外阴溃疡

　　一、发病原因

　　外阴溃疡多系外阴炎症引起，如非特异性外阴炎、单纯疱疹病毒感染、白塞病、外阴结核、梅毒、性病性淋巴肉芽肿等。此外，约有1/3的外阴癌，在早期表现为溃疡。有人认为外阴溃疡是眼-口-生殖器综合征的一个特殊发展阶段。

　　单纯疱疹性病毒是外阴溃疡最常见的病因。本病具有高度的接触传染性，如性交传染、胎儿致畸及患者本身的致癌作用，所以被引起广泛的关注。

　　软下疳为杜克雷(Ducrey)嗜血杆菌通过性交传染的疾病，亦是一种较常见的性病有溃疡性病变。

　　二、发病机制

　　由感染因素、自身免疫因素、环境因素、遗传因素、组织化生或肿瘤等因素使外阴皮肤及皮下组织发生炎性反应，出现微循环障碍、局部缺血、梗死、组织溃烂。

　　并发症一、急性外阴溃疡：多由各种原因的外阴炎引起，一般是外阴炎病变过程中的一种症状表现。

　　并发症二、前庭大腺炎：此症状多见于育龄妇女，主要是因为前庭大腺被葡萄球菌、链球菌、大肠杆菌等细菌感染所致，多引起急性炎症。

　　并发症三、霉菌性外阴炎：这种类型的外阴炎，是由一种类酵母菌感染而引起的外阴炎，常与霉菌性阴道炎并存。

　　Complication four, sexually transmitted diseases:During the onset process of sexually transmitted diseases such as vulvar condyloma acuminatum, chancroid, genital herpes, gonorrhea, and others, vulvar inflammation often occurs.

　　Complication five, non-specific vulvitis:Not paying attention to hygiene and being physically weak can make a woman's vulva more susceptible to bacterial invasion, causing vulvitis, such as cervicitis, vaginal inflammation, and so on.

　　Ulcers can occur on all parts of the vulva, most often on the inner sides of the small and large labia, followed by the mucosa of the prepuce and the area around the vaginal orifice. Ulcers can exist singly or fuse into a larger ulcer. Vulvar ulcers can present as acute or chronic:

　　I. Acute vulvar ulcer

　　1. Non-specific vulvitis:Ulcers often occur after scratching, may be accompanied by low fever and fatigue, severe local pain, superficial ulcers, fewer in number, and明显的 inflammation around them.

　　2. Herpesvirus infection:It has an acute onset. After contacting the source of infection with herpes simplex virus, there is usually a latent period of 2 to 7 days before fever, discomfort, inguinal lymphadenopathy, and herpes appear. Initially, there are multiple vesicles, which break down to form superficial multiple ulcers with severe pain. The ulcers often involve the small labia, especially the inner side, with 50% to 80% of cases involving the vagina, urethra, and cervix. The size of the ulcers varies, the bottom is gray-yellow, the marginal edges are slightly elevated, and there is marked congestion and edema. The ulcers often heal naturally within 1 to 2 weeks, but often recur. Due to the involvement of the vagina, urethra, and other areas, patients often have a large amount of leukorrhea, which initially is transparent serous fluid, then cloudy thin pus, and finally becomes yellow pus due to bacterial infection, accompanied by urinary symptoms such as urgency and difficulty in urination.

　　3. Behcet's disease:Acute vulvar ulcers are commonly seen in Behcet's disease, also known as the ocular-mouth-genital syndrome. It was previously believed that acute vulvar ulcers were a benign ulcer caused by large bacilli, which was a non-contact infection. Now it is generally believed that acute vulvar ulcers are a stage of Behcet's disease and can occur simultaneously or sequentially with ocular and oral lesions. Ulcers can occur widely on all parts of the vulva, especially on the inner and outer sides of the small labia and the prepuce. They have an acute onset, often recur, and are clinically divided into 3 types, which can exist singly or in combination, with gangrenous type being the most severe.

　　(1) Gangrenous type: usually has systemic symptoms first, such as fever and fatigue, with significant redness and swelling at the site of the lesion, irregular ulcer edges, excavating phenomena, severe local pain, a large amount of pus on the ulcer surface, or necrotic pseudomembrane ranging from dirty yellow to gray-black. After removal, the base appears uneven, the lesion progresses rapidly, and can cause small labial defects, with an appearance similar to vulvar cancer. However, the edges and base are soft and non-invasive.

