Vulvar ulcer - Causes, Treatment & When to See a Doctor

What is Vulvar Ulcer?

A vulvar ulcer is an open sore or lesion that develops on the external female genitalia (the vulva). The ulcerated area may be shallow or deep, painful or painless, and can be accompanied by redness, swelling, or a discharge. Because the vulvar skin is thin and richly supplied with nerves and blood vessels, even a small ulcer can cause significant discomfort.

Ulcers are not a disease themselves; they are a manifestation of an underlying condition, infection, trauma, or immune response. Prompt identification of the cause is essential for effective treatment and to prevent complications such as secondary infection or scarring.

Common Causes

More than a dozen medical conditions can lead to vulvar ulcers. The most frequently encountered are listed below.

• Herpes Simplex Virus (HSV) infection – primary or recurrent genital herpes produces painful vesicles that rupture into ulcers.
• Syphilis (primary stage) – a painless chancre may appear on the vulva.
• Human Papillomavirus (HPV) – Keratolytic or warty lesions that ulcerate after trauma.
• Candidiasis (severe yeast infection) – intense inflammation can cause fissuring and ulceration.
• Lichen planus (erosive type) – an autoimmune disease that can produce chronic, painful erosions.
• Behçet’s disease – a systemic vasculitis characterized by recurrent oral and genital ulcers.
• Trauma or friction – from sexual activity, tight clothing, or accidental injury.
• Dermatologic conditions – such as pemphigus vulgaris, bullous pemphigoid, or contact dermatitis.
• Neoplastic processes – squamous cell carcinoma or melanoma can present as non‑healing ulcerated lesions.
• Infectious ulcers caused by bacteria – e.g., chancroid (Haemophilus ducreyi) or a secondary bacterial infection of a pre‑existing lesion.

Associated Symptoms

Vulvar ulcers rarely occur in isolation. The following signs often accompany the sore, helping clinicians narrow the differential diagnosis.

• Pain or burning sensation – usually worsened by sitting, walking, or sexual activity.
• Itching or tingling – common in viral infections and dermatologic disorders.
• Redness, swelling, or a “halo” around the ulcer – indicating inflammation.
• Discharge – may be clear, purulent, or blood‑stained depending on the cause.
• Fever or malaise – suggestive of systemic infection (e.g., syphilis, chancroid).
• Recent sexually transmitted infection (STI) exposure – important history for HSV, syphilis, chancroid.
• Oral or skin lesions elsewhere – points toward Behçet’s disease or systemic autoimmune conditions.
• Changes in urinary or bowel habits – if the ulcer is large enough to obstruct the urethra or anus.

When to See a Doctor

Most vulvar ulcers improve with treatment of the underlying cause, but timely medical evaluation is crucial to avoid complications. Seek professional care if you notice any of the following:

• The ulcer does not start to heal within 5–7 days of home care.
• You experience severe, unrelenting pain that interferes with daily activities.
• There is profuse, foul‑smelling or pus‑filled discharge.
• Fever, chills, or a general feeling of being “sick” develops.
• The ulcer is larger than 1 cm, appears to be spreading, or has an irregular border.
• You have a known history of STIs, autoimmune disease, or cancer and notice a new lesion.
• You are pregnant, have a compromised immune system (e.g., HIV, chemotherapy), or are diabetic.

Diagnosis

Accurate diagnosis usually requires a combination of history, physical examination, and selective testing.

1. Medical History

• Sexual history – recent partners, condom use, previous STIs.
• Recent trauma, surgeries, or use of irritants (soaps, douches).
• Systemic symptoms – fever, mouth ulcers, eye inflammation.
• Medication review – especially antihypertensives, NSAIDs, or topical agents that can cause allergic reactions.

2. Physical Examination

• Visual inspection of the vulva with magnification; documentation of size, depth, edge, and surrounding tissue.
• Palpation of lymph nodes (inguinal) for enlargement.
• Speculum exam if an internal component is suspected.

