Lipschutz ulcers: evaluation and management of acute genital ulcers in women

Acute genital ulcers are painful and distressing to women and perplexing to the providers who care for them. The differential diagnosis includes sexually and nonsexually transmitted infections, autoimmune conditions, drug reactions, and local manifestations of systemic illness. However, in many cases, no causative agent is identified, and lesions are classified as idiopathic aphthosis. In the setting of fever and acute onset of genital ulcers in girls and women, the term Lipschutz ulcers has been used to describe ulcers associated with an immunologic reaction to a distant source of infection or inflammation. The aims of this article are to review the differential diagnosis and pathogenesis of acute genital ulcers, to offer an evaluation and classification scheme, and to discuss treatment options for the dermatologist who cares for women and girls with vulvar ulcers.     

Clinical and microbiologic studies of genital ulcers in Kenyan women

The etiology of genital ulcers in women in tropical regions is poorly understood. Eighty-nine women, presenting to a sexually transmitted disease clinic in Nairobi (Kenya) with a primary complaint of genital ulcers, were evaluated prospectively in a clinical and laboratory study. A final etiologic diagnosis was possible for 60 (67%) of the women. Culture for Haemophilus ducreyi was positive for 43 women, eight had secondary syphilis with ulcerated condyloma latum, three had primary syphilis, one had both chancroid and syphilis, two had moniliasis, two had herpetic ulceration, and one had a traumatic ulcer. The clinical characteristics that best distinguished chancroid from secondary syphilis were ulcer excavation and a rough ulcer base. No etiologic diagnosis was established for 29 patients. However, the clinical and epidemiologic features of these patients suggested that they were similar if not identical to the patients with H. ducreyi culture-positive chancroid. Further studies are necessary to determine the etiology of ulcers in females in whom no pathogen was identified.     

Nonspecific genital ulcers

Recent intervention of nonspecific genital ulcers has added refreshing dimensions to genital ulcer disease. It was considered pertinent to dwell on diverse clinical presentation and diagnostic strategies. It seems to possess spectrum. It includes infective causes, Epstein Bar Virus, tuberculosis, Leishmaniasis, HIV/AIDS related ulcers and amoebiasis. Noninfective causes are immunobullous disorders, aphthosis, Behcet's disease (BD), inflammatory bowel disease, lichen planus and lichen sclerosis et atrophicus, drug reactions, premalignant and malignant conditions, pyoderma gangrenosum, and hidradenitis suppurativa. The diagnostic features and treatment option of each disorder are succinctly outlined for ready reference.     

Hereditary spherocytosis presenting as indolent leg ulcers

Indolent leg ulcertation, which is the rarest manifestation of hereditary spherocytosis, started at the age of 5 years affecting a 15-year-old boy and his mother is reported. Review of literature showed very few reports from India and abroad. The response to oral folic acid was excellent.     

Cutaneous extramedullary hematopoiesis presenting as leg ulcers

Blistering distal dactylitis is a distinctive infection localized to the volar fat pad of the distal phalanx of the finger. The causative agent is a group A β-hemolytic streptococcus. The organism can be identified by a Gram-stained smear and culture of the blister fluid. The infection responds readily to incision and drainage, compresses, and a course of an appropriate oral antibiotic.     

Condom use prevents genital ulcers in women working as prostitutes. Influence of human immunodeficiency virus infection

Control of genital ulcer disease (GUD) is a proposed intervention to slow the dissemination of human immunodeficiency virus (HIV) infection. Programs for the control of sexually transmitted diseases (STD) should focus on groups of high-frequency transmitters, such as prostitutes and their clientele. This study illustrates the interaction between the prevalence of chancroid, use of barrier prophylaxis against STDs, and HIV infection in a population of female prostitutes in Nairobi. Four hundred and twenty three women were evaluated. Despite the increased use of condoms, the prevalence of genital ulcers remained constant between 1986-87 and 1987-88. Genital ulcer disease was simultaneously associated with HIV infection (adjusted odds ratio: 3.7, P less than .01) whereas it was independently and inversely associated with more consistent condom use (P less than .01). The authors conclude that genital ulcer disease can be controlled in these populations but concurrent HIV infection increases the difficulty of this intervention.     

Type I cryoglobulinemia presenting as hemorrhagic crusted leg ulcers

Cryoglobulins (CGs) are serum proteins that reversibly precipitate when the serum is cooled below 37 degrees C. Cryoglobulinemias are associated with a variety of diseases, including hematologic, autoimmune, and infectious. Isolation of CGs requires handling the specimen with extreme care. We describe a 70-year-old man, recently diagnosed with chronic lymphocytic leukemia, who developed hemorrhagic crusted skin ulcers on his legs that were pruritic and painful. Results of skin biopsies showed dilated superficial, mid-dermal and deep-dermal blood vessels containing pink amorphous material and red blood cells. Cryoglobulinemia was suspected; however, an initial search for CGs was negative. There was concern about suboptimal handling of the specimen, and the test was repeated. Two percent CGs with IgM kappa specificity were detected. This case illustrates the importance of the proper handling of specimens for evaluation of cryoglobulinemia.     

Primary macroglobulinemia presenting as multiple ulcers of the legs

Multiple ulcers developed on the lower legs of a 67-year-old man suffering from macroglobulinemia. Histological and direct immunofluorescence studies on biopsy specimens taken from the lesions revealed dilation of capillaries, deposition of large quantities of IgM in the vessels, and deposition of C3 in the vessel walls. A marked increase in blood Clq binding immune complexes was also noted. These findings suggest immune complex-induced ulceration. The fact that IgM-type cryoglobulins were positive implies that cryoglobulins derived from macroglobulins may play an important causative role in ulceration.     