　　(2) Chancroid type: relatively common, with mild symptoms, a slow course, numerous ulcers, shallow, red and swollen around the ulcers, irregular edges, and may also have excavating phenomena. They usually heal within a few weeks, but often new ulcers appear near the healed old lesions.

　　(3) Granuloma type: ulcers are as small as needleheads to rice grains in size, numerous, heal quickly, and have mild自觉symptoms.

　　4. Sexually transmitted diseases:Syphilis, chancroid, and sexually transmitted lymphogranuloma venereum can all cause vulvar ulcers.

　　(1) Syphilis: Vulvar ulcers caused by syphilis can appear in the primary and secondary stages of syphilis. Syphilis rash can develop into ulcers. After 2 to 4 weeks of incubation period after infection with syphilis, the initial syphilis lesions, chancres, appear at the local sites of spirochete invasion. The characteristic is painless, red, inflammatory, hard nodules, round, with a diameter of 1 to 2cm, superficial ulcers, regular edges, elevated periphery, smooth surface, deep red, with serous purulent secretion on the surface. The ulcers are usually solitary, located on the labia majora and minora and the labial frenulum, and can also be seen on the clitoris, urethral orifice, or cervix.

　　(2) Chancroid: Ulcers are often multiple, with an average of 4 to 5 primary ulcers in women. The ulcers can then autoimplant and form clusters of small ulcers around them. The ulcers generally heal within 1 to 2 months, with initial inflammatory papules, surrounded by erythema, which become pustules in 1 to 2 days, break down to form erosion, then expand to form ulcers. The ulcers vary in shape and size, with a diameter of 1 to 20mm, rough edges, sloping in shape, clear boundaries, surrounded by erythema, soft and deep base, covered with gray or yellow necrotic purulent secretion. Removal of the purulent secretion reveals a granulomatous base, which is painful and prone to bleeding.

　　(3) Lymphogranuloma venereum starts as a single papule and vesicle, vesicle or pustule, without pain or infiltration, and then breaks down into erosion or shallow ulcer. Ulcers are commonly found in the vestibule, labia minora, vaginal orifice, and perineal area. Lesions have a regular shape, flat edges, and superficial, and can heal spontaneously within a few days to a month without leaving scars.

　　Second, chronic vulvar ulcer

　　1. Tuberculosis:Vulvar tuberculosis is rare and occasionally secondary to severe pulmonary, gastrointestinal, reproductive organs, peritoneal, or bone tuberculosis. It often occurs on the labia or mucosa of the vestibule. The lesions develop slowly, often starting as a limited small nodule, which soon ulcerates into a shallow ulcer with soft and thin edges and excavated shape. The ulcer is irregular in shape, with an uneven base covered with caseous structure. The lesion is painless, but can cause severe pain after being stimulated or rubbed by urine. The ulcer does not heal for a long time and can spread to surrounding areas.

　　2. Cancer:Early vulvar malignant tumors may manifest as papules, nodules, or small ulcers. Lesions are often located on the labia majora and minora, clitoris, and posterior symphysis, etc., with or without vulvar leukoplakia. The ulceration of cancer is difficult to distinguish from that of tuberculosis by naked eye, and a biopsy is required for diagnosis.

　　First, prognosis:The prognosis of vulvar ulcers caused by different etiologies is also different.

　　Second, precautions:

　　1. Strengthen publicity and education, and strictly prohibit prostitution and pimping.

　　2. Pay attention to personal cleanliness and hygiene.

　　3. Treat early lesions promptly and thoroughly to prevent the lesions from progressing to the late stage.

　　4. Routine syphilis serological examination before marriage and during pregnancy.

　　5. Strictly select blood sources, and all blood donors should undergo syphilis serological tests.

　　6. Early treatment of vulvar ulcers caused by sexually transmitted diseases should effectively control infection and skin lesions, and trace the source of infection. Partners should be treated regardless of whether they have symptoms. Pay attention to mixed infection with other sexually transmitted diseases, especially simultaneous HIV infection. The most effective preventive method at present is to avoid contact with infectious skin lesions. Condoms can reduce the spread of the disease. Sexual activity should be avoided during the infection period.

