When a child presents with facial ulcers it is important to take a history of the lesions, to ask about any previous or family history of skin problems, and to 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, infections and some other common causes are discussed, along with the appropriate management.
Lesions of herpes simplex virus (HSV) start off as a vesicle on an erythematous base which ruptures easily.
Herpes simplex virus
Symptoms include fever, halitosis, reluctance to eat or drink, and tender cervical lymphadenopathy. Children often present late when there are multiple mouth and perioral lesions. As young children suck their digits look for lesions on the hands and feet.
Treatment for HSV should involve adequate pain relief and maintaining oral hydration. Aciclovir/valaciclovir is only indicated if the child is seen early with gingivostomatitis when there are just a few lesions present, or if the child is immunocompromised.
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 6 months of age.
Hand, foot and mouth disease due to Coxsackie virus is recognised by its characteristic distribution although only one of the three typical sites may be affected.
Mollusca contagiosum are dome shaped papules with an umbilicated centre, which if scratched may appear as facial ulcers.
Children with a predisposing dermatosis, such as eczema, may have widespread skin infection due to viruses such as eczema herpeticum (due to HSV) and eczema coxsackium.
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 5 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 infection, 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.
Scabetic lesions, due to Sarcoptes scabiei, are rare on the face but do occur in infants, usually in association with lesions on the trunk and limbs. It is usual for parents to have lesions on their arms.
Consider cutaneous leishmaniasis if ulcerated lesions fail to heal and the child has been to an endemic area. Lesions may become secondarily bacterially infected and grow Staphylococcus aureus. Early treatment is required to prevent cosmetic disfigurement.
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 lip and mouth is usually present.
Autoimmune skin disorders
Usually with autoimmune skin disorders lesions are present on the limbs and trunk. This is rare in children, and lesions tend to be characterised by vesicles or bullae and require a skin biopsy to diagnose.
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 on the abdomen and buttocks.
Ulcers develop when the blisters are scratched. Children usually present before puberty and it is most common in those who are preschool age. A number of drugs are associated with it. Spontaneous resolution often occurs after a few years but treatments such as dapsone may be needed to control symptoms.
Pemphigus vulgaris is a vesiculobullous disease of the skin and mucous membranes. It 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 excoriée occurs when comedones and pustules of acne are picked, squeezed or rubbed, and is more common in teenage girls. Picking the acne 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, arthralgia, and lymphadenopathy. 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 rarely affects the face and oral mucosa. The classic pattern is symmetrical papules and vesicles on the extensor aspects of the knees, elbows, and buttocks. It is important to recognise it due to its link with coeliac disease.
Dermatitis herpetiformis will respond to a gluten-free diet but may take many months to do so, and treatment with dapsone is often needed.
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. The urine is dark brown.
Genetic causes of facial ulcers, 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. It is important to recognise and refer the child to secondary care because of underlying psychological problems.
Causes of trauma includes burns, insect bites, and non-accidental injury, such as cigarette burns. It is important to check that history and findings are compatible.
This article, although covering a wide range of causes of facial ulcers, does not include the rarest causes and if lesions persist or appear atypical then a dermatological opinion should always be obtained.
- Dr Helen Goodyear is a consultant paediatrician with a special interest in paediatric dermatology, Heart of England NHS Foundation Trust, Birmingham