Cutaneous leishmaniasis (CL) is a neglected tropical disease with significant dermatological and psychosocial consequences, particularly in children. Despite its high prevalence in endemic regions like North Waziristan, Pakistan, limited research has examined the impact of lesion characteristics on pediatric quality of life (QoL). To determine the impact of lesion characteristics on dermatological QoL in children with CL in North Waziristan, Pakistan. A cross-sectional study was conducted from February 2023 to January 2024, including 384 children diagnosed with CL. QoL was assessed using the Children's Dermatology Life Quality Index (CDLQI). Lesion characteristics like ulceration, activity status (active vs scarred), location, and treatment history were recorded. Logistic regression was used to identify predictors of poor QoL. Out of total of 384 children with cutaneous leishmaniasis, the mean age of participants was 9.96 ± 3.20 years, with a mean CDLQI score of 8.21 ± 4.71. Most lesions were dry (98.7%) and non-ulcerative (91.4%), commonly located on the head, neck, and face (64.6%). Non-ulcerative lesions were significantly associated with higher odds of QoL impairment (AOR = 9.97, 95% CI: 2.48-74.15,  = .006). Scarred lesions had lower odds of impairment compared to active ones (AOR = 0.05, 95% CI: 0.01-0.17,  < .001). Leg lesions were linked to higher QoL impairment (AOR = 2.74, 95% CI: 1.26-6.17,  = .012), whereas head/neck/face lesions were not (AOR = 0.69, 95% CI: 0.39-1.22,  = .193). Children who had received treatment reported worse QoL (AOR = 0.19, 95% CI: 0.06-0.47,  = .001). Lesion characteristics significantly influence QoL in children with CL. Non-ulcerative and active lesions, leg involvement, and prior treatment were associated with greater QoL impairment, whereas scarred lesions showed better outcomes.