Differential diagnoses for this patient include vitiligo, cellulitis, tinea versicolor, and recurrent aphthous stomatitis (RAS). People with tinea versicolor often report disturbing and abnormal pigmentation. The affected regions of the skin include the trunk, abdomen, back, as well as the proximal extremities. However, the face, genitalia, and the scalp are less involved. The lesion color varies from reddish to white. Fine and dust-like scales often cover the affected area. Lesions can be macules or superficial papules that are characterized by fine scales, which may be only evident through a close examination. They can be mildly pruritic with pruritus becoming more pronounced when the patient has a high fever (Ely, Rosenfeld, & Stone, 2014). In this case, the pediatric patient did not present with dust-like scales covering the lesions. Therefore, tinea versicolor cannot be the main diagnosis.
Vitiligo is a skin and mucous membranes pigmentary disorder manifesting itself in the form of white macules or patches resulting from depigmentation and the loss of melanocytes. It is an acquired disease. White patches that occur when the skin is exposed to the sun are the main symptoms of vitiligo. They may affect arms, face, feet, hands or lips. Other areas include eyes, nostrils, mouth, genitals, navel, and rectal areas (Oiso et al., 2013). The patient in this case presented with red macules, but not white ones, which are notable in vitiligo. Therefore, this disease cannot be the main diagnosis.
Recurrent aphthous stomatitis (RAS) is among the most common lesions that affect the oral mucosa. It presents with small, multiple, and ovoid ulcers with yellow floors that are often surrounded by erythematous haloes. Minor aphthous lesions may affect the non-keratinized mucosa, particularly the buccal and labial one, tongue surface, and the floor of the mouth. Ulcers mostly appear in the anterior side of the mouth. Usually, they are less than one centimeter in diameter (Tarakji, Gazal, Al-Maweri, Azzeqhaiby, & Alaizari, 2015). The shapes of ulcers vary slightly depending on where they are located, with some being elongated, while others are rounded. Lesions can be found in the soft palate, lips, tongue, as well as the palatal fauces where they cause a lot of pain and dysphagia. The most important features to note during the examination of a patient with recurrent aphthous stomatitis include the family history and ulceration. Besides, it is necessary to focus on the full blood count, serum folate, as well as anti-endomysial and anti-gliadin antibodies (Tarakji et al., 2015). The pediatric patient in this case did not present with a yellow oral floor, being a characteristic of RAS; instead, the baby’s lips were magenta-colored. However, RAS remains the most concerning differential diagnosis because of painful ulcers. The pain can prevent the child from feeding properly.
The final differential diagnosis in this case is cellulitis, which is a severe inflammation that occurs on the dermis as well as hypodermis; nonetheless, it spares the facial plane. It often presents with warmth, tenderness, as well as swelling. Cellulitis can have a dusky hue that may at times be confused with an accidental injury, particularly where the superior maxillary part is involved. Surface breaks can have pustules often leading to hemorrhage bullae or a necrotic tissue discharge. Another concern is always when there is the release of discharge materials. The pediatric patient has not presented with these symptoms (Atzori, Manunza & Pau, 2013).
I would recommend conducting other diagnostic tests including the radiologic one to exclude dental pathologies or soft tissue thickening. A CT scan or MRI may also help in the fast acquisition of images for determining deep lesions or vascular complications (Atzori et al., 2013). Caregiver education should focus on the use of appropriate medications, review of patient’s response, and the need for a follow-up.
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In conclusion, from the results of the physical assessments performed on the toddler, it has been noted above that possible differential diagnoses can be vitiligo, cellulitis, tinea versicolor, and recurrent aphthous stomatitis (RAS). Eliminating these disease conditions, while performing such additional tests as a CT scan and MRI, can help to diagnose the disease that the child is suffering from.
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