　　7, Genital tuberculosis is mostly secondary infection, the primary focus of which is pulmonary tuberculosis. Therefore, it is of great significance to actively prevent and treat pulmonary tuberculosis to prevent genital tuberculosis. In addition to strengthening anti-tuberculosis publicity and education, efforts should be made to strengthen the health care of children and adolescents. Newborns weighing more than 2200g can be vaccinated with BCG 24 hours after birth, and it can be supplemented within 3 months if necessary. Infants and adolescent girls with negative tuberculin skin test results after 3 months should be vaccinated with BCG. It should be avoided to get pregnant during the active phase of tuberculosis. In addition, patients with genital tuberculosis may have tuberculosis bacilli in their vaginal secretions and menstrual blood, and isolation should be strengthened to avoid transmission.

　　According to the medical history and characteristics of the ulcer, secretion smear, culture, syphilis serological test, etc., should be performed when necessary to clarify the diagnosis.

　　1, Deterioration cell study for genital herpes, enzyme-linked immunosorbent assay.

　　2, Smear examination of soft chancre secretions, culture, Ito-Reenstieno reaction, etc., can detect the pathogen.

　　3, Auxiliary examination for sexually transmitted lymphogranuloma venereum: complement fixation test, dilution 16-64 times is positive; smear to find intracellular inclusions; chick embryo and cell culture to isolate chlamydia, etc.

　　4, Syphilis pathogen examination, that is, dark field examination, a small amount of serum exudate or lymphatic puncture fluid can be taken from the hard chancre of primary syphilis and placed on a glass slide, after adding normal saline, placed under a dark field microscope for observation. Judgment can be made based on the strong refractive index and movement of the spirochetes, and a diagnosis can be made.

　　5, Genetic diagnosis of infectious diseases: Polymerase chain reaction (PCR) for diagnosing genital infections has the characteristics of rapidity, accuracy, and high sensitivity.

　　6, Soft chancre tissue pathological examination: Soft chancre may be infected with syphilis at the same time, sexually transmitted lymphogranuloma venereum, inguinal granuloma, vaginal herpes, etc., and the corresponding pathogenic microorganisms can be detected.

　　7, Syphilis serological examination: This test is mainly to detect the presence of antiprevalin antibodies (reactive substances) in patients, a serological test for Treponema pallidum antigen, to determine the specific antibodies in serum.

　　　Vulvar ulcer dietary recipe (the following information is for reference only, detailed information needs to be consulted with a doctor)

　　1, Gentian Root and Egg:Boil 10 grams of gentian root in water, remove the residue and take the juice. Crack 3 eggs to make poached eggs and add 30 milliliters of honey. Eat on an empty stomach, 5 days as a course. It has the function of clearing heat and healing sores. It is used to treat vulvar ulcers; symptoms include severe vulvar burning and pain.

　　2, Coix Seed and Egg:Boil 60 grams of coix seed and extract the juice. Add 2 scrambled eggs and 60 grams of brown sugar. Eat the eggs and drink the soup, 1 time a day, for 6 days as a course. It has the functions of clearing heat and detoxifying, and drying dampness to heal sores. It is used to treat vulvar ulcers caused by damp-heat fire toxin; symptoms include severe vulvar heat and pain.

　　3, Ku Cha Gui Jia Decoction:Tea, pangolin, and angelica root, each 15 grams, are cooked together in a pot with half water and half wine. Take 2 times a day until the ulcer is healed. It has the functions of clearing heat and detoxifying, and promoting blood circulation to dissipate masses. It is used to treat vulvar ulcers caused by damp-heat fire toxin accumulation; symptoms include severe vulvar swelling and pain, and burning discomfort.

　　4. General's egg:Make a small hole at the top of a raw egg and add 3 grams of raw rhubarb powder. Seal the hole with paper and boil in water until cooked. Eat on an empty stomach, 3 times a day, for 4-5 days as a course. It has the function of cooling blood and healing boils. It is mainly used for vulvar ulcer with symptoms such as long-term non-healing and burning pain.

　　5. Cucumber and turmeric snake soup:Take one snake (about 250 grams) and peel it, remove the internal organs, and boil it in a pot of boiling water. Remove the bones and take the meat, then cook with 100 grams of turmeric, 60 grams of red beans, 30 grams of ginger, 8 red dates (with the seeds removed), and 500 grams of cucumber pieces in a pot with an appropriate amount of water. Boil with high heat and then simmer with low heat for 3 hours. Season and eat. It has the function of clearing heat, detoxifying, and promoting diuresis. It is mainly used for vulvar ulcer with damp-heat accumulation.

