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Common Pediatric Lip Lesions: Herpes Simplex/Recurrent Herpes Labialis, Impetigo, Mucoceles, and Hemangiomas Janna M

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Common Pediatric Lip Lesions: Herpes Simplex/Recurrent Herpes Labialis, Impetigo, Mucoceles, and Hemangiomas Janna M Clinical Pediatrics http://cpj.sagepub.com A Review of Common Pediatric Lip Lesions: Herpes Simplex/Recurrent Herpes Labialis, Impetigo, Mucoceles, and Hemangiomas Janna M. Bentley, Benjamin Barankin and Lyn C. Guenther Clin Pediatr (Phila) 2003; 42; 475 DOI: 10.1177/000992280304200601 The online version of this article can be found at: http://cpj.sagepub.com/cgi/content/abstract/42/6/475 Published by: http://www.sagepublications.com Additional services and information for Clinical Pediatrics can be found at: Email Alerts: http://cpj.sagepub.com/cgi/alerts Subscriptions: http://cpj.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations (this article cites 39 articles hosted on the SAGE Journals Online and HighWire Press platforms): http://cpj.sagepub.com/cgi/content/refs/42/6/475 Downloaded from http://cpj.sagepub.com at ALBERTA UNIVERSITY on May 24, 2008 © 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. A Review of Common Pediatric Lip Lesions: Herpes Simplex/Recurrent Herpes Labialis, Impetigo, Mucoceles, and Hemangiomas Janna M. Bentley, BSc1 Benjamin Barankin, MD' 2 Lyn C. Guenther, MD, FRCPC3 Summary: Lip lesions are a common presentation to the pediatrician's office. These lesions are often benign in children, without significant functional morbidity. However, owing to the prominent placement of lips and their role in communication, lip lesions can be alarming to patients as well as to their parents. For these reasons the pediatrician has an important role in recognizing, diagnosing, and treating the various types of labial dermatoses that commonly present to a pediatric practice. Four of the most common lip lesions a pediatrician will see are herpes simplex/recurrent herpes labialis, impetigo, mucoceles, and hemangiomas. This paper reviews the current literature on the diagnosis, treatment, and management of these 4 lesions. Clin Pediatr. 2003;42:475-482 Introduction important, not only to prevent lip is semi-elliptical. At the com- disease morbidity and mortality, missure, the lips meet laterally. L ips provide entrance to the but also to restore social accep- Each lip is attached to the adja- oral cavity and are promi- tance and self-esteem. cent alveolus by the frenulum. nently placed in the center During the 7th week of in- The orbicularis oris muscle circles of the face. They help manipulate trauterine life the lips start to de- both lips. A number of other mus- ingested food into the oral cavity, velop; by the 9th week, they are fully cles interdigitate with this muscle are involved with speech articula- developed. The upper lip is the re- and move the lips in other direc- tion and communication, reflect sult of fusion of the medial nasal tions. The 7th cranial nerve in- sexuality, and are important iden- prominences and maxillary promi- nervates these muscles. The tifying facial features. Any abnor- nence. The lower lip comes from mandibular branch of the 5th cra- mality or blemish is easily notice- the mandibular prominence of the nial nerve supplies the sensory in- able and a potential source of first branchial arch with the upper.' nervation. Lips are highly vascu- embarrassment. Diagnosis and The upper lip has the shape of larized and hairless. The vascular treatment of lip abnormalities is a "Cupid's bow," while the lower supply is from the labial branches of the facial artery. Lips have a "wet" internal mu- cosa and "dry" external mucosa. 'Department of Medicine; 2Division of Dermatology, University of Alberta; and 3Division of The junction appears as a "white Dermatology, Univeristy of Western Ontario, London, Ontario, Canada. line." The mucosa has a number of labial glands. Unlike other ar- Correspondence to: Lyn C. Guenther, MD, FRCPC, The Guenther Dermatology Research eas of the body covered by skin, 835 Richmond Ontario N6A 3H7 Canada. Centre, St., London, the external mucosa lacks the 2003 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A. tough keratin covering, has a CLINICAL PEDIATRICS JULY AUGUST 2003 CLINICAL PEDIATRICS 475 JULY/AUGUST 2003 Downloaded from http://cpj.sagepub.com at ALBERTA UNIVERSITY on May 24, 2008 © 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. Bentley, Barankin, Guenther thinner epithelium, less melanin, matic. An infected mother can these patients seroconverting by and lacks sebaceous and sweat transmit viral particles to her fetus age 5 years.5f6 Similarly, a British glands, all of which have a protec- vertically during delivery, due to study in 1999 reported a preva- tive function. These characteris- asymptomatic cervical shedding. lence of almost 100% seroconver- tics cause the lips to be more sus- The ensuing neonatal infection is sion by the age of 15 years.7 It has ceptible to damage from the difficult to diagnose clinically as been