Case study: vulval soreness

THE CASE

A 19-year-old woman complaining of vulval soreness presented with worsening vulval soreness and dysuria, but no vaginal discharge after being advised to buy fluconazole by a pharmacist. She was using the Pill, but no barrier contraceptive. Examination revealed several small superficial ulcers on both labia and bilateral inguinal lymphadenopathy. What is the diagnosis, management and differential diagnoses?

DIAGNOSIS AND MANAGEMENT

The clinical diagnosis is a genital herpes simplex (HSV) infection. A swab should be taken for viral culture to confirm the diagnosis of type-1 herpes simplex (HSV -1). HSV -1 classically affects the face and upper body while HSV -2 affects the genital region, but there is some crossover. Treatment is either aciclovir 200mg five times daily for five days or valaciclovir 500mg twice a day for five days, after which follow-up should be arranged. An endocervical swab to test for trichomonas, gonorrhoea and chlamydia should be done. Referral to a sexual health clinic may be appropriate.

Possible different diagnosis
- Candidiasis.
- Lichen planus.
- Lichen sclerosus.
- Syphilis.
- Behcet's syndrome.

Differential diagnoses
- Candidiasis.
- Common.
- Rarely may cause ulceration in severe cases.
- Itchy, sore vulvovaginitis.
- White, cheesy discharge.
- Men are also affected - balanitis.

Contributed by Dr Gwen Lewis, a GP in Windsor, Berkshire.

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