13. Painful lip and mouth ulceration

A 21-year-old woman presented with multiple oral ulcerations and bloody crusts on the ulcerated vermillion of both her lips. She also noted a rash, together with eye soreness and general myalgia. Her lesions began to appear 10 days after an episode of herpes labialis. She had had similar episodes of oral and lip ulcerations many times since the age of 18 and these often followed a respiratory or herpetic infection. Apart from a mild iron deficiency anaemia related to menorrhagia, for which she was treated with iron tablets, her medical history was otherwise clear.

Extra-oral examination showed lip lesions covered by bloody crusts (Figure 1). Reddish macules were also developing on the skin of her hands (Figure 2).

Oral examination showed painful ulcerations of various shapes and sizes on a diffuse erythematous background, mainly on the tongue, buccal mucosa and lips. The oral lesions were covered by whitish pseudo-membranes.