　　6. Dandelion decoction:Take 30 grams of dandelion, 90 grams each of Semiaquilegia adoxoides and Hemaraba, 50 grams of lonicera japonica, 15 grams of scallion white, and cook them together in a pot with an appropriate amount of water. Boil with high heat and then simmer with low heat for 1 hour. Dissolve an appropriate amount of brown sugar in the juice and take it all at once, or drink it frequently as tea. It has the function of clearing heat, detoxifying, resolving phlegm, and resolving boils. It is mainly used for vulvar ulcer with severe heat-toxin accumulation.

　　7. Dandelion and mung bean soup:Boil dandelion (10 grams) to make a decoction, then add 50-100 grams of mung beans and cook into porridge. Stir in sugar to taste before eating. It has the function of clearing heat, detoxifying, and resolving boils. It is mainly used for heat-toxin type vulvar ulcer.

　　What foods are good for vulvar ulcer?

　　1. It is recommended to eat amaranth, cabbage, mustard green, taro, kelp, purple kelp, chicken blood, snake meat, and pangolin when itchy.

　　2. Eat more vegetables and fruits.

　　3. Drink more tea or light beverages.

　　4. Prefer foods that cool blood and detoxify. Examples include mung beans, glutinous rice, cucumber, bitter melon, portulaca oleracea, green tea, etc.

　　What foods should be avoided for vulvar ulcer?

　　1. Avoid stimulant drinks such as coffee.

　　2. Avoid spicy and irritant foods such as scallions, garlic, ginger, and cinnamon.

　　3. Avoid smoking and drinking.

　　4. Avoid greasy, fried, moldy, and preserved foods.

　　5. Avoid poultry such as roosters and geese.

　　6. Avoid seafood and刺激性, allergenic foods when itching is severe.

　　1. Treatment

　　1. Treatment of acute vulvar ulcer

　　(1) Local treatment: ① Local symptomatic treatment: Maintain the cleanliness, dryness, and reduce friction of the vulva; take a bath with potassium permanganate solution at a concentration of 1:5000. For ulcers caused by nonspecific vulvitis, local application of antibiotic ointment can be considered. For other ulcers, treatment should be based on different etiologies. Washing the affected area with 0.1% cresol solution or applying a damp compress can be helpful. Neomycin, chloramphenicol, gentamicin, diclofenac ointment or cream can be applied externally, or these drugs can be added to the damp compress solution for application. ② Topical corticosteroid ointment is better during the period of ulcer improvement. ③ Ultraviolet and helium-neon laser therapy has certain efficacy.

　　(2) General treatment: ① Taking oral complex vitamin B, vitamin C, and systemic antibiotics has a certain therapeutic effect on the disease; for gangrenous cases, systemic application of corticosteroids and antibiotics can be considered. ② Intramuscular injection of human serum gamma globulin can enhance the body's resistance and promote the regression of skin lesions.

　　(3) Traditional Chinese medicine treatment: ① Apply indigo powder and tin powder locally. ② Mica powder is ground into fine powder, mixed with glycerin after high-pressure sterilization, and a few drops of 1% tetracaine solution are added to make a paste. Before treatment, apply a cotton ball soaked with 1% tetracaine solution to the ulcer surface for 3 to 10 minutes to relieve pain, and then gently apply the mica glycerin paste to the ulcer. Treatment resulted in healing in 23 cases, with an average healing time of 42 days. ③ When there is purulent discharge and necrotic tissue in female vulvar ulcers, apply purple scab ointment (containing 9g of calomel, red powder, amber powder, sandalwood powder, and blood scab, 0.9g of borneol, calcined pearl powder, 30g of beeswax, 120ml of sesame oil). ④ The treatment principle is to strengthen the spleen, clear heat, and detoxify and promote diuresis: use the Decoction for Promoting Diuresis (Herba epimedii, Semen coicis, Phellodendri, Poria, Cortex phellodendri, Rhizoma alismatis, Talcum, and Coptis), add Baihu Decoction for high fever, and add Tufuling for excessive leukorrhea.

