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A 43-year-old woman presented to genito-urinary medicine with skin-coloured, papillomatous papules on the mons pubis and superior labia majora (figure 1). Routine sexually transmitted infection screening was normal. Given the papillomatous appearance, a diagnosis of genital warts was made but treatment with cryotherapy and immiquimod cream was unsuccessful.
Further history revealed that subtle vulval papular changes first appeared 6 years previously, following a severe primary genital herpes simplex virus (HSV) type 1 infection, confirmed by PCR, which had caused extreme pain and marked swelling. Treatment with oral acyclovir was delayed by 7 days as the patient was …
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