Rash Flashcards
What are important questions to ask in HOPC?
Are they well or unwell?
Acute onset vs. chronic issue
New issue or previous occurrences?
Progression - Worsening or resolving, Changing in its nature
Description of rash
Appearance – colour, shape, individual vs. clusters of lesions, crusting/scabbing/scaling, vesicles/fluid filled/blistering, oozing/weeping/bleeding
Distribution - Diffuse vs. localized, Region of body, Surface of body – flexural vs. extensor vs. palmer/dorsal surfaces
Itchy
iSigns of infection or inflammation
Important associated features?
Fever
Localising features
-Meningism – headache, photophobia, neck pain/stiffness, unwell
-URTI – cough, congestion, coryza, wheeze/SOB
-Joint pain, swelling
-GIT – diarrhoea, abdominal pain
Other important information to obtain from history?
Triggers/modifying factors
i. Allergies
ii. Stress/emotion
iii. Irritants - Soaps/detergents, wool
Context
a. Travel history
b. Sick contacts
Past & family history
a. Antenatal and birth history
b. Growth and developmental history
c. Asthma
d. Allergies
e. Eczema
What are DDx for vesicular rash?
Impetigo (school sores)
Coxsackie (hand, foot & mouth)
Varicella
What are DDx for papular (raised) rash?
Urticaria
Molluscum
Warts
Rubella
What are DDx for red blanching rash?
Fever + exanthema Roseola Kawasaki disease Parvovirus (erythema infectiousum) Measles Drug reactions
What are DDx for purpuric rash?
Enteroviral, HIB, pneumococcus Septicaemia Leukaemia Henoch-Schoenlein purpura ITP Trauma/child abuse
What are DDx for red/dry/scaly rash?
Eczema
Psoriasis
Tinea
Nappy rash
What are DDx for blue/black rash?
Vascular malformations
Haemangioma
Mongolian spots
What Ix shoudl be considered for rash + fever?
Bloods
a. FBE
b. CRP
c. ESR
d. Blood cultures
CXR
Lumbar puncture
Roseola infantum (HSV-6)
What is the description of the rash?
Erythematous, maculopapular papular
Blanching
Not itchy or painful
Trunk & limbs
Rarely spreads to face & neck
Often confused as drug rash
Roseola infantum (HSV-6)
Clinical features?
Common, mild
Sudden onset, high fever lasting 3 – 5 days
URTI symptoms
Rash appears ~3-5 as fever is subsiding (fever is not always followed by the rash)
Complications – febrile convulsions (causes 1/3 in <2yrs), aseptic meningitis, hepatitis
Roseola infantum (HSV-6)
Management?
Supportive and symptomatic treatment
Coxsackie (Hand, foot & mouth disease)
Rash description?
Vesicles – cheeks, gums, tongue
Papulovesicular rash (can look haemorrphagic) – palms, soles, fingers, toes, buttocks, genitals, limbs
Coxsackie (Hand, foot & mouth disease)
Clinical features
Sore throat
Fever
Anorexia
Coxsackie (Hand, foot & mouth disease)
Management?
Symptomatic
a. Analgesia
b. Fluids
Infection precaution
a. Exclusion from school until fluid in blisters is dried only
b. Excreted in faeces for weeks
Parvovirus (Erythema infectiousum)
Rash features?
Three stages of the rash:
- Slapped cheek appearance of rash – red, blanching, lasts 1-3 days, feels burning hot
- Maculopapular rash – limbs +/- trunk
- Reticular rash – lace-like pattern that appears in heat, cold and friction
Parvovirus (Erythema infectiousum)
Clinical features?
Non-specific prodrome/viral symptoms
+/- fever (15 – 30%)
Rash can persist for 6 weeks intermittently – reappears when hot
Mainly clinical diagnosis but PCR & serology available
Complications – arthritis, bone marrow suppression, foetal hydrops
Parvovirus (Erythema infectiousum)
Management?