　　2. Treatment of genital herpes

　　(1) Antiviral treatment: ① Acyclovir (acyclovir, ACV): A type of open-chain purine nucleoside that can inhibit viral DNA synthesis and has a smaller effect on the synthesis of host cell DNA. It is currently recognized as an effective antHSV drug. Severe cases can be administered intravenously with 5mg/(kg?8h) of acyclovir (ACV), for 7 to 10 days; mild cases can take 200mg of acyclovir (ACV) orally, once every 6 hours, for 7 to 10 days, given within 2 to 3 days of the onset of the disease, such as blisters and ulcers, which can significantly alleviate symptoms, reduce pain, shorten the course of the disease, and reduce viral shedding. However, treatment cannot prevent the recurrence of GH. Acyclovir (ACV) is contraindicated during pregnancy. Recurrent patients can take or apply acyclovir (ACV) locally. When applied externally, it should not be applied to the cervix and vagina. The drug is excreted by the kidneys in 95%, with no significant toxic side effects. A few patients have reported transiently increased transaminases, and intravenous infusion at too high a concentration or too fast a rate can cause phlebitis. ② Valacyclovir (VC): The levorotatory valine ester of acyclovir (ACV), with the advantages of a long half-life and fewer dosing times. Dosage: 500mg, twice a day, for 5 days; severe cases can be taken for 10 days. ③ Famciclovir (Famvir): Orally absorbed completely, rapidly converted into penciclovir in the small intestine and liver, which is phosphorylated by virus-specific enzymes, interfering with viral DNA synthesis by stopping the formation of short chains. Dosage: Primary GH 250mg, three times a day, for 5 days; recurrent GH 125mg, twice a day, for 5 days. ④ Ganciclovir (dihydroxypropoxy methylguanosine, DHPG): 5 to 10mg/(kg?d), administered intravenously in three divided doses, for 14 days. ⑤ Ribavirin (Virazole, Ribavin, RBV): Inhibits the replication and synthesis of various viral DNA and RNA, dosage: Primary GH, 15mg/(kg?d), intramuscular injection; recurrent GH, 0.4g, twice a day, for 5 days.

　　(2) Immunotherapy: ① Interferon (interferon, IFN): It can induce the activity of a series of enzymes, degrade viral mRNA and terminate replication, and can also interfere with the protein synthesis process of viruses, affecting viral replication. Dosage: Primary GH, INF-a 50,000U/(kgd), intramuscular injection, for 1-2 weeks; recurrent GH is 100,000U/kg, single dose intramuscular injection. ② Polyinosinic acid: 2mg, intramuscular injection, once every 3 days, which can induce the synthesis of interferon. ③ Transfer factor: 2mg intramuscular injection, twice a week, for 2-3 weeks, which can enhance the body's immunity. ④ Levamisole: 25-50mg, 3 times a day, for 3 days, then stop for 4 days, and can be repeated 2-3 times.

　　(3) Local treatment: ① The following ointments can be selected for local application: 90.5% iodine glycerol (herpes ointment), topical application, 3 times a day. ② 0.5% neomycin ointment, topical application, 3 times a day. ③ 5% acyclovir (acyclovir) ointment, topical application, 4-6 times a day, for 7-10 days consecutively.

　　3. Treatment of Behcet's disease

　　When systemic symptoms are present, attention should be paid to improving the overall condition, proper rest should be taken, nutrition should be increased, and in severe cases, corticosteroid hormones can be administered during the acute phase to alleviate symptoms, such as prednisone (prednisone) orally 20-40mg/d, but in cases of thrombophlebitis and central nervous system involvement, antibiotics are often needed to be used simultaneously with hormones. After the condition is stable, the dose of hormones should be gradually reduced. Immunosuppressants such as cyclophosphamide or azathioprine can also be used in combination with hormones, which have a certain therapeutic effect. Vitamin B and vitamin C can be taken orally for adjuvant treatment. In the chronic phase, traditional Chinese medicine can be used for treatment, mainly focusing on clearing heat, detoxifying, drying dampness, dispelling wind, relieving itching, and pain relief. Pay attention to keeping the vulva clean, dry, and reducing friction. Local application of compound neomycin ointment, 1%-2% silver nitrate ointment, or applying Bingpeng powder can be used.

　　4. Treatment of external genital syphilis

　　Since 1943 when Mahoney, Arnold, and Harris first used penicillin to treat syphilis, it has been effective with rapid action, few side effects, complete eradication of the spirochete, and remains the most ideal drug for expelling syphilis to this day. There have been no reports of TP resistant to penicillin.

