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Consider Complex Aphthosis in Young Girls' Vulvar Ulcers


 

HOT SPRINGS, VA. — Complex aphthosis may be the cause of noninfectious vulvar ulcers in young females, Dr. Judith Burgis said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

“When we see vulvar ulcers in these girls, especially after their sexual debut, we tend to immediately think of an infectious etiology like herpes simplex,” said Dr. Burgis, of the department of ob.gyn. at the University of South Carolina, Columbia.

“But the differential diagnosis for these types of lesions is actually quite diverse,” she said.

Dr. Burgis presented a case series of 12 girls, aged 6–16 years, with vulvar ulcers; 11 of the girls were premenarcheal and sexually naive. The one postmenarcheal patient was sexually active. All 12 of the patients had been referred by their pediatricians for management of the ulcers, and many had been told that they had a herpes simplex infection. “This is a very anxiety-provoking diagnosis for both the girl and her parents.”

None of the ulcers was positive for viral, bacterial, or fungal pathogens.

Two girls, both of whom had recurrent oral and genital ulcers, were referred for a rheumatology evaluation with a presumed diagnosis of Behçet's disease.

The ulcers in three other patients had identifiable etiology. An 11-year-old with a several-month history of severe itching and a periclitoral ulcer unresponsive to topical yeast medication had lichen simplex. The large ulcer on a 6-year-old was related to chemotherapy for acute lymphocytic leukemia. Another 11-year-old had myelodysplasia and sacral agenesis; her ulcers were related to incontinence and diaper use.

But the final seven cases had no readily identifiable cause, Dr. Burgis said. Six of these girls were premenarcheal; one was postmenarcheal. Epstein-Barr serology and testing for infections were negative in all of them. There were no reasons to suspect trauma or sexual abuse in any patient, and all other laboratory testing was unrevealing. None of the girls had inflammatory bowel disease or Crohn's disease, both of which can cause vulvar ulcers.

“Since we found no common pathogen and no sign of systemic illness, we concluded the diagnosis was probably complex aphthosis,” Dr. Burgis said. “The etiology is unknown; it may be primary or may be secondary due to a systemic illness, perhaps of viral etiology.”

All these girls had an unremarkable course of recovery over 1–3 weeks, Dr. Burgis said. They were treated with superpotent topical corticosteroids, clobetasol ointment, and 2% topical Xylocaine for pain. Those with an accompanying cellulitis also received antibiotics.

Since we found no common pathogen and no sign of systemic illness, we diagnosed complex aphthosis. DR. BURGIS

None of the ulcers was positive for viral, bacterial, or fungal pathogens. Courtesy Dr. Judith Burgis

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