Paediatric medicine - Child presenting with facial ulcers

Dr Helen Goodyear describes some of the common causes of facial lesions seen in children.

When a child presents with facial ulcers it is important to take a history of the lesions. Enquire about any previous or family history of skin problems and look for skin lesions on the limbs and trunk.

This article covers a wide range of causes of facial ulcers but does not include the rarest causes. If lesions persist or appear atypical then a dermatological opinion should always be obtained.

Infection is the most common reason for facial ulcers in children. Here, infection and some other common causes are discussed along with the appropriate management.

Viral infections
Lesions of herpes simplex virus (HSV) gingivostomatitis start off as a vesicle on an erythematous base, which ruptures easily.

Symptoms include fever, halitosis, reluctance to eat or drink and tender cervical lymphadenopathy. Children often present late when there are multiple oral and perioral lesions. Because young children often suck their fingers and toes, look out for lesions on their hands and feet.

Treatment for HSV should involve adequate pain relief and oral hydration. Aciclovir is only indicated if the child is seen early with gingivostomatitis when there are just a few lesions present or if the child is immuonocompromised.

Leishmaniasis will leave scars

Children with a predisposing dermatosis, for example eczema, may have widespread skin infection (eczema herpeticum).

Chickenpox may begin on the face, although typically the trunk is affected. Herpes zoster is more common in children who had chickenpox at less than six months of age.

Hand, foot and mouth disease due to Coxsackie virus is recognised by its characteristic distribution. Scabetic lesions are rare on the face but do occur in infants, usually in association with lesions on the trunk and limbs.

Mollusca contagiosum are dome-shaped papules with an umbilicated centre, which if scratched may appear as ulcers.

Bacterial infections
Impetigo, due to Staphylococcus aureus and/or group A beta-haemolytic streptococcus, characteristically presents with a yellow-brown honeycomb crust but may be bullous leaving ulcers.

Impetigo is most common in children under five years of age, and peaks in the late summer months.

If the infection is localised treat with a topical antibiotic, or use a systemic one if there are several patches.

Mycobacterial infections such as TB or atypical infections may present as facial ulcers. Congenital syphilis may present with a bullous rash which ulcerates. Typically it is most pronounced on the hands and feet.

Cutaneous leishmaniasis
Consider cutaneous leishmaniasis if ulcerated lesions are present which fail to heal and the child has travelled to an endemic area. Lesions may acquire a secondary bacterial infection of S aureus.

Impetigo due to Streptococcus infection has a characteristic pattern

It is important to recognise cutaneous leishmaniasis and treat as soon as possible to prevent cosmetic disfigurement.

Erythema multiforme
Erythema multiforme is a polymorphic eruption. Lips, buccal mucosa and tongue may be affected. If two or more mucosal surfaces are affected, then Stevens-Johnson syndrome should be considered. Extensive necrosis of the lips and mouth is usually present.

Autoimmune disorders
Usually with autoimmune skin disorders lesions are present on the limbs and trunk. These are rare in children, tend to be characterised by vesicles or bullae and require a skin biopsy to make the diagnosis.

In chronic bullous disease of childhood (linear immunoglobulin A dermatosis), clusters of blisters in rings ('string of pearls') may develop on the face and around the mouth as well as elsewhere on the body, most commonly the abdomen and buttocks. Ulcers develop when the blisters are scratched.It resolves spontaneously often after a few years but treatments such as dapsone are often needed.

Pemphigus vulgaris is a vesiculobullous disease of the skin and is characterised by vesicles, bullae and raw areas on mucous membranes. Stomatitis is the presenting feature in 50 per cent of children with pemphigus vulgaris. Pemphigoid and epidermolysis bullosa acquisita are rare but may affect the face.

Acne
Acne excoriee occurs when comedones and pustules of acne are picked, squeezed or rubbed and is more common in teenage girls. The picking exacerbates the skin condition and can lead to scarring. Consider anxiety, depression and emotional problems and treat any acne still present as well as emphasising the importance of stopping picking of the skin.

Acne fulminans is an ulcerative form of acne, usually in teenage boys, that is acute in onset and is associated with systemic symptoms such as fever and arthralgia. Urgent dermatology referral is needed.

Any skin disorder which is itchy, such as atopic eczema, may lead to repetitive scratching of the skin which may lead to facial ulcers.

Dermatitis herpetiformis
Dermatitis herpetiformis rarely affects the face and oral mucosa. The classical pattern is symmetrical papules and vesicles on the extensor aspects of the knees, elbows and buttocks. It is important to recognise due to its link with coeliac disease. Dermatitis herpetiformis will respond to a gluten-free diet but may take months to do so. Treatment with dapsone is often needed.

Porphyria
Erythropoietic protoporphyria is the most common porphyria in childhood. Small pitted scars are typically present on the nose and cheeks. Photosensitivity is present with a burning or stinging sensation on exposed skin.

Porphyria cutanea tarda, which may be familial or due to drugs, alcohol or infection, causes skin fragility leading to vesicles, blisters and erosions.

Other disorders
Genetic disorders such as epidermolysis bullosa and incontinentia pigmenti have usually been present from birth.

Dermatitis artefacta is a rare psychological condition. Lesions are in accessible sites and do not follow any recognisable pattern. Refer because of underlying psychological problems. Trauma could result in ulcerations. Causes may include burns and non-accidental injury. It is important that history and findings are compatible.

  • Dr Goodyear is consultant paediatrician, Heart of England NHS Foundation Trust.

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