　　(1) Treatment Principles: Clear diagnosis, early regular and adequate treatment, treatment for both partners, prohibition of sexual intercourse during treatment, strict assessment of cure status, regular follow-up examination within 3 years after cure.

　　(2) Treatment Plans: ① Early syphilis (primary, secondary, and latent syphilis with a course of disease within 2 years): A Penicillin: a Procaine penicillin (procaine penicillin G) 8 million units, administered intramuscularly, 1 time/day, for 15 consecutive days. b Benzathine penicillin (benzathine benzylpenicillin) 24 million units, administered intramuscularly in both gluteal regions, once a week, for a total of 23 times. B Allergic to penicillin: a 500mg erythromycin, taken orally, 4 times/day, for 15 consecutive days. b 500mg tetracycline, taken orally, 4 times/day, for 15 consecutive days. c 100mg doxycycline (doxycycline hyclate), taken orally, 2 times/day, for 15 consecutive days. ② Late syphilis: A Penicillin: a Procaine penicillin 8 million units, administered intramuscularly, 1 time/day, for 20 consecutive days. b Benzathine penicillin 24 million units, administered intramuscularly once a week, for a total of 3 times. B Allergic to penicillin: a 500mg erythromycin, taken orally, 4 times/day, for 30 consecutive days. b 500mg tetracycline, taken orally, 4 times/day, for 30 consecutive days. c 100mg doxycycline (doxycycline hyclate), taken orally, 2 times/day, for 30 consecutive days. d 100mg minocycline (minocycline hydrochloride), taken orally, 2 times/day, for 20 consecutive days. e 500mg azithromycin, taken orally, 1 time/day or every other day, for 10 consecutive days. Azithromycin is effective for skin lesions and is recommended for patients allergic to penicillin and those with concurrent chlamydial infection.

　　5. Treatment of Chancroid:Antibiotic sensitivity test should be conducted first to guide clinical medication.

　　(1) Comprehensive Treatment: In 1998, the treatment plan for chancroid recommended by the U.S. Centers for Disease Control and Prevention (CDC): ① 1g azithromycin, taken orally as a single dose; ② 250mg ceftriaxone, administered intramuscularly as a single dose; ③ 500mg ciprofloxacin, taken orally, 2-3 times/day, for 3 consecutive days; ④ 500mg erythromycin, taken orally, 4 times/day, for 7 consecutive days. In China, in addition to the above plan, the commonly used treatment plans include: ① Sulfamethoxazole/trimethoprim (cotrimoxazole) 2 tablets, 2 times/day, for 1-2 weeks; ② 100mg doxycycline (doxycycline hyclate), taken orally, 2 times/day, for 10-14 days; ③ Combined use of erythromycin and doxycycline (doxycycline hyclate); ④ 2g spectinomycin, administered intramuscularly as a single dose; ⑤ 500mg amoxicillin plus 125mg clavulanate potassium, taken orally, 3 times/day, for 7 consecutive days.

　　(2) Local treatment: Keep the area clean, and use potassium permanganate solution, hydrogen peroxide (peroxide), or povidone-iodine (polyvinylpyrrolidone-iodine) for cleaning, moist敷 or soak the area, and apply erythromycin ointment, mupirocin (Bactroban) ointment, ichthammol ointment; for lymph nodes that have abscessed, it is generally not advisable to incise them, but rather to repeatedly puncture and aspirate pus, and inject antimicrobial drugs.

　　6. Treatment of lymphogranuloma venereum

　　(1) Systemic treatment: Lymphogranuloma venereum (LGV) requires early treatment, and the duration of medication should be long. Systemic treatment can be chosen from the following oral medications according to the situation: ① Tetracycline 500mg, 4 times a day, for 21 days. ② Sulfamethoxazole/trimethoprim (combined sulfamethoxazole trimethoprim) 2 tablets, 2 times a day, for 14 days. ③ Erythromycin 500mg, 2 times a day, for 14 days. ④ Doxycycline 200mg, 2 times a day, for 21 days. ⑤ Minocycline (Minocin) 100mg, 2 times a day, for 14 days, with the first dose doubled.

　　(2) Local treatment: For lymph nodes without abscess, cold wet敷 or ultra-short wave therapy can be performed. If there is a fluctuating sensation, sterile syringes can be used to puncture from the upper normal skin of the lesion to aspirate pus, and incision and drainage should be prohibited to avoid the formation of fistulas that are difficult to heal. Locally, a potassium permanganate solution of 1:5000 to 1:8000 can be used for cleaning, and sulfonamide powder can be applied externally. If severe ulceration occurs, skin grafting can be performed, and for rectal stricture, dilation can be performed. For severe cases and elephantiasis, surgical excision can be performed.