Supportive & symptomatic management
Highly infectious until rash appears, therefore school exclusion inappropriate
Identify if pregnant contacts
Varicella Zoster (Chicken pox)
Rash description?
Rash erupts over 3 – 5 days following prodrome
Crops of small papules that quickly become vesicular and crust over
Can occur anywhere
Most typical locations scalp, face, trunk, mouth, conjunctivae
Varicella Zoster (Chicken pox)
Clinical features?
Prodrome (short) fever, lethargy, anorexia
Natural Hx
Infectious 1-2 days before rash appears
Generally benign, self-limiting
Usually unwell for ~5-7 days
Complications - Bacterial superinfection, pneumonia, Encephalitis, cerebillitis, Reye syndrome
Complications more common in infants & > 15 yrs
Varicella Zoster (Chicken pox)
Management?
Prevention
a. Vaccination recommended for children > 12 months without hx of varicella
Infection precautions
a. Infectious from 1-2 before rash and until all lesions have fully crusted over
b. Mus be excluded from school until full recovery (all lesions crusted over) or at least one week after the eruption first appears
Symptomatic Rx
a. Calamine lotion, pinetarsal bath
b. Cool compress
c. Oral antihistamines at night to improve sleep
d. Avoid itching
If immunocompromised or some neonates, consider admission and:
a. IV acyclovir
b. ZIG
Rubella (German Measles)
Rash description?
Maculopapular rash
Small, discrete lesions
Starts on face and spreads to trunk and limbs over 24 hrs
LAD proceeds rash by 5-10 days
Rubella (German Measles)
Clinical features?
Mild febrile illness prodrome – general viral and coryza symptoms
Prodrome lasts 1-5 days
LAD – post-auricular, occipital
Asymptomatic in some (25-50%)
Complications only if perinatal infection
Rubella (German Measles)
Management?
School exclusion – 5 days from onset of rash
Check pregnant contacts
Symptomatic & supportive management
Diagnosis - Serology
Molluscum
Rash description?
Firm, pearly dome-shaped lesions
Central umbilication
May last months
Molluscum
Clinical features?
Eczema may develop in surrounding skin – usually this prompts presentation
Eczema can obliterate the primary lesions
Can become secondarily infected (bacterial)
Molluscum
Management?
Education
– very common, caused by a virus, benign, they may develop a few or more and they can last months (will not resolve until full immune system developed) – Don’t share towels but no other restrictions
Treatment of surrounding eczema
Uncomplicated lesions should be left alone
Bothersome, isolate lesions – cryotherapy
Larger areas – immune stimulation agents, 5% benzyl peroxide
Kawasaki disease
Rash description?
Polymorphus rash
- Measles like (red, blotchy, raised)
- Maculopapular
- Generalised erythema
- Target-like
Desquamation may occur later
Kawasaki disease
Clinical features?
Predominantly affects <5 years
More common in boys
Diagnosis often delayed as presentation similar to many other viral Exanthems
Complications – coronary artery dilation or aneurysm formation
Clinical features can occur sequentially or may not be all present at the same time – infants less than 12 mths often have incomplete symptoms to meet diagnosis
Clinical diagnosis
Fever > 5 days AND 4/5: polymorphous rash, bilateral conjunctivitis, mucus membrane changes, peripheral changes or cervical LAD
Fever – needs to last at least 5 days for diagnosis
Head & Neck
Bilateral ‘dry’ conjunctivitis – no exudate (differentiates from other viral causes)
Mucus membrane changes - strawberry tongue, dry cracked lips, redness of oropharyngeal mucosa
Cervical LAD – usually unilateral, single, painful
Peripheries
Non-pitting, uncomfortable oedema in feet and hands – reluctance to walk
Arthralgia in hip and knee
Palmar erythema – no pattern to redness, may be fluctuate in intensity
Erythema of soles
Kawasaki disease
Management?
