Editor,—Lesions that fail to heal despite appropriate therapy should always be biopsied to look for an underlying diagnosis. We have seen a 44 year old woman who presented with genital ulceration and lichen sclerosus and was culture positive for herpes simplex virus (HSV) type 1. After treatment with two courses of oral aciclovir there was some reduction in ulceration and resolution of symptoms. However, in view of the persisting solitary ulcer and the presence of lichen sclerosus (fig 1) a biopsy was performed. Histology was reported as showing poorly differentiated invasive squamous cell carcinoma with vulval dystrophy but no features of wart virus infection. She was promptly referred to the gynaecological oncology department where local radiotherapy and chemotherapy were the initial treatments of choice as the tumour extended close to the anal margin. The immediate response was encouraging but subsequently vaginal adhesions and difficulty with micturition developed. A pelvic CT scan showed bilateral inguinal node involvement (fig 2). Radical block dissection was subsequently performed but lymphoedema and local skin nodules developed and she died 2 years after diagnosis.

Vulval cancer accounts for 3–5% of female genital tract malignancies. Risk factors include lichen sclerosus, vulval intraepithelial neoplasia, and infection with oncogenic human papillomavirus (HPV) types.¹ STDs other than HPV are also associated with an increase in the risk of developing vulval neoplasia.² The presence of antibodies to HSV type 2 has been implicated as a risk for cervical pathology³ but a role for HSV in vulval neoplasia is unclear. Vulval basal cell carcinoma presenting as culture negative genital herpes has been reported.⁴ In our case the carcinoma was culture positive for HSV; this may have been due to new infection or to reactivation of pre-existing HSV in the presence of malignancy. This case highlights the need for biopsy of herpetic lesions which fail to respond to standard therapy.

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Figure 1

Appearance of the vulva—ulceration remains despite therapy for HSV. Note white plaques, small haemorrhages, and labial resorption typical of lichen sclerosus.

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Figure 2

Pelvic CT scan showing bilateral inguinal lymphadenopathy.