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.
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
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
- Supportive (hydration/maintain airway)
- Identify and remove causative agent
- Apply emollient ointment
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
- Topical – mupirocin/ retapamulin
- Systemic: Dicloxacillin or cephalexin (to cover both staphylococcal and streptococcal infection)
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
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
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
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.
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)
- Mild disease: Topical corticosteroids / Oral antihistamines / Mouthwash (lidocaine, diphenhydramine, antacids)
- Severe oral mucosal involvement: Systemic glucocorticoids (Oral prednisone)
- Ocular involvement: Refer to ophthalmologist immediately
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.
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
Hand Food Mouth Disease
Causes: Coxsackievirus A16 and enterovirus A71
- 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.
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
Chickenpox (Varicella Zoster)
- 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.
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)
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
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).
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
Common disease of childhood
Appearance: Flesh-coloured, dome shaped papules on skin
Associated symptoms – usually painless / sometimes pruritic
Treatment: Lasts approximately 18 months without the need for treatment
1. Meningococcal rash – James Heilman, MD – http://commons.wikimedia.org/wiki/File:Vasculitis.JPG
2. Steven Johnson Syndrome – http://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