What are the causes and treatment options for common facial lesions in children?

Common Facial Lesions in Children: Causes and Treatment

Most Common Facial Lesions by Category

The most common facial lesions in children include infectious causes (impetigo, molluscum contagiosum, viral warts), inflammatory conditions (atopic dermatitis), and vascular lesions (infantile hemangiomas, capillary malformations). 1, 2, 3

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Infectious Lesions

Impetigo and Bacterial Skin Infections

• Impetigo is the most common superficial bacterial infection affecting children's faces and extremities, typically caused by Staphylococcus aureus or β-hemolytic streptococci. 1, 3
• For minor skin infections like impetigo, apply mupirocin 2% topical ointment as first-line therapy. 1
• For nonpurulent cellulitis without drainage or abscess, prescribe empirical therapy targeting β-hemolytic streptococci (such as cephalexin or amoxicillin) for 5-10 days. 1
• If MRSA is suspected (purulent drainage, no response to β-lactams), use clindamycin alone OR combine TMP-SMX or doxycycline (if ≥8 years old) with a β-lactam antibiotic. 1
• Never use tetracyclines in children under 8 years of age due to tooth discoloration risk. 1

Molluscum Contagiosum

• Molluscum presents as firm, rounded, pink or skin-colored papules with shiny, umbilicated surfaces, most common in school-aged children. 2, 3
• The gold standard treatment is nonintervention—lesions are self-limited and resolve spontaneously in 6-9 months in immunocompetent children. 2, 4
• Treat only when lesions are extensive, symptomatic (pruritic, inflamed), complicated by eczema or bacterial superinfection, or causing significant psychosocial distress. 2, 5, 4
• Treatment options include cryotherapy, curettage, cantharidin, or topical agents (potassium hydroxide, salicylic acid), but the decision to intervene must be a joint decision among child, parents, and practitioner, prioritizing symptom reduction first. 5, 4

Viral Warts (Verruca Vulgaris)

• Verruca vulgaris is caused by HPV types 2 and 4, presenting as well-circumscribed growths with white pebbly or papillary surfaces, most commonly on hands/fingers but can occur on face via autoinoculation. 1
• Surgical excision is the recommended treatment for oral or facial warts to prevent spread, as these lesions are infectious. 1
• Spontaneous regression commonly occurs after months to years without intervention. 1

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Inflammatory Lesions

Atopic Dermatitis (Eczema)

• Atopic dermatitis is diagnosed by pruritus plus at least three of: flexural involvement, personal/family history of atopy, dry skin, or visible eczema. 6, 7
• In infants, lesions appear on cheeks, trunk, and extensor surfaces; older children show more localized chronic lesions in flexural areas. 7
• Coin-shaped (nummular) erythematous plaques can represent an atopic dermatitis variant, even when diffusely distributed and minimally pruritic. 7
• First-line therapy: Apply fragrance-free emollients liberally immediately after 10-15 minute lukewarm baths. 7
• Second-line: Use topical corticosteroids appropriate for age, site, and disease extent. 7
• Avoid dietary restrictions without professional supervision—they rarely help and can cause nutritional deficiencies. 7

Molluscum-Associated Dermatitis

• Children with atopic dermatitis develop widespread molluscum lesions complicated by comorbid dermatitis, inflammation, and pruritus. 4
• Even children without atopic dermatitis can develop dermatitis, inflammation, or pruritus around molluscum lesions. 4

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Vascular Lesions

Infantile Hemangiomas

• Infantile hemangiomas are highly vascular, raised lesions with well-defined borders that appear before 4 weeks of age, with maximum growth by 5 months. 1, 6
• Midline lumbosacral infantile hemangiomas raise suspicion for underlying spinal dysraphism. 1
• Large segmental hemangiomas with reticular patterns overlying the lumbosacral spine are associated with LUMBAR syndrome (spinal, genitourinary, and anorectal malformations) in up to 55% of cases. 1
• Facial hemangiomas warrant evaluation for PHACE syndrome (posterior fossa malformations, hemangiomas, arterial anomalies, cardiac defects, eye abnormalities). 6

Capillary Malformations

• Port wine stains (PWS) are flat, darker red-purple lesions with well-defined borders that darken over time. 1
• Nevus flammeus simplex (salmon patch) are flat, pink or red capillary malformations with less defined borders. 1
• Midline capillary malformations overlying the spine are intermediate-risk markers for spinal dysraphism and warrant imaging evaluation. 1

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Mastocytosis (Urticaria Pigmentosa)

• Mastocytosis presents with red-brown to yellow lesions as multiple macules, plaques, or nodules on trunk and extremities, appearing before 6 months of age. 6
• Darier's sign (urticaria and erythema after stroking the lesion) is pathognomonic for mastocytosis. 6
• Evaluate for systemic symptoms: flushing, pruritus, abdominal pain, diarrhea, hypotension, respiratory symptoms. 6
• Emergency signs requiring immediate intervention: flushing, dyspnea, wheezing, nausea, vomiting, diarrhea, hypotension. 6

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Diagnostic Algorithm for Facial Lesions

Step 1: Determine Age of Onset

• Lesions before 4 weeks → infantile hemangioma 6
• Lesions before 6 months → mastocytosis or congenital eczema 6
• School-age children → molluscum contagiosum, impetigo, atopic dermatitis 2, 4, 3

Step 2: Assess Distribution Pattern

• Trunk/extremities → mastocytosis 6
• Flexural areas → atopic dermatitis 6, 7
• Face/extremities → impetigo 1, 3
• Scattered on exposed areas → molluscum contagiosum, viral warts 2, 3

Step 3: Perform Specific Physical Exam Maneuvers

• Test Darier's sign: positive = mastocytosis 6
• Assess for umbilication: present = molluscum contagiosum 2, 3
• Check for honey-crusted lesions: present = impetigo 1, 3
• Evaluate pruritus: obligatory for atopic dermatitis diagnosis 6, 7

Step 4: Identify Associated Systemic Features

• Fever with rash → consider roseola, erythema infectiosum, scarlet fever 3
• Rash after fever resolution → roseola 3
• "Slapped cheek" appearance → erythema infectiosum (fifth disease) 3
• Systemic symptoms with mastocytosis → evaluate for anaphylaxis risk 6

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Critical Pitfalls to Avoid

• Do not confuse erythema multiforme with Stevens-Johnson syndrome—SJS presents with widespread purpuric macules, blisters, and mucosal involvement requiring immediate specialized care. 1, 7
• Do not dismiss recurrent styes as benign—they may represent early ocular rosacea before facial manifestations appear in children. 8
• Do not use tetracyclines in children under 8 years old. 1
• Do not restrict diet in children with atopic dermatitis without professional supervision. 7
• Do not ignore midline cutaneous markers overlying the spine—nearly 70% of children with spinal dysraphism display at least one high-risk cutaneous marker. 1