Exclude other DDx – staphylococcal infection (scaled skin syndrome, TSS), streptococcal (scarlet fever), measles, Steven’s Johnson syndrome, drug reaction, rheumatoid/juvenile arthritis
Investigations – all patients must have:
a. ASOT/Anti-DNAase B – exclude strep infection
b. Platelet count – marked thrombocytosis in 2nd week of illness
c. ECHO – at least 2; one initially and at 6-8weeks later
- IV immunoglobulin – preferably within 10days of illness
- Aspirin daily for 6-8 weeks
Meningococcal disease
Petechial and purpuric rash
Non-blanching
Late sign – can appear 12-36 hrs later)
Meningococcal disease
Peak < 2 years and adolescence
Preceding viral infection or a blanching rash does not exclude meningococcal disease
Sudden onset of symptoms; often deteriorate rapidly
General viral type – fever, malaise, arthralgia, myalgia, headache, vomiting
Lethargy, reduced conscious state
Suggestive of meningococcal disease
- Leg pain
- Confusion
- Photophobia – late sign > 12 hrs
- Neck pain/stiffness – late sign > 12 hrs
May present with signs of shock
May present with pneumonia, URTI or occult bacteraemia
Meningococcal disease
Management?
Commence empirical IV antibiotics as soon as meningococcal disease suspected
a. Ceftriaxone or Cefotaxime
b. Penicillin if cephalosporin’s unavailable
c. IM can be used if IV access can’t be obtained within 15 minutes
Dexamethasone
ABCD
a. Fluid bolus – careful with fluids if suspect meningitis as often increased ADH secretion
Blood cultures
Other investigations within first hour
a. Meningococcal PCR if blood cultures obtained after antibiotic administration
b. FBE
c. U&Es
d. Glucose
e. Coagulation screen – if appropriate (DIC complication)
f. LP – usually not in acute management, consider if suspect meningitis
Infection control
a. Contact precautions
b. Treatment of contacts
Impetigo (Strep & Staph)
Rash description?
Infection of the epidermis
Causes GABHS, S. aureus
Lesions are rounded, well demarcated and are grouped & asymmetrical
Areas of ooze + crusts
Commonly on face, trunk or limbs
Can be bullous lesions
Painless
Progressive – rapidly spread/increase
Impetigo (Strep & Staph)
Clinical features?
Highly contagious
Common particularly in young children and in hotter months
Clear up in a few days, but may need to be treated again
May be associated with fever
If strep – monitor for post-strep glomerulonephritis
Impetigo (Strep & Staph)
management?
Localised, uncomplicated
a. Wash crusts off
b. Saline baths – dry lesions
c. Topical mupirocin 2% ointment
Extensive
a. Swabs - MCS
b. May require antibiotics flucloxacillin or cephalexin
Infection precaution
a. Excluded from school until treatment is started and the sores are completely covered with watertight dressing
Scarlet Fever (Group A Strep – S. pyogenes)
Rash description?
Diffuse red flushing
Torso and skin folds
Blanching
Circumoral pallor (pale around mouth)
‘Sand-paper’ like feel
Scarlet Fever (Group A Strep – S. pyogenes)
Clinical features?
Peak age = 5 – 10 yrs; extremely uncommon <5yrs
Prodrome – sudden onset high fever
+/- headache, abdo pain, vomiting, malaise
+/- strawberry tongue (initially may be white)
Cervical + submandibular LAD
Pharyngo-tonsillitis – usually starts as this
Rash appears within ~2hrs of prodrome
Complications – Post-strep GN, quinsy, acute rheumatic fever
Scarlet Fever (Group A Strep – S. pyogenes)
management?
- Clinical diagnosis may be confirmed with:
a. Throat swab – less useful as many school-aged children are normal carriers
b. ASOT + anti-DNAase B more specific - Penicillin
Staphylococcal scalding syndrome
Rash description?
