Lipschutz Ulcer: Symptoms, Types, Causes and Treatment

Lipschutz ulcer—also known as acute vulvar ulcer, ulcus vulvae acutum, or non-sexually acquired acute genital ulcer—is a rare but striking condition that can cause significant concern for patients and healthcare providers alike. Sudden and painful, these ulcers often appear in young women or girls with no history of sexual activity, leading to confusion and fear. While the name may be unfamiliar outside specialist circles, understanding Lipschutz ulcer is crucial for accurate diagnosis, appropriate reassurance, and effective care.

In this article, we’ll explore everything you need to know about Lipschutz ulcer: its symptoms, the types that have been described, what causes these ulcers, and how they are treated. Each section draws on the latest research and clinical case reviews to provide clarity on this unusual but important diagnosis.

Symptoms of Lipschutz Ulcer

Lipschutz ulcers often present dramatically, with patients experiencing acute pain and distress. These sudden-onset ulcers can be alarming, but recognizing the key symptoms helps distinguish them from more common sexually transmitted or autoimmune conditions.

Symptom	Description	Frequency / Notes	Source(s)
Pain	Sudden, severe vulvar pain	Nearly universal; often prompts medical attention	1 2 3 7
Ulceration	1–3 well-defined, necrotic ulcers, ≥10mm	Usually on vestibule/labia minora; symmetric possible	1 7 8
Systemic Sx	Flu-like symptoms: fever, fatigue, malaise	Commonly precedes or accompanies ulceration	1 3 4 8 12
Lymphadenopathy	Enlarged, tender inguinal lymph nodes	Present in many cases	1 3 7
Voiding Issues	Pain on urination, difficulty voiding	Affects a substantial subset	1 3
Recurrence	Recurrent episodes	Occasional; more common than previously thought	7 10

Table 1: Key Symptoms

Classic Clinical Features

Lipschutz ulcers typically appear acutely, with patients reporting the rapid onset of intense vulvar pain. The ulcers are usually few in number—most often one to three—and are well-circumscribed, necrotic, and larger than 10 mm. They often develop on the vestibule or labia minora, but can sometimes affect the labia majora or lower vagina. The center of the ulcer is usually covered by a grayish or yellowish fibrinous exudate, surrounded by a sharply demarcated border. Symmetry is a notable feature, and sometimes the ulcers appear in a "kissing" pattern on opposing labial surfaces 1 3 7 8.

Associated Systemic and Local Symptoms

A striking aspect of Lipschutz ulcer is its frequent association with systemic symptoms resembling a viral illness. Patients often describe fever, malaise, fatigue, and sometimes headaches or nausea just before or at the time the ulcers appear 2 4 8 12. Enlarged, tender inguinal lymph nodes are common, and some patients experience dysuria or even urinary retention due to pain 1 3 7. In about 10% of patients, oral aphthous ulcers ("canker sores") are also reported 1.

Course and Recurrence

Most Lipschutz ulcers heal spontaneously within two to three weeks, leaving little or no scarring 1 7 10 11. However, recurrence is possible, and recent case series suggest it may be more common than originally thought, with up to 30% experiencing more than one episode 7 10. The acute, non-recurrent form remains the classic presentation, but clinicians should be aware of the possibility of repeated episodes.

Types of Lipschutz Ulcer

While Lipschutz ulcers were initially described as a single clinical entity, further research has identified distinct types based on their course, severity, and associated features. Recognizing these types helps tailor clinical management and avoid unnecessary interventions.

Type	Key Features	Course/Recurrence	Source(s)
Acute, Non-recurrent	Sudden onset, severe pain, associated infection	Self-limited, resolves ≤3 weeks	1 5 7 8
Chronic/Recurrent	Mild pain, slower progression, possible recurrences	May recur, less severe symptoms	5 7 10
Symmetric ("Kissing")	Bilateral, mirror-image ulcers on labial surfaces	Often seen in acute presentation	1 8
Male Counterpart	Painful scrotal ulcer (juvenile gangrenous vasculitis)	Similar triggers, rare in males	5

Table 2: Types of Lipschutz Ulcer

Acute, Non-recurrent Type

This is the classic form: patients (often young, sexually inactive women) suddenly develop painful genital ulcers accompanied by systemic symptoms such as fever or malaise. The ulcers are necrotic, well-demarcated, and usually heal within three weeks without recurrence 1 5 8. Primary Epstein-Barr virus (EBV) infection is frequently implicated, but other infections can serve as triggers 1 5.

Chronic or Recurrent Type

A less commonly described variant, the chronic or recurrent type, involves milder ulcers with a slower, torpid progression. These may recur and are less likely to be associated with fever or systemic symptoms. The etiology is less clear, and these cases can be mistaken for idiopathic aphthous ulcers or Behçet’s disease 5 7 10.

Symmetric ("Kissing") Ulcers

Some patients, particularly those with the acute type, develop ulcers that appear on opposing labial surfaces—giving a mirror-image or "kissing" appearance. This pattern helps differentiate Lipschutz ulcers from other causes of genital ulceration 1 8.

Male Counterpart

Interestingly, a similar syndrome has been reported in males: juvenile gangrenous vasculitis of the scrotum. This rare condition shares many features with the acute form of Lipschutz ulcer, including association with pharyngeal infections and acute, painful ulceration, suggesting a shared pathophysiology 5.

Causes of Lipschutz Ulcer

The exact cause of Lipschutz ulcer remains incompletely understood, but research points to a set of common infectious and immunological triggers. Importantly, this is not a sexually transmitted disease, and its appearance in young, sexually inactive individuals supports a nonvenereal etiology.