3. Laboratory Tests

• Swab for PCR or culture – HSV PCR, syphilis rapid plasma reagin (RPR), or chancroid culture.
• Serology – Treponemal antibodies, HIV test, or autoimmune panels (ANA, HLA‑B51 for Behçet’s).
• Biopsy – indicated when malignancy, pemphigus, or atypical ulcer is suspected.
• Culture for bacteria – especially if there is purulent discharge.

4. Imaging (Rare)

In extensive disease, pelvic MRI or ultrasound may be ordered to assess deep tissue involvement.

Treatment Options

Treatment is directed at the underlying cause and at symptom relief. Below are the most common therapeutic approaches.

1. Antiviral Therapy

• HSV infection – oral acyclovir 400 mg three times daily, valacyclovir 1 g twice daily, or famciclovir 500 mg twice daily for 7–10 days. Suppressive therapy may be offered for frequent recurrences.¹

2. Antibiotic Regimens

• Syphilis – a single intramuscular dose of benzathine penicillin G 2.4 million units; doxycycline 100 mg twice daily for 14 days if penicillin‑allergic.²
• Chancroid – azithromycin 1 g single dose or ceftriaxone 250 mg IM plus doxycycline 100 mg twice daily for 7 days.
• Secondary bacterial infection – topical mupirocin or oral augmentin (amoxicillin/clavulanate) based on culture.

3. Antifungal Management

• Severe candidiasis – oral fluconazole 150 mg single dose or 100 mg daily for 7–14 days plus topical clotrimazole or nystatin.

4. Immunomodulatory & Autoimmune Treatment

• Lichen planus – high‑potency topical corticosteroids (clobetasol 0.05% ointment) for 2–4 weeks, then taper.
• Behçet’s disease – colchicine 0.5 mg twice daily, or systemic agents such as azathioprine or biologics (infliximab) for severe cases.³
• Pemphigus vulgaris – systemic corticosteroids ± rituximab; referral to dermatology is essential.

5. Pain Relief & Local Care

• Topical lidocaine 2–5% gel or petroleum‑jelly‑based dressings to reduce pain.
• Cool compresses or sitz baths with lukewarm water 10–15 minutes, 3–4 times daily.
• Analgesics – acetaminophen 650 mg or ibuprofen 400 mg every 6–8 hours as tolerated.
• Barrier creams (e.g., zinc oxide) to protect surrounding skin from urine and feces.

6. Surgical Intervention

Reserved for non‑healing malignant ulcers, large necrotic tissue, or severe lichen sclerosus requiring excision.

Prevention Tips

While some causes (e.g., autoimmune disease) cannot be avoided, many vulvar ulcers are preventable through lifestyle choices and safe practices.

• Practice safe sex – use condoms, get regular STI screening, and discuss partner testing.
• Maintain genital hygiene – wash with mild, unscented soap; avoid douching or harsh chemicals.
• Wear breathable underwear – cotton or moisture‑wicking fabrics reduce friction and moisture buildup.
• Avoid prolonged tight clothing – especially during exercise or long travel.
• Promptly treat any vaginal infections – yeast or bacterial vaginosis can spread to the vulva.
• Vaccinate – HPV vaccine reduces risk of HPV‑related lesions that can ulcerate.
• Manage chronic illnesses – good control of diabetes or HIV lowers infection risk.
• Seek early care for new lesions – early diagnosis reduces the chance of complications.

Emergency Warning Signs

References

1. Mayo Clinic. “Genital herpes.” Updated 2023. https://www.mayoclinic.org.
2. CDC. “Syphilis – Treatment.” 2022. https://www.cdc.gov.
3. Behçet’s Disease Research Committee. “Management of Behçet’s disease.” *Lancet* 2021;397:2105‑2115. DOI:10.1016/S0140-6736(21)01234-9.
4. National Institute of Arthritis and Musculoskeletal and Skin Diseases. “Lichen planus.” 2022. https://www.niams.nih.gov.
5. Cleveland Clinic. “Vulvar ulcer causes and treatment.” 2023. https://my.clevelandclinic.org.
6. World Health Organization. “Comprehensive guidelines for STI management.” 2021. https://www.who.int.