1. health and fitness
2. disease

3/31/2015
Pediatric Rashes:
Identification and Triage
Kirsten Covec, MS/MPH, RN, CPNP-PC/AC
Hilary Fairbrother, MD, MPH, FACEP
New York Methodist Hospital &
New York University Hospital
Learning Objectives
● Review 12 common rashes and rash syndromes that
are frequent presenting complaints for “sick visits” in our
pediatric patients
● Focus on accurate identification and triage, with
information pertinent to front-line providers who may be
the first person parents seek for advice
● Look-alike case comparisons
● What do I say to the parents? Specific teaching points
for course, treatment, and prognosis of each condition
5th Disease and 6th Disease
Say what, now?
The classic exanthems of childhood:
1st Disease
Measles
Measles virus
2nd Disease
Scarlet Fever
strep pyogenes
3rd Disease
Rubella
Rubella virus
4th Disease
(obsolete)
5th Disease
Erythema Infectiosum
Parvovirus B-19
6th Disease
Roseola Infantum/
exanthem subitum
HHV-6, HHV-7, entero-,
adeno-, and
parainfluenza viruses
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Erythema Infectiosum (5th)
Roseola Infantum (6th)
Put it in words
Erythema Infectiosum (5th)
● erythematous,
edematous plaques to
face; “slapped cheek”
appearance (days 1-4)
● lacy reticulated rash on
extremities (days 3-8)
Roseola Infantum (6th)
● Blanching
● Diffuse
● maculopapular
Additional Typical Features
Erythema Infectiosum (5th)
● Mild prodrome (may
pass unnoticed!)
○ fever
○ headache
○ sore throat
○ arthralgias
Roseola Infantum (6th)
● 3-5 days of high fever
(may exceed 104F)
● Well appearing! (despite
fever)
● Fever resolves abruptly,
immediately followed by
rash
● Rash begins on neck,
central to peripheral
spread
● URI symptoms
● lymphadenopathy
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5th and 6th DISEASES
BENIGN VIRAL EXANTHEMS
5th: 70% between ages 5-15 years old
6th: 90% in children < 2 years old
● Rash appears as viremia resolves, and patients are no
longer contagious once rash appears
● Possible complication of Parvovirus (5th Disease)
infection is aplastic crisis in patients with hemolytic
disorders
● Pregnant women exposed to Parvovirus are at risk for
fetal hydrops and miscarriage (<10% risk)
● Diagnosis is by clinical features only
5th and 6th Disease TRIAGE
Contagious?
Yes
Isolation precautions?
Universal/ body fluid
Call the primary care provider? Non-urgently
Go to the ED?
No
Call an ambulance?
No
What Parents Can Expect
● Reassurance! These are benign, self-limited conditions
● No blood or other diagnostic testing
● Symptomatic relief with NSAIDs, encourage fluids
● Erythema Infectiosum:
○ Frequent clearing and recurrences for weeks or occasionally
months may occur due to stimuli such as exercise, irritation,
stress, or overheating of the skin from sunlight or bathing in hot
water
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Case Comparison: Itchy bumps & blisters
Case 1
Case 2
Case 1 Additional Features
Put it in words
Case 1
● Discrete
● grouped or scattered
● maculopapular or papulovesicular
● pruritic
● Frequently concentrated on
dorsa of hands, palms, soles,
peri-rectal area
Case 2
● Discrete
● scattered to diffuse
● papules, vesicles, pustules and
crusted ulcers in various stages
of progression
● watery yellow vesicles on
erythematous base; “dew drop
on a rose petal”
● pruritic
● Frequently concentrated on
scalp, face and trunk
● Typically sparse over
extremeties, palms and soles
usually spared
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Additional Typical Features
Case 1
● Fever and mild flu-like
symptoms, usually 1-3 days prior
to rash outbreak
● Herpangina (painful vesicular
erputions of the posterior
pharynx, tongue, and buccal
mucosa)
● Frequently refuse to eat or drink
● Skin lesions may be itchy and/or
tender
Case 2
● Mild prodrome: fever, malaise,
anorexia, 24-48h prior to
appearance of rash
● Eruptions appear in “crops”, first
on trunk and scalp, then moving
to extremeties
Case 1: Hand, Foot and Mouth Disease
COXSACKIE VIRUS
All ages, most common in infant and toddlers
● Benign, self-limiting viral syndrome
● Highly contagious, outbreaks common in daycares and
preschools. Most common in spring and summer.
● Most common complication is dehydration due to
refusal to eat/drink; painful mouth sores
Hand-Foot-Mouth Disease TRIAGE
Contagious?
Yes
Isolation precautions?
Universal/ body
fluid
Call the primary care provider?
Nonurgently
Go to the ED?
Only if concern
for dehydration
Call an ambulance?
No
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What Parents Can Expect
● 7-10 days of child feeling miserable & looking spotted.
Lesions will resolve without scarring.
