Photo Quiz

Tongue Ulcer in a Young Child

 

Am Fam Physician. 2019 Mar 15;99(6):385-386.

A healthy six-year-old boy presented with a painful ulcer on his tongue. Earlier in the day, he had received treatment at a dermatology clinic for foot and hand lesions.

Physical examination revealed a large (approximately 10 × 7 mm) lesion on the tip of his tongue (Figure 1). He had multiple flat lesions on his hands and feet that were between 2 and 8 mm in size and surrounded by an erythematous base (Figure 2 and Figure 3).

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FIGURE 1


FIGURE 1

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FIGURE 2


FIGURE 2

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FIGURE 3


FIGURE 3

Question

Based on the patient's history and physical examination findings, which in-office dermatologic treatment did he most likely receive?

  • A. Cantharidin.

  • B. Cryotherapy.

  • C. Intralesional Candida.

  • D. Pulsed dye laser.

  • E. Salicylic acid 17%.

Discussion

The answer is A: cantharidin. This patient was being treated with cantharidin for warts. Cantharidin is a substance secreted by the blister beetle (Epicauta lamniscata). When applied to warts, this vesicant causes painless blistering beneath the wart within 24 hours. Cantharidin can be used as an alternative to cryotherapy with liquid nitrogen in young children because it is less painful and better tolerated. As the skin at the site of the wart begins to blister, the blood supply is cut off. The lesion then crusts over, and the crusted blister typically falls off after several days. Parents are instructed to wash off the cantharidin two to four hours after application to prevent excessive blistering.1

Despite the use of bandages on his hands, based on the lesion and the timeline, it is likely that the child's tongue was exposed to cantharidin from the child placing his fingers in his mouth. His oral lesion resolved with triamcinolone paste (Oralone), and there were no lasting complications. Although cantharidin is effective for wart treatment and generally safe at all ages, one of the multiple other treatment

Address correspondence to Samantha J. Bartling, DO, at sam.bartling@gmail.com. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

1. Mulhem E, Pinelis S. Treatment of nongenital cutaneous warts. Am Fam Physician. 2011;84(3):288–293.

2. Perman M, Sterling JB, Gaspari A. The painful purple digit: an alarming complication of Candida albicans antigen treatment of recalcitrant warts. Dermatitis. 2005;16(1):38–40.

3. Dasher DA, Burkhart CN, Morrell DS. Immunotherapy for childhood warts. Pediatr Ann. 2009;38(7):373–379.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

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