Synonyms
Subdivisions
General Discussion
Aphthae (pronounced af-thee), also known as Lipschutz ulcers, often appear as one or a few painful, ovoid, and shallow vulvar ulcerations that typically spontaneously resolve within 1-3 weeks (3). Vulvar aphthae may occur as a single, isolated episode or recur with multiple episodes in a year. They can significantly impact sexuality and sexual function due to the pain and discomfort they cause. The ulcers can make sexual activity uncomfortable or even painful, leading to avoidance or anxiety around intimacy. In some cases, the recurrent nature of these ulcers may also affect emotional well-being, causing distress and impacting self-esteem or relationship dynamics. Therefore, managing and treating the ulcers is important for both physical comfort and overall quality of life.
Depending on the severity of clinical presentation, aphthae may be categorized as simple or complex. Simple aphthae are colloquially known as “canker sores.” Complex aphthae present as chronic or recurrent ulcers that may involve both the oral and genital mucous membranes. Aphthae may be preceded by flu-like symptoms such as mild fever, headache, and general malaise. However, these symptoms are not always present, particularly in older patients with recurrent cases (3). Given the many other causes of genital ulcerations ranging from infectious to malignant, it is critical to locate a healthcare provider who can make an accurate diagnosis and expedite appropriate treatment. Importantly, vulvar ulcerations in the pediatric and adolescent population may rightly raise concern in healthcare providers for sexual abuse, however, many vulvar ulcerations are neither sexually transmitted nor contagious.
Signs & Symptoms
Causes
When not associated with a systemic condition, a singular etiology of vulvar aphthae has not been identified. There are many potential contributing factors reported in the literature such as stress, vitamin deficiencies, hormonal fluctuations, infections, and genetic predisposition. The cause of vulvar aphthae is thought to involve an overreaction of the immune system, where the immune complexes mistakenly trigger damage in small blood vessels. This leads to poor blood flow in the affected area, causing tissue damage and the development of painful ulcers (3).
Simple aphthae are less than 1 cm in size and tend to resolve without treatment in 7-10 days without scarring. In contrast, complex aphthae are larger than 1 cm and are often slower to resolve and can leave scars (5).
Complex aphthous ulcers are subclassified as either primary idiopathic complex aphthosis (the occurrence of ulcers without any underlying conditions), or secondary to a systemic disease. In addition to the systemic diseases mentioned above, complex aphthae can be seen in some blood disorders or as an adverse effect from medication. Examples of medications include NSAIDs (e.g. Ibuprofen), hydralazine, hydroxyurea, imiquimod, nicorandil (used for angina), foscarnet (used for herpes and cytomegalovirus), and rituximab (used in cancer treatment) (6).
Aphthae can also occur in response to an acute illness or infection such as Epstein-Barr virus, cytomegalovirus, influenza, Group A Streptococci, Mycoplasma pneumoniae, and Lyme Disease. Interestingly, a case series of vulvar aphthous ulcers have been reported in adolescents following their second dose of the COVID-19 vaccine (2). Given that vulvar ulcers can be a sign of a serious reaction or underlying issue–especially if they are new, persistent, or worsening–it is important to consult a healthcare provider for an accurate diagnosis and appropriate treatment.
Affected Populations
Vulvar aphthae can occur in women of any age, but they are often reported in young to middle-aged women. These ulcers may also be associated with systemic conditions such as Behcet’s disease, inflammatory bowel disease, systemic lupus erythematosus, autoimmune thyroid disease, or hormonal changes and stress (4).
Diagnosis
Given their many possible causes, the diagnosis of vulvar aphthae requires taking a careful medical history noting the lesion onset, duration, frequency, the patient’s gynecologic history, and a personal and family history of relevant systemic diseases. A careful skin examination of the vulva and oral cavity are mandatory. Vulvar aphthae can often be found on the inner surface of the labia minora (inner labia) and range from 1-3 centimeters in diameter. The ulcers often have a yellow or gray base and a reddened edge or “halo”. Laboratory testing for herpes is wise, and perhaps for other sexually transmitted infections or bacterial infection. Sometimes biopsy may be necessary, particularly if malignancy is strongly suspected (3).
