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A quick summary of some of the key paediatric rashes, including appearance, cause, investigation and management. If you have any suggestions for further rashes to add, or any tweaks to the article, please let us know in the comments. If you need to improve your dermatological history taking skills then check out our guide here. If you want to learn how to examine a skin lesion check out our guide here.


Meningococcal rash

Cannot miss! Emergency!

Cause: Neisseria meningitidis

Appearance: Non-blanching purpuric or petechial rash. All children presenting with this assumed to have meningococcus until proven otherwise.

Glass test to demonstrate non-blanching rash 

Other symptoms: Pyrexia / Malaise / Meningitis ( 20-30%) / Pneumonia

Management: Immediate admission to hospital /  IV Ceftriaxone / Give IV fluids if in shock

Complications: Septicemia / Meningitis / Myocardial failure

Meningococcal rash

Meningococcal rash


Steven-Johnsons syndrome / Toxic epidermal necrolysis

Emergency! The patient can lose excessive fluids quickly!

Causes: Drugs / Chemicals (burns) / Infections / Systemic illnesses

Appearance: Widespread blisters/bullae over erythematous/ macular/ haemorrhagic skin.   Can also have haemorrhagic erosions on mucus membranes. Has positive Nikolsky sign.

Progression: Blisters start on face before spreading to other areas.

Associated symptoms: Fever / Arthralgia / Myalgia / Conjunctivitis / Pneumonitis

Management:

  • Supportive (hydration/maintain airway)
  • Identify and remove causative agent
  • Apply emollient ointment
Steven Johnson Syndrome

Steven Johnson Syndrome


Impetigo

Cause: Staphylococcal aureus or streptococcal skin infection

Appearance: Erythematous macules (may progress to be vesicular/ bullous) on face/neck/hands

Epidemiology: infants and young children

Management:

  • Topical – mupirocin/ retapamulin
  • Systemic: Dicloxacillin or cephalexin (to cover both staphylococcal and streptococcal infection)
Impetigo

Impetigo


Kawasaki disease

Cause: Autoimmune-mediated – medium-sized blood vessel vasculitis

Symptoms: Fever > 5 days / conjunctivitis / polymorphous exanthem / fissuring of lips / strawberry tongue / diffuse erythema of oral and pharyngeal mucosa / periungual desquamation of fingers and toes / erythema of palms and soles

Other features: Arthralgia / Septic meningitis / Coronary artery aneurysm / Vasculitis and other cardiac conditions (congestive heart failure, myocarditis, arrhythmias, mitral insufficiency, acute MI)

Investigations: Echocardiography (needs follow up 6 weeks later) / ESR / CRP / Alpha-1 antitrypsin

Management: High dose IV immunoglobulin / Aspirin

Strawberry tongue

Strawberry tongue


Staphylococcus Scalded Skin Syndrome

Cause: Exfoliative staphylococcal toxin

Appearance – Blistering initially, then desquamation – affecting flexural areas/buttocks/hands/feet

Epidemiology: typically in children <3 years old

Associated symptoms: Fever / Irritability / Diffuse blanching erythema around mouth / Desquamation as above / positive Nikolsky’s sign

Management: IV flucloxacillin


Eczema herpeticum

Dermatological emergency

Cause: Type I HSV co-infection with active atopic eczema

Primary infection: in pre-school children, presenting with sore throat, pyrexia, stomatitis, vesicles or ulceration in oral cavity and face.

Secondary infection frequently occurs : Cluster of itchy and painful blisters on face and neck. New blisters have umbilication, old blisters crust and form sores.

Secondary bacterial infection may lead to impetigo or cellulitis

Management: Oral acyclovir / Systemic antibiotics for secondary bacterial infection


Erythema nodosum

Appearance: Red or violet subcutaneous nodules located pretibially

Causes: Streptococcal pharyngitis / Idiopathic / Sarcoidosis / Primary TB / Inflammatory bowel disease / Drug reaction

Management: Disease usually self-limiting or resolves with the treatment of the underlying disorder.

Erythema nodosum

Erythema nodosum


Erythema multiforme

Causes: HSV(90%) / Mycoplasma pneumonia / Medications / Autoimmune disease / Sarcoidosis

Appearance: Target-like lesions on skin.  Progresses to erosions of bullae – (which can involve oral, genital or mucosal areas)

Management:

  • Mild disease: Topical corticosteroids / Oral antihistamines / Mouthwash (lidocaine, diphenhydramine, antacids)
  • Severe oral mucosal involvement: Systemic glucocorticoids (Oral prednisone)
  • Ocular involvement: Refer to ophthalmologist immediately
Erythema multiforme

Erythema multiforme


Measles

Appearance: Maculopapular rash lasts 6-8 days.

Associated symptoms: Fever / Coryza / Cough / Non-purulent conjunctivitis / Koplik spots

Epidemiology: Young children – peak in late winter / spring

Treatment: Supportive, can give antibiotics to prevent secondary infection

Prevention: MMR Vaccine at 18 months.