A case of bacillary angiomatosis presenting as leg ulcers

We report a 32-year-old immunocompetent man who had multiple leg ulcers caused by bacillary angiomatosis without a history of direct contact with cats. Bacillary angiomatosis should be kept in mind in the differential diagnosis of leg ulcers in cases of unknown aetiology.     

Etiology of nonvesicular genital ulcers in Winnipeg

Twenty-eight patients with recent onset of nonvesicular ulcerative genital lesions were studied prospectively to define the microbial etiology. Causative agents identified included herpes simplex virus (HSV), Chlamydia trachomatis, Haemophilus ducreyi, and Treponema pallidum. Three women and 25 men (seven of whom were homosexual) were studied. Ten patients did not have an etiology identified. Nine patients had syphilis, six had genital herpes, one had chancroid, one had granuloma inguinale, and one had a human bite injury. Six of seven homosexual men had syphilis, as compared with one of eight heterosexual men (P less than .002). Among heterosexual men, five had atypical HSV infections, three with extensive balanoposthitis and two with chancroidal ulcers. Of the clinical characteristics examined, induration of the ulcer base and tenderness on palpation were predictive of etiology, whereas numbers of ulcers and regional lymphadenopathy were not. H. ducreyi was not a common cause of genital ulcers in Winnipeg, and it was not found as a commensal or superinfecting organism in ulcers caused by other agents.     

Osteomyelitis presenting as genital sore: a case report.

A female attending the skin outpatient department presented with a genital sore which was treated as chancroid. On further investigation it proved to be the opening of a sinus secondary to chronic osteomyelitis of the pubic symphysis.     

An unusual case of pemphigus vulgaris presenting as bilateral foot ulcers

We describe an unusual presentation of pemphigus vulgaris, an autoimmune intraepidermal blistering skin disease associated with autoantibodies to the desmosome glycoprotein, desmoglein 3. A 60-year-old man presented with bilateral ulceration on the dorsum of the feet. These clinical features persisted for 4 months before more characteristic signs of pemphigus vulgaris, including mouth ulceration and skin erosions, developed. The atypical presentation led to a delay in diagnosis and initiation of the appropriate treatment. Pemphigus vulgaris may have unusual manifestations, such as nail dystrophy, paronychia, or granulation tissue-like lesions, but this case of bilateral foot ulceration highlights a further, perhaps unique, clinical presentation of this autoimmune disease.     

Epstein-Barr virus-associated genital ulcers: an under-recognized disorder

Infectious mononucleosis is the best-known syndrome associated with primary Epstein-Barr virus infection. Although a variety of cutaneous and mucosal manifestations are recognized in infectious mononucleosis, genital ulcers have only rarely been described. We describe an otherwise healthy 14-year-old girl in whom painful genital ulcers developed during an episode of serologically-confirmed primary Epstein-Barr virus infection. Clinical, serologic, and histopathologic evaluation failed to disclose evidence of any other etiologic explanation for her lesions. The patient remains well, without recurrence. To date, only 13 instances of genital ulceration in females attributable to Epstein-Barr virus infection have been reported.     

生殖器溃疡中单纯疱疹病毒的检测和分型

目的：了解性病门诊生殖器溃疡患者中单纯疱疹病毒（HSV）感染情况，并评价聚合酶链反应（PCR）－微孔板反向杂交检测和分型方法在生器疱疹诊断中的意义。方法：采用病毒分离培养、普通PCR和PCR－微孔板反向杂交法同时对200份生殖器溃疡标本作了HSV检测与分型。结果：PCR－微孔板反向杂交法的敏感性和特异性分别为98．1％和95．9％，PCR－微孔板杂交法分型结果与病毒分离培养法和普遍PCR的分型结果完全相符。生殖器溃疡中HSV检出率为30％（60／200），其中HSV－2感染占96．7％（58／60）。结论：HSV－2是性病门诊患者生殖器溃疡的主要病因之一，PCR－微孔板反向杂交法是一种适用生殖器溃疡标本中HSV的检测与分型的快速、敏感和特异的诊断方法。     

Biological therapy in genital psoriasis in women

Genital psoriasis (GenPs) is a frequent manifestation of psoriasis, causing distress, especially in women. We prospectively studied a population of 74 psoriatic women with severe and generalized psoriasis eligible to biologic therapy, to examine which biologic therapy is more effective on GenPs and to study possible associations between PASI severity and GenPs. Overall, 25/74 (34%) had GenPs: 6 received Ixekizumab, 7 Ustekinumab, 8 Adalimumab, 2 Secukinumab, 1 Etanercept, 1 Certolizumab. Therapies were administered based on PASI severity, independently from the presence of GenPs. Side effects, PASI score, sPGA‐G scale for GenPs were recorded at time 0 and after 6 month of therapy. The mean sPGA‐G scale value was 2.8 before treatment. After biologic therapy, all patients except one, improved of at least one point. Mostly, patients treated with anti‐IL17 (Secukinumab, Ixekizumab) and anti‐IL12/23 (Ustekinumab) improved. Mean PASI ranged from 10 to 16.3 before treatment. After 6 months of therapy, 4 anti‐TNFα patients, 6 anti‐IL17 and 1 anti‐IL12/23, reached PASI 90. At time 0, no correlation between PASI and sPGA‐G was visible (Pearson r = 0.10, p = .620). From our data, GenPs apparently responds favorably to IL17A inhibitors, but further studies, based on larger numbers of patients, are needed.