　　7. Treatment of early vulvar squamous cell carcinoma

　　(1) Surgical treatment: Surgery is the first-line treatment for early vulvar invasive squamous cell carcinoma. Since early vulvar invasive squamous cell carcinoma generally has no inguinal lymph node metastasis and no lymphatic or vascular invasion, it is not necessary to adopt the standard radical surgery. It only requires a wide excision of the vulva, even a local wide excision of the vulvar lesion, which means only removing the lesion and 1-2 cm of surrounding skin can achieve satisfactory results, without the need for inguinal lymph node dissection. Wharton reported 25 cases of early vulvar cancer, where only a wide vulvectomy was performed, and none of the patients had recurrence or death after treatment. Reducing the scope of surgery can retain as much normal tissue as possible, reduce surgical injury and postoperative complications, and try to maintain the physiological function of the organ, which can more effectively improve the quality of life.

　　(2) Radiotherapy is only used for patients who cannot tolerate surgery.

　　(3) Chemotherapy is not considered for early vulvar invasive squamous cell carcinoma.

　　8. Treatment of vulvar basal cell carcinoma

　　(1) Surgical treatment: It is advisable to perform a more extensive local excision, including part of the surrounding normal skin and deep subcutaneous tissue. Generally, it is not necessary to perform radical vulvectomy or inguinal lymph node dissection. If the urethra, vagina, anus, or there is a suspicion of positive inguinal lymph nodes, a biopsy should be performed. If pathological confirmation shows metastasis, inguinal lymph node dissection should be performed. For patients with positive deep inguinal lymph nodes, pelvic lymph node dissection should be performed.

　　(2) Radiotherapy: Applicable only to early-stage basal cell carcinoma, as basal cell carcinoma is sensitive to radiotherapy. Due to the poor tolerance of normal skin in the vulva to radiation, it is easy to develop vulvar radiation inflammation, ulcers, and pain during treatment, so radiotherapy is not suitable for patients in the middle and late stages.

　　(3) Chemotherapy: The efficacy of anticancer chemotherapy for basal cell carcinoma is poor, but it can be used as a supplement to comprehensive treatment for advanced cases.

　　9. Tuberculosis treatment:The five principles are 'early, combined, regular, moderate, and full course'. The treatment for skin tuberculosis is the same as that for tuberculosis of other organs, and local treatment, surgical treatment, and physical therapy can be supplemented if necessary. The following points are elaborated on the treatment of skin tuberculosis:

　　(1) Systemic antituberculosis drug treatment: Common types, dosages, administration methods, and main adverse reactions of antituberculosis drugs: isoniazid (isoniazid, abbreviated as INH, H) tablets, 0.1g per tablet; rifampicin (rifampicin, abbreviated as RFP, R) capsule, 0.15g per capsule; pyrazinamide (pyrazinamide, abbreviated as PZA, Z) tablet, 0.25g. Ethambutol (ethambutol, abbreviated as EMB, E) tablet, 0.25g per tablet. Streptomycin (streptomycin, abbreviated as SM, S) injection (sulfate), 0.75g per vial. The following is a short-term interval therapy for pulmonary tuberculosis, and skin tuberculosis can choose an appropriate plan according to the condition.

　　① Plan 1: 2H3R323E3/4H3R3 intensive phase: isoniazid, rifampicin, pyrazinamide, and ethambutol once every other day, for a total of 2 months, taking medication 30 times. Continuation phase: isoniazid and rifampicin once every other day, for a total of 4 months, taking medication 60 times. The total course is 90 times. ② Plan 2: 2H3R323S3E3/6H3R3E3 intensive phase: isoniazid, rifampicin, pyrazinamide, streptomycin, and ethambutol once every other day, for a total of 2 months, taking medication 30 times. Continuation phase: isoniazid, rifampicin, and ethambutol once every other day, for a total of 6 months, taking medication 90 times. The total course is 120 times. ③ Plan 3: 2H3R323/4H3R3; intensive phase: isoniazid, rifampicin, and pyrazinamide once every other day, for a total of 2 months, taking medication 30 times. Continuation phase: isoniazid and rifampicin once every other day, for a total of 4 months, taking medication 60 times, with a total course of 90 times. Ethambutol treatment cannot be given to children under 0-14 years old or those without the ability to judge symptoms.

