Vulvar Ulcerations in Adolescents Following Both COVID-19 Infection and Vaccination

Background: Vulvar aphthous ulcers have been associated with a number of viral illnesses. These young women often present to the emergency department (ED) due to sudden, painful symptoms. We describe three cases: two cases of adolescents who developed vulvar aphthous ulcers following infection with Coronavirus, SARS-CoV-2, and one case of vulvar aphthous ulcer following the second dose of COVID-19 vaccine.

Case: Case 1: 6 days after COVID-19 diagnosis, a 9-year-old presented to the ED with 4 days of vulvar swelling and pain. She was diagnosed with a vulvar aphthous ulcer. 3 days later she represented with increased pain and urinary retention. She had bilateral shallow lesions with ragged borders. She denied prior sexual activity, abuse or trauma. Herpes Simplex Virus (HSV) 1/2 testing was negative. She was treated supportively with oral steroids, topical anesthetic, non-steroidal anti-inflammatories (NSAIDs), and sitz baths. With 10 days of steroids, symptoms improved. At 3 weeks, ulceration had healed with small residual scar. Case 2: 4 days after COVID-19 diagnosis, a 19-year-old presented to the ED, with a progressively painful vulvar lesion. We identified a unilateral vulvar aphthous ulcer with shallow lesion with ragged borders. She denied prior sexual activity, abuse or trauma. HSV testing was negative. She was treated supportively with topical anesthetic, NSAIDs, and sitz baths. Symptoms resolved within 2 weeks, with residual scar at 3 weeks. Case 3: 4 days after receiving second dose of Pfizer-BioNTech COVID-19 vaccine, a 16 year old presented to the ED with dysuria, vulvar pruritus, vulvar discharge, and labial swelling. She denied prior sexual activity. At follow up 1 day later in pediatric gynecology office, she had bilateral “kissing lesions” with punched-out appearance and necrotic eschar. Testing for HSV1/2, Epstein-Barr, mycoplasma, and cytomegalovirus were negative. She was treated supportively with topical steroids and NSAIDs with resolution of symptoms within a week.

Comments: These cases add to the growing body of literature describing acute vulvar aphthous ulcers as COVID-19 infection sequelae. To our knowledge this is the first case report of vulvar aphthous ulcer following COVID-19 vaccination. Non-sexually acquired vulvar aphthous ulcers remain a diagnosis of exclusion but testing for associated viral infections is not always performed. Affected patients often present to EDs for care. In the young child, multidisciplinary supportive care can be helpful in avoiding admission for sequelae like urinary retention. In this time of pandemic, testing for COVID-19 infection or inquiring about recent COVID-19 vaccination should be considered in all young women presenting with acute genital ulcerations.