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).

 Enlarge     Print



 Enlarge     Print



 Enlarge     Print




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%.


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 Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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.

A collection of Photo Quizzes published in AFP is available at

Previously published Photo Quizzes are now featured in a mobile app. Get more information at

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at To be considered for publication, submissions must meet these guidelines. E-mail submissions to



Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Editor's Collections

Related Content

More in Pubmed


Feb 15, 2020

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article