Child With Progressive Perioral Lesions

1. Case Presentation

A 12-year-old girl with no significant past medical history presented with encrusted and oozing perioral lesions. The rash began as a small papule on the lower lip that ruptured, followed by the appearance of additional lesions over several days (Fig. 1). While visiting extended family, she went 2 days without proper wound care or cleansing, during which the lesions rapidly worsened, forming thick perioral scales with erythema (Fig. 2). Her mother attempted aluminum acetate solution (Domeboro) soaks with partial improvement (Fig. 3). Prior to in-office evaluation, the patient was teleprescribed topical mupirocin. At her pediatrician visit, given the extent of crusting and progression, she was prescribed an oral antibiotic in addition to the topical. Within 2 days of systemic therapy, the lesions markedly improved (Fig. 4).

Figure 1.

Week of March 13, after the first small blister appeared.

Figure 2.

Sunday, March 19, after no attention to the blemishes.

Figure 3.

After Domeboro soak.

Figure 4.

Two days after topical and 1 day after oral antibiotic use.

2. Diagnosis

This patient’s presentation was consistent with nonbullous impetigo, a superficial bacterial infection most often caused by Staphylococcus aureus or group A Streptococcus.¹ Classic honey-colored crusts can mimic other conditions such as bullous impetigo, herpes simplex, or tinea.¹ Although impetigo is often self-limited, untreated cases may lead to cellulitis or poststreptococcal glomerulonephritis, underscoring the importance of timely diagnosis.² According to the American Academy of Pediatrics’ Red Book, nonbullous impetigo is typically treated with topical mupirocin or retapamulin.³ However, when lesions are numerous or occur among multiple family members, childcare groups, or athletic teams, oral antibiotics active against Staphylococcus aureus and group A Streptococcus (eg, amoxicillin or clavulanate and cephalexin) are recommended.²

This case provides uncommon sequential photographic documentation of disease progression when treatment was delayed, followed by rapid improvement with systemic therapy. Most guidelines recommend topical antibiotics for limited impetigo, reserving oral agents for widespread or severe disease, but defining “severity” is often challenging in practice.^1,4 The partial improvement after Domeboro soaks also suggests a potential adjunctive role in softening crusts and enhancing antibiotic penetration, although such remedies should not replace antimicrobial therapy.⁴ For emergency physicians, undifferentiated pediatric rashes are common presentations. This case emphasizes the need for prompt recognition of impetigo and appropriate antibiotic selection that aims to maximize effectiveness while minimizing adverse effects.

Funding and Support

By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.