An Approach to Pediatric Rashes Neethi Patel, D.O. Learning Objectives 1.To identify common features of rashes seen in the pediatric population as well as pathognomonic features of certain pathologies 2.Develop an approach to help make the diagnosis 3.Distinguish between rashes requiring more aggressive investigation and those which can simply be observed History -Onset of rash -Evolution of lesions -Associated symptoms -Presence of pruritis -Exposures -Medications -Sick contacts -Immunization Status 1
Physical Exam -Complete physical exam looking for findings other than rash -Location of rash -Quality of rash -Morphology of rash -Pattern of rash Terminology Macule flat lesion,usually a circumscribed change of colour Papule small, solid, elevated lesion Nodule a large, solid, palpable and elevated lesion Plaque a lesion slightly raised over a larger area Blister an elevated lesion,fluid filled Ulcer depressed lesion with loss of surface epithelium Atrophy a depressed lesion with intact surface epithelium Crust a mixture of scale and serum yellowish accretions on the surface of a lesion Petechiae non raised red-brown non blanchable lesions 2
Summary of Paediatric Skin Rashes: Adapted from Paediatric Handbook 6th Ed. Royal Children's Hospital, Melbourne Viral Exanthems -Hand Foot Mouth -Fifth s Disease -Roseola -Molluscum contagiosum -Varicella -Measles Hand Foot Mouth -Usually caused by the enteroviruses, most commonly Coxsackie -Fever, headache, malaise, anorexia, with occasional GI symptoms -Oral lesions are mildly painful yellow ulcers with red halo -Exanthem consists of vesicular lesions on extremities, most often palmar and plantar surfaces; can occasionally include diaper area and perioral lesions 3
Hand Foot Mouth Fifth s Disease -Parvovirus B19 -Characterized mainly by its exanthem -Fever and constitutional symptoms are rare -Rash begins on face with a macular redness to cheeks often described as slapped cheek -Followed by development of a macular lacy erythematous rash, usually on extremities Fifth s Disease 4
Roseola -HHV 6 -High persistent fever for approx 72 hours -Anorexia and irritability -Erythematous maculopapular exanthem occurring simultaneously with defervescence Vincent Hu, https://flic.kr/p/bjrtp4 Molluscum Contagiousum -Dome shaped papular lesions with a waxy appearance and umbilicated ceentrs -Caused by a poxvirus -Spread by scratching -Will eventually subside spontaneously Chicken Pox -Caused by the varicella-zoster virus -Prodromal illness with fever, malaise and mild uri sx -Lesions often start on trunk and scalp and then spread peripherally in different crops -Lesions are vesicular and fluid filled surrounded by red halos which eventually burst and then crust and then slough off -Hallmark of this exanthem is to find lesions in multiple stages at once 5
Measles -Prodrome of fever, malaise, cough (dry), coryza (runny nose), and conjunctivitis (clear d/c with photophobia), pt s often ill and lethargic appearing -Koplik s spots are tiny bluish-white dots surrounded by red halos on buccal mucosa which typically develop 1-2 days after prodrome -Exanthem (often seen on day 3-4) is a blotchy erythematous blanching maculopapular rash that spreads cephalocaudally over 3 days, usually involves palms/soles Measles -Rash becomes confluent over proximal areas as it progresses -Older areas tend to have capillary leak causing them to no longer blanch -Rash fades 2-3 days later and often is followed by desquamation -Pt s are contaigous 4 days before rash until about 4 days after rash 6
Measles -Scarlet Fever -Impetigo Bacterial Infections Scarlet Fever -Occurs with beta-hemolytic strep -Fever, sore throat, headache and abdominal pain -Exanthem is erythematous and blanching, begins on trunk and rapidly spreads peripherally and feels rough and sandpapery -Face is flushed with perioral pallor -Rash often accentuates in creases and skin folds -Strawberry tongue 7
Scarlet fever Scarlet Fever, Exanthem. Jefferson Clinical Images Web site. http://jeffline.jefferson.edu/jci/. Accessed July 15, 2016. Impetigo -caused by staph or strep -lesions usually on exposed areas -vesicular lesions which often evolve to honey crusted areas -Diaper candidiasis -Tinea -Sebhorrhea Fungal Infections 8
Diaper Candidiasis -Bright red eruption usually with sharp borders and satellite papular lesions -Can be seen with oral thrush -Often found in intertrigenous areas Tinea Capitis -can present in various ways as patches of alopecia sometimes with erythema and/or scaling -lesions often annular -intense inflammation of these lesions make them boggy with pustules called kerions -must be treated with oral antifungals Tinea Corporis -fungal infection ringworm -annular lesions, often well circumscribed with central clearing with an active vesicular border -lesions often start off papular or pustular and evolve to form papulosquamous lesions 9
Seborrhea -red scaly eruption which often has a waxy appearance -occurs commonly on hair bearing and intertriginous areas -on scalp, often associated with a thick yellowish scale Seborrhea Allergic or reactive rashes -Urticaria -Eczema -Contact Dermatitis -Scabies -Drug eruption -Erythema Multiforme -Stevens Johnson 10
Urticaria -intensely pruritic -well-demarcated wheals with an edematous white center with surrounding redness or reverse -lesions often transient Eczema -very common skin eruption -red dry rough itchy papules/plaques that often ooze and crust -often found on cheeks and flexural creases Contact Dermatitis -Eczematous eruption found in a specific area, often related to contact with an irritant -Treatment often involves removal of offending agent and topical steroids 11
Scabies -highly contaigous infestation caused by a mite -eruption appears 4-6 weeks after contact and is caused by hypersensitivity response to mite -intensely pruritic papules and vesicles -linear burrows- small scaly linear papule with pinpoint vesicles at ends -found in toe/finger webs Morbilliform Drug eruption -usually associated with common drugs such as amoxicillin -maculopapular rash ranging from fine to blotchy -usually on face and trun and spread to extremities -can become confluent Erythema Multiforme -distinctive acute hypersensitivity reaction -can be caused by many agents- drugs, viruses, foods -target lesions -not as pruritic and less transient -can be bullous 12
Stevens Johnson -progression of EM -involves mucous membranes and large areas of epidermal necrosis and shedding -constitutional symptoms are prominent, very ill appearing -fluid and electrolyte imbalances are the concern Stevens Johnson -Pityriasis Rosea -Gianotti-Crosti Eruptions 13
Pityriasis Rosea -benign, self-limited -herald patch followed by eruption of small oval lesions, pink in color with slight scale arranged mostly on trunk in christmas tree pattern -resolves in about 4-6 weeks -mostly likely viral etiology Pityriasis Rosea Gianotti Crosti -Papular Acrodermatitis -often associated with viral illness -abrupt appearance of crops of discrete firm papules with flat tops distributed over extremities, buttocks and face -usually spares trunk and scalp -no steroids- makes worse 14
Gianotti Crosti References Zitelli, Basil J.; Davis, Holly W. Atlas of Pediatric Physical Diagnosis Third Edition; 1997 Wikimedia images 15