Cause/Trigger	Examples / Description	Frequency / Notes	Source(s)
Infectious (Viral)	EBV, CMV, Influenza A/B, Adenovirus, Parvovirus B19, SARS-CoV-2/COVID-19	Most common, especially EBV	1 3 4 5 7 9
Infectious (Bacterial)	Mycoplasma pneumoniae	Less common, but notable	1 7
Immunologic reaction	Post-infectious immune activation	Central role in pathogenesis	1 6 8
Drug-related	Rare; certain medications implicated	Case reports only	3
Unknown/Idiopathic	No clear trigger identified	2/3 of cases remain idiopathic	7 8 10

Table 3: Causes and Triggers

Infectious Triggers

Epstein-Barr Virus (EBV)

EBV is the most frequently linked infectious agent, particularly in the classic acute type. Many patients experience "infectious mononucleosis syndrome" just before ulcer onset—characterized by fever, sore throat, lymphadenopathy, and fatigue 1 5 9. However, not all cases are associated with EBV, and other viruses are also common triggers.

Other Viruses

Cytomegalovirus (CMV), Influenza A and B, Adenovirus, Parvovirus B19, and most recently SARS-CoV-2 (COVID-19) have all been reported as triggers for Lipschutz ulcer 3 4 7 9. In some cases, the ulcer appears shortly after a confirmed infection or vaccination, suggesting a possible post-infectious immune response 9.

Mycoplasma pneumoniae

This bacterial organism has been identified in a subset of cases, often in association with respiratory symptoms. Testing for Mycoplasma should be considered, particularly when viral causes are excluded 1 7.

Immunological Mechanisms

What unites these diverse triggers is the likely immunological mechanism: an exaggerated local immune response to a systemic infection, resulting in acute mucosal ulceration. This helps explain the association with flu-like symptoms and the absence of direct viral or bacterial invasion at the ulcer site 1 6 8.

Drug-Related and Idiopathic Cases

Rarely, drugs or other non-infectious exposures have been implicated. However, in up to two-thirds of cases, no clear cause is ever identified despite thorough investigation 7 8 10.

Treatment of Lipschutz Ulcer

While the presentation of Lipschutz ulcer can be dramatic and distressing, the good news is that most cases resolve quickly with supportive care. Correct diagnosis is essential to avoid unnecessary interventions and to reassure patients and families.

Treatment	Approach/Medication	Notes/Outcome	Source(s)
Supportive Care	Analgesics (NSAIDs, Paracetamol), topical anesthetics	Mainstay; most ulcers heal in 2–3 weeks	1 3 8 11 12
Local Care	Hygiene, topical antibiotics if needed	Prevents secondary infection	3 10 11
Corticosteroids	Systemic/topical in severe cases	May relieve pain, but no effect on duration	1 3
Antivirals/Antibiotics	Only if specific infection is identified	Rarely needed; not routine	3 7 10
Reassurance	Education about benign nature	Reduces anxiety, avoids overtreatment	1 3 8 10

Table 4: Treatment Strategies

Supportive and Symptom-Based Care

Most patients require only supportive treatment: pain control with oral NSAIDs or paracetamol, and topical anesthetics such as lidocaine gel to ease discomfort during urination or daily activities 1 3 8 11 12. Hygiene measures—gentle cleansing and avoidance of irritants—are important. Secondary infection is rare but can be prevented with topical antibiotics if indicated 3 10 11.

Corticosteroids

In severe or refractory cases, topical or short courses of oral corticosteroids may be considered to reduce pain and inflammation. However, studies show that systemic corticosteroids do not shorten the overall duration of illness 1 3. Their use should be limited to selected cases after careful exclusion of infectious etiologies.

When to Use Antivirals or Antibiotics

Routine use of antivirals or antibiotics is not indicated unless a specific treatable infection (e.g., herpes simplex or bacterial superinfection) is identified through laboratory testing 3 7 10. Most cases are idiopathic or post-viral and resolve without such therapy.

Reassurance and Education

Given the alarming appearance of the ulcers and frequent concern about sexually transmitted infections, it is essential to reassure patients and families about the benign, self-limited nature of Lipschutz ulcer 1 3 8 10. Unnecessary investigations and treatments should be avoided.

Healing and Follow-Up

Nearly all ulcers heal without scarring in 1–3 weeks. Regular follow-up may be needed to monitor healing and address any recurrence 1 7 10 12. If ulcers persist beyond three weeks or are recurrent, further evaluation for alternative diagnoses (e.g., Behçet’s disease, autoimmune conditions, or malignancy) is warranted.

Conclusion

Lipschutz ulcer is an uncommon but important cause of acute genital ulceration, especially in young women and girls. Recognizing its key features can help prevent misdiagnosis, unnecessary anxiety, and inappropriate treatment. Here’s a summary of what we’ve covered:

• Symptoms: Sudden, painful, necrotic vulvar ulcers, often with systemic flu-like symptoms and tender lymph nodes.
• Types: Acute non-recurrent (classic), chronic/recurrent, symmetric (“kissing”), and rare male counterparts.
• Causes: Most commonly triggered by viral infections (EBV, CMV, influenza, COVID-19), but two-thirds of cases remain idiopathic.
• Treatment: Supportive care and reassurance are the foundation; most ulcers heal without intervention. Corticosteroids may be used in severe cases but do not speed healing.

Key Takeaways:

• Lipschutz ulcer is NOT sexually transmitted.
• The ulcers are self-limiting and generally heal within 2–3 weeks.
• A careful diagnostic approach is required to exclude other causes.
• Patient education and reassurance are crucial to effective management.

Armed with this knowledge, clinicians, patients, and families can approach Lipschutz ulcer with greater confidence and less fear.