Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2023;13(1):e2023054 1 Vulvar Aphthous Ulcer in an Adolescent Girl Suffering From COVID-19 Infection Christina Fotiadou1, Elizabeth Lazaridou1, Zoe Apalla1 1 Aristotle University of Thessaloniki, Faculty of Health Sciences, Second Department of Dermatology-Venereology, Larisa, Greece Citation: Fotiadou C, Lazaridou E, Apalla Z. Vulvar Aphthous Ulcer in an Adolescent Girl Suffering From COVID-19 Infection. Dermatol Pract Concept. 2023;13(1):e2023054. DOI: https://doi.org/10.5826/dpc.1301a54 Accepted: July 10, 2022; Published: January 2023 Copyright: ©2023 Fotiadou et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Christina Fotiadou, MD, PhD, Aristotle University of Thessaloniki, Faculty of Health Sciences, Second Department of Dermatology-Venereology, 1 Chrysochoou st, 41221, Larisa, Greece, E-mail: christinafotiadou@yahoo.com Case Presentation A 15-year-old girl presented with a two-day-history of a painful vulvar lesion. Clinical examination revealed a well-demarcated ulcer (2 cm) with a fibrinous center located on the left minor labia (Figure 1). There was a second smaller ulcer opposite to the large one imitating a “kissing pattern”. Both developed simultaneously. Regional lymph nodes were unaffected (no pain, no oedema). She suffered from mild sys- temic symptoms (low fever and rhinorrhea) and was tested positive for COVID-19 (Polymerase Chain Reaction test-PCR) three days before the appearance of the ulcer. The patient was not under treatment for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) or for any other disease. Per- sonal and family history for previous oral or vulvar aphthosis, as well as for inflammatory bowel or other autoimmune dis- eases, was negative. The patient had no history of prior sexual activity and serological tests for Epstein Barr, Cytomegalovi- rus and Syphilis were also negative. The prescribed treatment included a mid-potency topical steroid twice daily. The ulcers healed within 10 days. Both the parents and the patient gave consent to publish images of the lesion. Teaching Point Acute genital aphthous ulcers (AGU) or Lipschutz ulcers represent a rare, painful and distressing condition that commonly affects sexually inactive adolescent girls.[1] Although AGUs are considered an idiopathic condition, they have also been linked to several infections, autoim- mune conditions and topical trauma. COVID-19, on the other hand, has been linked to several cutaneous mani- festations (among which the reactivation of herpes zos- ter) but its relationship with AGU is still poorly clarified. [1] The most common infections, which are temporally associated with AGU, are those caused by Ebstein-Barr and Cytomegalovirus viruses and in a lesser extent by in- fluenza and mumps viruses, as well as salomonella and mucoplasma. The underlying mechanism in these cases is probably a dysregulation of the immune system with cyto- kine activation due to systemic illness. The fact that Sars – Cov-2 virus causes a systemic autoimmune inflammatory response which affects multiple organ systems could be the link between the development of aphthous ulcers and COVID infection.[2] 2 Image Letter | Dermatol Pract Concept. 2023;13(1):e2023054 References: 1. Vismara SA, Lava SAG, Kottanattu L, et al. Lipschütz’s acute vul- var ulcer: a systematic review. Eur J Pediatr. 2020;179(10):1559- 1567. DOI: 10.1007/s00431-020-03647-y. PMID: 32296983. 2. Krapf JM, Casey RK, Goldstein AT. Reactive non-sexually related acute genital ulcers associated with COVID-19. BMJ Case Rep. 2021;14(5):e242653. DOI: 10.1136/bcr-2021-242653. PMID: 33952571. PMCID: PMC8103359. Figure 1. Aphthous ulcer located on the left labia minora of a 15-year-old girl suffering from COVID-19. The ulcer has well-demarcated borders, erythematous background and fibrinous center.