Widespread blistering rash caused by toxin
Distribution – umbilicus (neonates), nose, nasopharynx or throat, conjunctiva
Starts with macular erythema initially on face & major flexures – becomes more generalised
Flaccid bullae develop 2 days later, skin wrinkles and shears off – most marked in groin, neck fold
Mucosae uninvolved
Skin is exquisitely tender
Staphylococcal scalding syndrome
Clinical features?
Primarily affects neonates and young children
Usually febrile
Fluid loss rarely significant
Heal over 4-8 days with no sequelae
Staphylococcal scalding syndrome
Management?
- Cultures
a. Obvious sites of infection or nasopharynx and throat - Supportive
a. Nursed naked on non-stick material with minimal handling
b. Avoid topical agents in early stages
c. Analgesia - Flucloxacillin is treatment of choice
a. Emollients once skin dries and desquamation commences
Measles (Rubeola Virus)
Rash description?
Appears 3-4 days later
Red, blotchy, raised
Starts in hairline and moves down the body
Becomes confluent and later may become desquamate – the more confluent, the more severe
Lasts 4-7 days
Measles (Rubeola Virus)
Clinical features?
Prodrome – Fever, coryza, conjunctivitis,
Koplick spots – white spots on red buccal mucosa
Infectious from 2 days before illness to 5-days after rash onset
Measles (Rubeola Virus)
Management?
Diagnosis – serology (IgM positive after rash), PCR (nasopharyngeal aspirate)
Symptomatic & supportive Rx
Consider Vitamin A supplement in immunocompromised and young infants with severe disease
Complications – otitis media, pneumonia, encephalitis & sclerosing panencephalitis
Can be fatal (bacterial complications most commonly)
Urticaria (Hives)
Rash description?
Pruritic elevated skin lesions, surrounded by erythematous base (wheal)
Due to extravasation of plasma into dermis
May be local or generalised
Well circumscribed but often coalesce
May see excoriation
Vary in size
Transience of indivudal lesions
Urticaria (Hives)
Clinical features?
Common condition
May be idiopathic or associated with preceding cause
Possible causes – medications, infections, foods (infrequently), bites/stings, physical (pressure, cold, exercise)
Observe for dyspnoea or dysphagia in first few hours (anaphylaxis)
Most common DDx = erythema multiforme – not itchy, not transient, target lesions, often mucosal involvement
Urticaria (Hives)
Management?
- Remove identifiable causes if any
- Cool compress
- Education – explanation, information, reassurance
- Anti-histamines – itching
a. Promethazine (Phenergan) if >2 yrs
b. Cetirizine (Zyrtec) if >1 yr
c. Steroid creams and diet manipulation not indicated/effective
Eczema
Rash description?
Rash
Dry, itchy, inflammatory chronic skin disease
Remitting, relapsing course
Eczema
Epidemiology
Typically begins in childhood
Affects ~30% children
Onset usually before 12 months
Most ‘grow out of it’ before age 5
Eczema
Diagnosis
- Itch
- AND 3 or more of:
a. Hx of involvement in skin creases
b. Personal hx of asthma or hayfever
c. Hx dry skin in last year
d. Onset < 3 yrs
e. Visible flexural eczema
Eczema
Maintenance Rx?
- Education
a. Triggers
b. Avoid irritants i.e. soaps, overheating, pets, prickly/woolly clothing - Moisturiser
a. Prevent dryness of skin - Daily cool bath
- Control itch
a. Distract child if scratching - Consider Vitamin D supplement
Eczema
Flare Rx?
Used if acute deterioration (flare) increased erythema and itch
- Topical steroids
a. Hydrocortisone 1% - Tar creams (lichenification)
- If secondary infection
a. Antibiotics or antivirals
b. Cool bath with added salt, 4% bleach and bath oil - Wet dressings
- Cold compressing relief of itch
- Consider referrals
a. Eczema workshop
b. Allergy testing and advice
Outpatient clinic