estimated that up to 40% of elements, environment, trauma, the symptoms are very nonspe- seropositive individuals develop and infection. cific and may not be recognized. recrudescent disease, resulting in A comprehensive English lan- It has been shown that mothers site-specific, recurrent ulcera- guage literature search of MED- who experience a primary genital tions such as herpes labialis, or LINE from 1966 to 2002 was per- herpes simplex virus (HSV)-infec- "cold sores."8 formed. Initially, the following tion in the third trimester of their On initial infection, oral her- MeSH terms were used: "lips," pregnancy, who are seronegative pes classically presents as a gin- "pediatrics," and "prevalence," to at delivery, have a 33-50% chance givostomatitis, affecting the oral establish 4 of the most common of transmitting the virus to their mucosa with small vesicles that lesions. An informal survey of pri- infant.2 Conversely, secondary re- rapidly break open releasing a yel- mary care physicians in Edmon- activation of HSV in a seropositive lowish exudates (Figure 1). The ton, Alberta, Canada, was also woman during the intrapartum vesicles are replaced by painful ul- performed to identify which le- period incurs a 3% risk of vertical cerations, along with edematous, sions were most commonly seen transmission to her infant.2 punched-out lesions of the gingi- clinically, and these results fur- Herpes simplex virus type 1 val margin. Primary oral herpes ther reinforced the MEDLINE (HSV-1) classically causes the infection can occur on the inner search. Following the determina- "above the waist" lesions, includ- mucosal border of the lips, but tion of common pediatric lip le- ing the oral and perioral lesions, the pathognomonic "cold sore," sions, the term "pediatrics," and keratoconjunctivitis.3 It is which manifests extraorally on along with "recurrent herpes labi- thus implicated in most cases of the vermilion border of the lip, is alis," "impetigo," "mucocele," or recurrent herpes labialis, while a recurrent herpes simplex infec- "hemangioma" were searched. HSV-2 is responsible in 10% to tion, or "herpes labialis." It occurs The majority of the papers in- 15% of recurrent oral ulcera- following reactivation of latent cluded in this review were cur- tions.4 Ninety percent of the US herpes virus in the cells of the rent randomized, controlled tri- population is seropositive for trigeminal ganglia. als, prospective or retrospective HSV-1 by the time they reach their Unlike the primary gingivos- population-based studies, case re- teenage years, with at least 90% of tomatitis, recurrent herpes labi- ports, and reviews. This paper re- views 4 common pediatric lip le- sions: herpes simplex/recurrent herpes labialis, impetigo, muco- celes, and hemangiomas. Herpes SiWmlex/ Rcurrent Herpes Labialis The herpes simplex viruses are responsible for a large num- ber of cutaneous infections in hu- mans. There are 2 types of herpes infections recognized clinically: primary and recurrent. The pri- mary infection is often missed as it commonly occurs during ado- lescence and may be asympto- Figure 1. Primary herpes simplex gingivostomatitis. 47 CLNCLPDARCSJL/UUT20 476 CLINICAL PEDIATRICS Downloaded from http://cpj.sagepub.com at ALBERTA UNIVERSITY on May 24, 2008 JULY/AUGUST 2003 © 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. Common Pediatric Lip Lesions alis is much milder in its manifes- the physician's discretion.'2 To been performed in children at tation, without the systemic symp- date, no studies directed at the this point. Application of topical toms. A tingling, burning, or itch- benefits of acute treatment of 1% penciclovir cream every 2 ing feeling may occur such lesions have been completed hours when awake for 4 days was prodromally at the site of the im- in the pediatric population. How- shown to decrease the duration of pending lesions, 12-36 hours be- ever, if the decision to treat an healing (1-day reduction in heal- fore eruption.4 Classically, a sin- acute eruption is made, first line ing time as compared to vehicle), gle, well-localized cluster of 3-5 treatment is generally an oral an- pain, and viral shedding in adult vesicles appears containing the tiviral medication such as acy- patients. 16 virus.9 With recruitment of in- clovir. In children less than 12 Controlled studies have been flammatory cells the vesicles ul- years of age, the recommended performed in adults showing that cerate and crusting occurs within dose of oral acyclovir is 20 mg/kg prophylactic treatment for herpes the first 24-48 hours after appear- every 8 hours.'2 In postpubertal labialis is beneficial using oral acy- ance of the initial lesions.4 It is at children (>12 years old), adult clovir or famciclovir.12'17'8 Adult the time of vesicular rupture that dosing schedules can be fol- studies show that short-term pro- lesions are most contagious9 and lowed.12 Besides acyclovir, fami- phylactic therapy is warranted in the lesions remain contagious un- clovir and valacyclovir have also some situations such as when the til healed.
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