Aphthae

Benign aphthae of the vulva may or may not occur with concomitant oral lesions. The age of onset is in childhood, by about the age of six, and there may be a family history. The lesions are usually multiple and small. Less commonly, the lesions are solitary or few but larger, referred to as giant aphthae. Herpetic infection has to be excluded and there is often a premenstrual exacerbation once the menarche is reached. The etiology remains unknown. The lesions are superficial and painful with a yellow base surrounded by a red areola (Fig. 14). They are distributed most frequently on the labia minora and heal quickly.

Many eponymous names have been assigned to acute vulvar ulcers, many of which are probably examples of benign aphthae, e.g., Sutton's ulcer.

Lipschutz's ulcer, which occurs in young women, is a separate entity. This is usually one large deep painful ulcer that develops very rapidly and is covered with an adherent slough. The ulcer is sited most frequently in the inner aspect of one of the labia minora. Occasionally, two ulcers develop at apposing sites bilaterally (Fig. 15). The ulcer heals spontaneously over several weeks leaving some scarring. The Lipschutz-type ulcer is sometimes associated with a systemic infection such as infectious mononucleosis (34-36), typhoid, or paratyphoid fever. Healing is spontaneous but may take several weeks and leaves some scarring. Differential diagnoses include Herpes simplex infection with type 1 or 2, erythema multiforme, and Langerhans cell histiocytosis.

Table 8 Lichen Sclerosus

Clinical

Differential

Diagnosis Symptoms

appearance

diagnosis

Therapy

Lichen sclerosus Severe itch and,

White wrinkled

Lichen planus,

Potent topical

if ulcerated or

epithelium

morphea, and

steroid

fissured, pain;

with ecchy

mucous

dyspareunia

moses fissures

membrane

in the

pemphigoid

interlabial

sulci; scarring

Figure 14 (See color insert) Benign aphthae with erythematous halo and slough-covered central ulceration.

Treatment: This includes symptomatic treatment with analgesics either oral or topical. Astringent soaks with either potassium permanganate solution 1:10,000 or Monsel's solution followed by a topical corticosteroid and/or topical tetracycline have been used but may exacerbate symptoms.

Genital Ulcers Vulva

Figure 15 (See color insert) Lipschutz' ulcer. There are two large and deep ulcers apposed on either side.

Table 9 Aphthae

Diagnosis Symptoms Clinical appearance Differential diagnosis

Therapy

Aphthae Pain

Central slough-covered ulcer with erythematous halo

Herpes simplex, Behcet's syndrome erythema multiforme and blistering disease

Moderate to potent topical steroid and tetracycline mouth washes

In very severe ulceration that may occur with the Lipschutz ulcer, a short course of oral steroids may be required. Testing for herpes virus is mandatory, as a positive result will lead to specific therapy (Table 9).

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