Main complaint and medical history

A healthy 3 year old boy was referred to the oral medicine clinic for the assessment of multiple perioral ulcerations. The mother indicated that the child had fallen down 5 days ago and hurt his lips and chipped two teeth. A doctor was not consulted as she felt the upper lip had a very minor cut. After 3 days, the child began to develop small blisters around his lips and mouth spreading rapidly and even formed sores on his hands. The child was obviously in pain and unable to effectively communicate.


Clinical examination:

The child was scared, in pain and crying. The pain appeared to originate from the site of trauma and not the area presenting with the lesions. Multiple well circumscribed crusting ulcers were present on the upper and lower lips. Areas of coalescing ulceration appeared on the skin of the lip covered with amber like crust. The left side of the lower anterior cheek was more densely affected than the right side. Similar single lesions appeared on the fingers of the left hand and both feet.


Figure 1: Extra-oral presentation from left and right side


Figure 2: Ulceration seen on the lateral aspect of the finger

Intra-oral examination revealed a laceration on the labial mucosa of the upper lip with mild inflammation. The ulceration was mainly contained to the skin with almost no sign of mucosal involvement. The teeth 51 and 61 incisal edges were fractured just into dentine with no associated dental mobility and the surrounding labial gingiva was inflamed. Remaining intra-oral soft tissues were healthy buy oral hygiene was poor.


Differential diagnosis:

  • Non bullous Impetigo
  • Primary HSV with secondary infection
  • Hand foot and mouth with secondary infection


As the lesion was primarily extra-oral, dermatology was consulted and agreed with a diagnosis of impetigo. Treatment involved wound cleansing with chlorhexidine followed by the topical application of Bactroban cream three times a day under a wound dressing. The patient was followed up a week later and the lesions had resolved with minor scarring still visible. Further dental management was completed at the department of pediatric dentistry.