspareunia (painful intercourse).

Sources: Mayo Clinic, CDC, WHO.

Common Causes

Several infectious, inflammatory, traumatic, and systemic conditions can produce vulvar ulcers. The most frequent culprits are:

• Herpes simplex virus (HSV) infection – primary or recurrent genital herpes produces painful grouped vesicles that break down into ulcers.
• Syphilis (primary stage) – a painless chancre may develop on the vulva.
• Behçet’s disease – an autoimmune vasculitis that causes recurrent, painful oral and genital ulcers.
• Sexually transmitted bacterial infections – chlamydia, gonorrhea, or Mycoplasma genitalium can lead to ulcerative cervicitis that extends to the vulva.
• Autoimmune blistering diseases – pemphigus vulgaris or mucous membrane pemphigoid create erosions that may ulcerate.
• Contact dermatitis or chemical irritation – harsh soaps, spermicides, or topical medications can cause ulcerating dermatitis.
• Trauma – sexual activity, childbirth, surgical procedures, or accidental friction can create a break in the skin that becomes an ulcer.
• Cancer – squamous cell carcinoma of the vulva or melanoma may present as a non‑healing ulcer.
• Vasculitis or hematologic disorders – conditions such as systemic lupus erythematosus (SLE) or leukemia can produce ulcerative lesions.
• Incontinent skin breakdown – chronic moisture and irritation from urinary or fecal incontinence can erode the vulvar skin.

Associated Symptoms

Vulvar ulcers rarely occur in isolation. Look for these accompanying signs, which can help narrow the underlying cause:

• Burning, itching, or stabbing pain at the ulcer site
• Fever, chills, or malaise (suggesting systemic infection)
• Multiple oral ulcers (common in Behçet’s disease)
• Vaginal discharge – yellow, green, or blood‑tinged
• Painful urination (dysuria) or difficulty emptying the bladder
• Bleeding or spotting, especially after intercourse
• Lymphadenopathy – swollen inguinal lymph nodes
• Skin lesions elsewhere on the body (e.g., rash, papules)
• Joint pain or swelling (possible connective‑tissue disease)

When to See a Doctor

Because vulvar ulcers can indicate serious infections or malignancy, prompt medical evaluation is essential when any of the following occur:

• The ulcer does not begin to heal within 5–7 days despite home care.
• Severe pain interferes with walking, sitting, or urination.
• You notice a fever ≥ 38 °C (100.4 °F) or chills.
• There is a rapid increase in ulcer size or depth.
• Bleeding is profuse or persists after activity.
• You have a known sexually transmitted infection (STI) and the ulcer appears within 2 weeks of exposure.
• History of cancer, immunosuppression, or chronic illness accompanies the ulcer.
• Repeated episodes occur (≥ 3 times in a year) without clear cause.

Diagnosis

Accurate diagnosis relies on a combination of history‑taking, physical examination, and targeted investigations.

Clinical Evaluation

• Detailed sexual and medical history – partners, recent new sexual contacts, prior STIs, autoimmune disease, medication use, trauma.
• Full genital inspection – using a speculum and adequate lighting; documentation of ulcer size, number, borders, and surrounding erythema.
• Pap smear or HPV testing – if cancer is a concern.

Laboratory Tests

• Swab for HSV PCR or culture – most sensitive for herpes.
• Serologic testing for syphilis (RPR/VDRL and confirmatory FTA‑ABS).
• Nucleic‑acid amplification tests (NAAT) for chlamydia, gonorrhea, Mycoplasma.
• Complete blood count (CBC) and inflammatory markers (ESR, CRP) – assess for systemic infection or vasculitis.
• Autoimmune panels (ANA, anti‑dsDNA, HLA‑B51 for Behçet’s) when indicated.

Histopathology

If the ulcer is atypical, chronic, or suspicious for malignancy, a punch or excisional biopsy is performed. Pathology can reveal:

• Viral cytopathic changes (HSV, CMV)
• Granulomatous inflammation (infections, sarcoid)
• Neoplastic cells (squamous cell carcinoma, melanoma)
• Interface dermatitis characteristic of autoimmune blistering diseases.

Imaging

Rarely required, but pelvic MRI or ultrasound may be ordered if there is concern for deep pelvic extension, abscess formation, or tumor staging.