Measles rash

Measles rash


Glandular Fever/Infectious Mononucleosis

Cause: Epstein Barr Virus

Associated symptoms: Fever / fatigue / sore throat / lymphadenopathy 

Macularpapular rash can occur due to being treated with penicillin whilst infected with EBV

EBV penicillin rash

EBV penicillin rash


Hand Food Mouth Disease

Causes: Coxsackievirus A16 and enterovirus A71

Appearance:

  • Oral vesicles which rupture to form ulcers mainly on tongue and buccal mucosa(Enanthem)
  • Macular, maculopapular or vesicular exanthema on hands, feet, buttocks, legs, arms.

Management: Supportive, but children with complications may require hospitalization.

Hand, foot & mouth disease

Hand, foot & mouth disease


Erythema infectiosum/ Fifth disease

Cause – Parvovirus B19

Begins with: fever, coryza, headache, nausea and vomiting

2-5 days later: Malar rash with circumoral pallor (slapped cheek rash), then lace like rash on trunk and extremities follows

Epidemiology: Outbreaks among school-aged children

Treatment: Supportive as virus is self-limiting

If fetus contracts disease, can result in miscarriage, intrauterine fetal death, and/or non-immune hydrops fetalis

Fifth disease

Fifth disease


Chickenpox (Varicella Zoster)

Appearance:

  • Starts on head and trunk, then spreads throughout body.
  • Red macules-> papule->pustule-> crusting

Epidemiology: Between 1 and 6 years, peaks in winter and spring

Associated symptoms: Headache / Anorexia / URTI / Fever / Itching

Treatment: Antihistamines / Acetaminophen / Acyclovir / VZIG for prophylaxis for contact at risk individual.

Aspirin is contraindicated due to Reye’s syndrome.

NSAIDS are contraindicated due to increased risk of severe skin and soft tissue infections.

Varicella zoster rash (c8-t1)

Varicella zoster rash (c8-t1)


Napkin rash

Cause: Candida albicans- in skin creases.  Candida secondarily infects areas of irritant dermatitis that has been left untreated for more than 3 days

Appearance: Beefy red plaques / Satellite papules / Superficial pustules

Treatment: Frequent application of emollient, topical antifungal agent (nystatin, clotrimazole or ketoconazole)


Scabies

Cause: Infestation of skin by mite Sarcoptes scabiei resulting in pruritic eruption

Appearance: Small, erythematous papule with haemorrhagic crusts on fingers, elbows, axillary folds, thighs, genitalia, feet

Treatment: Massage in 5% permethrin cream from neck to soles of feet, then wash off after 8-14 hours, with 2nd application 1-2 weeks later recommended

Scabies nodules

Scabies nodules


Tinea corporis

Dermatophyte infection of the body

Causes: Trichophyton Rubrum / Microsporum Canis / Epidermophyton

Appearance Pruritic, circular, erythematous scaly patch spreading centrifugally. Central clearing is seen.

Treatment: Daily application of topical antifungals. Systemic therapy indicated in patients with failed topical therapy- terbinafine, fluconazole or itraconazole (PO).

Tinea Corporis

Tinea Corporis


Tinea Capitis

Dermatophyte infection of the scalp

Appearance: Well demarcated scaly lesion, can be “gray patch”, “black dot” and favus

Treatment: Systemic treatment with PO Griseofulvin/Terbinafine

Tinea Capitis

Tinea Capitis


Molluscum contagiosum

Common disease of childhood

Cause: Poxvirus

Appearance: Flesh-coloured, dome shaped papules on skin

Associated symptoms – usually painless / sometimes pruritic

Treatment: Lasts approximately 18 months without the need for treatment

Molluscum Contagiosum

Molluscum Contagiosum


References

1. Meningococcal rash – James Heilman, MD – http://commons.wikimedia.org/wiki/File:Vasculitis.JPG

2. Steven Johnson Syndrome – Dr. Thomas Habifhttp://www.dermnet.com/Stevens-Johnson-Syndrome/picture/14975

3. Impetigo – http://commons.wikimedia.org/wiki/File:Impetigo-infected.jpg

4. Strawberry tongue – http://commons.wikimedia.org/wiki/File:Kawasaki_symptoms_B.jpg

5. Erythema nodosum – http://commons.wikimedia.org/wiki/File:ENlegs.JPG

6. Erythema multiforme – http://commons.wikimedia.org/wiki/File:Erythema_multiforme_minor_of_the_hand.jpg

7. EBV penicillin rash – By Matibot (mine) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

8. By KlatschmohnAcker (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

9. By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

10. By Fhgd (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

11. Tinea Capitis – By myself (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0-3.0-2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/4.0-3.0-2.5-2.0-1.0)], via Wikimedia Commons

12. Molloscum contagiosum – Evanherk from nl [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons