Facial Ulcers and Blisters

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Dermatitis Artefacta
  • Tuberculosis
  • Pemphigus
  • Actinomyces
  • Primary Syphilitic Chancre or Tertiary Syphilitic Gumma
  • Cutaneous Leishmaniasis
  • Cancrum Oris

Ready Reckoner

Key distinguishing features of the most common diagnoses

BCCHerpes ZosterKeratoacanthomaImpetigo HSV
Feverish and UnwellNoYesNoNoPossible
Rapid DevelopmentNoYesYesYesYes
RecurrentPossibleNoNoPossibleYes
Occurs in ChildrenNoPossibleNoYesYes
Multiple LesionsNoYesNoYesYes

Possible Investigations

  • Acute lesions very rarely require investigation; chronic lesions pose more of a diagnostic problem. In such cases, biopsy, or excision biopsy, is the gold standard test. Cytology after scraping the lesion with a scalpel blade may be helpful in diagnosing basal cell carcinoma. Syphilis serology may very rarely be useful if primary or tertiary syphilis is suspected.

Top Tips

  • Remember that herpes simplex can occur on the face at sites other than the lip. The appearance of the lesions and their recurrent nature should provide the diagnosis.
  • ‘Rodent ulcer’ is a kinder term than basal cell carcinoma, especially for small lesions, as it is less likely to arouse unnecessary anxiety. Nonetheless, impress upon the patient the importance of attending the appointment with the specialist.
  • Patients with herpes zoster are at risk of a number of anxieties because of the existence of various ‘old wives’ tales’ about shingles. Establish any fears and take time to explain the natural history of the condition, including the possibility of post-herpetic neuralgia.
  • In children with recurrent impetigo, consider an underlying condition – particularly eczema.

Red Flags

  • If in any doubt about the diagnosis, urgent dermatological referral for skin biopsy is indicated. Remember that chronic facial ulceration is rarely benign.
  • Ulceration in a previously abnormally pigmented area of skin suggests advanced local malignancy.
  • Beware attempting excision biopsy of facial lesions unless specially trained. Areas of cosmetic importance can be medico-legal minefields.
  • Ask about foreign travel – leishmaniasis develops from the bite of a Mediterranean or South American sandfly.
  • Beware of herpes zoster or simplex developing around the eye – significant complications may follow, so treat and follow up carefully and obtain an ophthalmological opinion if necessary.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.