Treatment Options

Therapy targets the underlying cause, promotes healing, and relieves symptoms. Management is usually multidisciplinary, involving primary care, gynecology, dermatology, and infectious disease specialists.

Pharmacologic Treatments

• Antiviral therapy – Acyclovir, valacyclovir, or famciclovir for HSV (dose 5 days for primary infection; suppressive dosing for recurrences).
• Antibiotics – Doxycycline or azithromycin for syphilis (single dose benzathine penicillin G is preferred); ceftriaxone or doxycycline for chlamydia/gonorrhea.
• Corticosteroids – Topical high‑potency steroids (clobetasol 0.05 % twice daily) for inflammatory or autoimmune ulcers; short oral prednisone taper for severe Behçet’s or pemphigus.
• Immunomodulators – Colchicine, thalidomide, or biologics (e.g., adalimumab) in refractory Behçet’s disease.
• Antifungal agents – If candidal superinfection is present (fluconazole 150 mg PO single dose).
• Analgesics – NSAIDs or acetaminophen for pain; topical lidocaine 5 % gel for localized relief.

Non‑Pharmacologic & Home Care

• Gentle cleansing with warm water; avoid scented soaps or douches.
• Apply barrier ointments (e.g., zinc oxide or petroleum jelly) to keep the area moist and protect from friction.
• Use loose‑fitting, breathable cotton underwear.
• Cold compresses for acute pain or swelling.
• Maintain good bladder hygiene; empty bladder regularly to reduce moisture.

Surgical/Procedural Interventions

• Incision and drainage of secondary abscesses.
• Excisional biopsy or wide local excision for confirmed vulvar cancer.
• Laser or electrosurgical ablation for refractory HSV lesions (rare).

Follow‑up Care

Re‑evaluate 1–2 weeks after initiating therapy to ensure healing, adjust medications, and screen for complications. Women with chronic ulcerative conditions should have routine gynecologic examinations (every 6–12 months).

Prevention Tips

While not all vulvar ulcers are preventable, many risk factors can be mitigated:

• Practice safe sex – Use condoms consistently; limit number of sexual partners.
• Get screened regularly – Annual STI testing if sexually active; prompt treatment of any infection.
• Vaccinate – HPV vaccine reduces risk of HPV‑related lesions; Hepatitis B vaccine for overall sexual health.
• Maintain genital hygiene – Wash with mild, fragrance‑free cleansers; pat dry.
• Avoid irritants – Skip scented tampons, pads, or wet wipes; use hypoallergenic laundry detergents.
• Manage chronic diseases – Keep diabetes, autoimmune disorders, and immunosuppression under control.
• Address incontinence – Use absorbent pads, skin barriers, and pelvic floor exercises to reduce moisture.
• Seek prompt care for trauma – Any laceration or severe friction should be cleaned and monitored.

Emergency Warning Signs

Key Take‑aways

• Ulcus vulvae is a symptom, not a disease; identifying the underlying cause is critical.
• Common triggers include HSV, syphilis, Behçet’s disease, trauma, and vulvar cancer.
• Pain, discharge, fever, and lymph node swelling often accompany the ulcer.
• Seek medical attention promptly if the ulcer persists > 7 days, is very painful, or is accompanied by systemic signs.
• Diagnosis combines a thorough exam, targeted laboratory tests, and often a biopsy.
• Treatment ranges from antivirals/antibiotics to topical steroids and, when needed, surgical management.
• Prevention focuses on safe sexual practices, good genital hygiene, and control of chronic illnesses.
• Emergency red flags include rapid spreading infection, uncontrolled bleeding, high fever, or urinary obstruction.

For personalized advice, always consult a qualified health professional. This article is for educational purposes and does not replace professional medical evaluation.

References:

1. Mayo Clinic. “Genital herpes.” https://www.mayoclinic.org.
2. Centers for Disease Control and Prevention. “Syphilis – CDC Fact Sheet.” https://www.cdc.gov.
3. World Health Organization. “Behçet’s disease.” https://www.who.int.
4. Cleveland Clinic. “Vulvar cancer.” https://my.clevelandclinic.org.
5. National Institutes of Health. “Autoimmune blistering diseases of the skin.” https://www.niaid.nih.gov.

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