　　(2) Topical drug treatment: ① For early skin lesions, streptomycin 0.4-1.0g and isoniazid 100mg can be added to the anesthetic for local injection, once every other day. ② Local application of antituberculosis drugs: 1% rifampicin ointment, 0.5g-1% isoniazid ointment, or 15g-20% para-aminosalicylic acid ointment can be applied topically to the damaged area. ③ Drug corrosion: 5%-20% tannic acid ointment has a destructive effect on tuberculosis lesions, and it should start with 5% concentration and gradually increase the concentration. For significantly proliferative lesions, silver nitrate rod, potassium permanganate crystals, mercuric nitrate, trichloroacetic acid, or lactic acid can be used as corrosive agents.

　　(3) Surgical excision: The early damage of skin tuberculosis is small and can be completely excised by surgical operation. However, the incision must be made 0.5cm outside the damaged area on the normal skin, and the depth should be cut to the muscle membrane.

　　(4) Physical Therapy: ① X-ray irradiation: Generally ineffective, but may have some benefits for ulcers and hypertrophic proliferative damage. It can be irradiated 1-2 Gy each time, once a week, for a total of 3-4 weeks. X-ray irradiation can flatten hypertrophic proliferative damage, promote ulcer healing, and soften keloids and promote the absorption of tuberculous tissue. ② Ultraviolet irradiation treatment: Moderate sunlight exposure or ultraviolet irradiation can enhance body resistance, promote local skin blood circulation and absorption of tuberculous tissue, but excessive irradiation may cause dissemination of visceral tuberculosis, especially pulmonary tuberculosis. ③ Electrocryotherapy, cryotherapy, laser therapy: These three treatment methods can be selected according to the situation and are suitable for small lesions with limited area and scope.

　　(5) Traditional Chinese Medicine Treatment: For skin tuberculosis, the effect of antituberculosis drugs is relatively reliable, and generally no traditional Chinese medicine is needed for treatment. However, for some patients with symptoms of both Qi and blood deficiency, traditional Chinese medicine treatment can be added, and the treatment principles are summarized as follows. ① Qi and blood tonification, blood circulation and blood stasis removal method: A Decoction of Ten Full Supplements: Astragalus, Cinnamon, Rehmannia, Angelica, Pinellia, Tangerine peel, Safflower, Atractylodes, Uncaria, Poria, Cimicifuga, Licorice. B Invigorating the spleen and activating blood: Astragalus, Codonopsis, Atractylodes, Poria, Angelica, White peony, Safflower, Achyranthes, Uncaria, Licorice. ② Clear heat and resolve phlegm, soften hardness and disperse nodules method: A Decoction for Resolving Scrofula: Scrophularia, Oyster, Fritillaria. B Modified Decoction of Sea藻玉壶: Scrophularia, Trichosanthes, Licorice, Celery salt, Houttuynia, Angelica, Sea藻, Aurantium, Platycodon, Fritillaria, Prepared rhubarb, Mint, Forsythia, Rehmannia, Prunella, Scrophularia, Alisma, Atractylodes, Licorice. C Decoction for Internal Scrofula: Scrophularia, Trichosanthes, Licorice, Celery salt, Houttuynia, Angelica, Sea藻, Aurantium, Platycodon, Fritillaria, Prepared rhubarb, Mint, Forsythia, Rehmannia, Prunella, Scrophularia, Alisma, Atractylodes, Licorice. ③ Warming Yang and resolving carbuncle, dispersing cold and unblocking method: Modified Decoction of Yang He. ④ Clear heat and detoxify method: Compound Jin Yang tablet: Toad venom, Fritillaria, Herba scutellariae, Herba Houttuyniae, Root of Herba polygoni, 2 times/d, 6-8 tablets each time.

　　(6) Other: Lichenoid psoriasis, necrotic tuberculoid eruption, and lupus vulgaris of the face, etc., if tuberculous foci are found, the above treatment plan should be adopted. If tuberculous foci are not found and antituberculosis treatment is ineffective, corticosteroids, vitamin A acid drugs can be taken orally or topically, and some tuberculoid eruptions can heal spontaneously.

　　II. Prognosis

　　The prognosis of vulvar ulcers caused by different etiologies is also different.