Sudden onset of painful genital ulcers: What could it be?
A 23-year-old woman presents with painful vulval ulcers and severe dysuria (Figure). She has not been sexually active for the past three months and is otherwise well. She has no history of gastrointestinal disease.

On examination, several superficial ulcers are visible that have a red areola and a sloughy yellow-green base measuring 3 to 5 mm. The lesions are located mainly on the labia minora, which are oedematous. She does not have any oral ulceration.

The patient reports similar episodes over the past few years that have resolved spontaneously. On this occasion, however, the ulcers are so painful that she is not able to urinate and she requires admission to hospital for catheterisation.

She was diagnosed with Nonsexually acquired genital ulceration (NSAGU) based on clinical findings. In the situation where the patient was unable to walk or urinate, a short course of oral prednisone (25 mg/day) resulted in rapid relief of pain and with prednisone being rapidly withdrawn as soon as ulcers are healed.

Case learnings:-
-NSAGU can range in severity and there are no formal treatment guidelines. For mild cases of genital ulceration, the mainstays of treatment are avoidance of irritating factors (tight clothing, perfumed soaps, pads and liners) and use of analgesia and topical treatment.

- Skin biopsy can be traumatic for a patient who is already in severe pain, particularly an adolescent, and the results are nonspecific. Investigation for primary herpes simplex virus and secondary bacterial infection is essential and should include skin swabs for polymerase chain reaction (PCR) testing and culture.

-The anti-inflammatory properties of corticosteroids can be useful. Potent topical corticosteroids are generally safe to use, and when applied in an ointment base for two weeks or less to settle a minor flare they do not cause side effects.

- For severe cases, hospitalisation for pain management including catheterisation may be required. Prophylactic doxycycline (50 to 100 mg/day) may be effective to control flare-ups and prevent recurrence.

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