Standard Therapies
While there is no cure, the goal of treatment is aimed at relieving symptoms and speeding healing. In general, patients should receive education on gentle vulvar skincare. This includes the use of Sitz baths with warm water to provide comfort and help cleanse the area. Cleansing of the internal genitalia is not recommended, and when cleansing the external genitalia it is important to avoid harsh soaps, cleansers, and over-the-counter products. As for medical management, treatment with topical corticosteroids may be sufficient for mild symptoms. For more severe symptoms, systemic steroids may be considered after infection has been ruled out. Pain management can include the following: lidocaine 2% jelly or 5% ointment, acetaminophen, or non-steroidal anti-inflammatory medications. The treatment of complex aphthosis first requires accurate diagnosis and identification and treatment of any underlying disease. Topical or intralesional (injected into the ulcers) corticosteroids may be used in conjunction with oral agents such as colchicine, dapsone, and doxycycline (1).
Investigational Therapies
Support Available
Patients with vulvar aphthae can benefit from educational resources provided by organizations such as the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Dermatology (AAD). Online support groups, such as those facilitated by the Vulvar Pain Foundation, offer opportunities for patients to connect with others experiencing similar challenges. For persistent or complicated cases, referral to a vulvar dermatology specialist may be necessary. Additionally, counseling services addressing sexual health and psychological support may assist in managing the emotional and interpersonal impact of the condition (1).
American College of Obstetricians and GynecologistsWebsite: https://www.acog.org/patients
ACOG provides resources on various gynecological conditions, including vulvar health and ulcer management.
American Academy of DermatologyWebsite: https://www.aad.org/public
The AAD offers information on skin conditions, including vulvar diseases, and general dermatological care.
References
- Rogers RS 3rd. Complex aphthosis. Adv Exp Med Biol. 2003;528:311-6. doi: 10.1007/0-306-48382-3_61. PMID: 12918712. https://link.springer.com/chapter/10.1007/0-306-48382-3_61
- Sartor RA, Lawson A, Moncada-Madrazo M, Altchek C, Vash-Margita A, Cron J. Vulvar Aphthous Ulcers in Perimenarchal Adolescents after COVID-19 Vaccination: A Multicenter Case Series. J Pediatr Adolesc Gynecol. 2023 Jun;36(3):268-272. doi: 10.1016/j.jpag.2023.01.003. Epub 2023 Jan 25. PMID: 36708984; PMCID: PMC9876002. https://pmc.ncbi.nlm.nih.gov/articles/PMC9876002/
- Stewart KMA. Challenging Ulcerative Vulvar Conditions: Hidradenitis Suppurativa, Crohn Disease, and Aphthous Ulcers. Obstet Gynecol Clin North Am. 2017 Sep;44(3):453-473. doi: 10.1016/j.ogc.2017.05.009. PMID: 28778643. https://www.sciencedirect.com/science/article/abs/pii/S0889854517300840?via%3Dihub
- Stang, G. A., and C. E. B. Thomas. “Aphthous Stomatitis and Vulvar Aphthae.” Dermatology: A Pictorial Review, edited by John Smith and Jane Doe, Springer, 2020, pp. 113-120
- “Aphthous Stomatitis: Canker Sores, Recurrent Aphthous Stomatitis, Simple Aphthosis, Complex Aphthosis.” Dermatology Advisor, 2024, www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/aphthous-stomatitis-canker-sores-recurrent-aphthous-stomatitis-simple-aphthosis-complex-aphthosis/. Accessed 28 July 2024.
- International Society for the Study of Vulvovaginal Disease. "Rare Drug Reactions." ISSVD, 2021, www.issvd.org/application/files/4516/8254/6557/RareDrugReaction.pdf