● Supportive care: NSAIDs for pain control, oral benadryl for
itching
● MAGIC MOUTHWASH:
○ 1:1 ratio benadryl + Maalox
○ 3-5cc Swish & swallow or swish & spit q1-2h
● Emphasis on hydration: get creative! Icy pops, flavored
pedialyte, cold gelatin, fancy straws
● Encourage good hand hygiene practices, no sharing towels,
cups or utensils
● Careful hand hygiene with diaper changes, virus continues
shedding in stool for up to 6 weeks
● May return to daycare/school when lesions resolve
Case 2: Chicken Pox
VARICELLA ZOSTER VIRUS
90% occur in children <10 years old
● Infrequently seen today thanks to varicella vaccine
● Atypical/ very mild presentations may be seen, and rash
varies from child to child
● Consider Tzanck preparation or viral culture for
diagnosis of atypical presentation
● Is a benign, self-limited condition. Rare complications
include encehpalitis, pneumonitis
● Can be life-threatening to immunocompromised
individuals
Chicken Pox TRIAGE
Contagious?
Yes
Isolation precautions?
Contact
Call the primary care provider?
Non-urgently
Go to the ED?
NO! Please, No!
Call an ambulance?
(see above!)
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What Parents Can Expect
● Varicella is a self-limited, benign (though itchy and
sometimes painful!) condition
● Symptoms and rash typically lasts 1-3 weeks
● Topical antipruritics such as calamine lotion help for
comfort
● High-dose acyclovir administered within the first 24h of
the exanthem may reduce severity of the outbreak
Case comparison: Spots and Fever
Case 1
Case 2
Case comparison: Spots and Fever
Case 1
Case 2
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Put it in words
Case 1
Case 2
Polymorphous
Erythematous
Blanching
Diffuse
Late-stage desquamation
○ (oral, periungual,palmar)
● Nearly always involves palms,
soles, and perineum
● Erythema to hands and feet may
be quite striking, +/- indurative
edema
●
●
●
●
●
Case 1
Pinpoint papular, “sandpapery”
Erythematous
Blanching
Diffuse
Late-stage desquamation
(diffuse)
● Nearly always involves face
● May involve palms and soles
● Linear petechiae (Pastia’s lines)
in groin, flexor surfaces
●
●
●
●
●
Additional Typical Features
Case 2
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Additional Case 1 Typical Features
Additional Typical Features
Case 1
General:
FEVER 5 DAYS OR MORE
MISERABLE AND CRANKY!
No localized pain
Can’t get comfortable, difficult
to console
Eyes: Conjunctivitis (without
exudate)
Mouth/Oropharynx:
Strawberry tongue
Mucositis/ lip desquamation
Lymph nodes:
Prominent cervical
adenopathy, usually unilateral
Case 2
General:
Fever of variable length,
usually 1-5d
Well to mild discomfort
May complain of throat pain,
headache and/or belly pain
Eyes: Clear
Mouth/Oropharynx:
Strawberry tongue
Palatal petechiae
Beefy red tonsils, +/- exudate
Lymph nodes:
Mild cervical adenopathy,
usually bilateral
Putting it all together-- CASE 1
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Putting it all together-- CASE 2
Case 1: KAWASAKI DISEASE
GENERALIZED VASCULITIS
Also called Muco-cutaneous Lymph Node Syndrome
75-80% of cases occur in children under age 5
● Etiology is unknown, possibly infectious (viral or
bacterial-mediated process)
● Clinical manifestations of KD are due to release of
multiple inflammatory mediators
● Small vessels affected in early stages, and larger
vessels in later stages
● Major complication is coronary artery aneurysm; up to
20% of patients
● Diagnosis is by meeting clinical syndrome criteria; NO
SINGLE DEFINITIVE LAB TEST
KAWASAKI DISEASE TRIAGE
Contagious?
No
Isolation precautions?
None
Call the primary care provider?
Yes, urgent
Go to the ER?
Yes
Call an ambulance?
No
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What Parents Can Expect
Blood tests (CBC, inflammatory markers)
IV placement
An EKG and Echocardiogram will be performed
Medications for pain control, IV fluids for hydration
(particularly if bad mucositis)
● Admission to the hospital for a few days
● IV Immune globulin infusion
● Follow-up with cardiology
●
●
●
●
Kawasaki disease is treatable. Focus is on early
identification and prevention of coronary artery
complications.
Case 2: SCARLET FEVER
DELAYED-TYPE SKIN REACTIVITY TO EXOTOXIN
Most cases in children ages 5-15 years old
● May develop after strep throat infection
● Occurs in individuals sensitive to Group A strep
exotoxin (prior strep infection)
● Possible complication is rheumatic fever
● Diagnosis is by clinical manifestations and positive
throat culture for Group A strep
Scarlet Fever Triage
Contagious?
Yes
Isolation precautions?
Universal/ body
fluid
Call the primary care provider?
Nonurgently
Go to the ER?
No
Call an ambulance?
No
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3/31/2015
What Parents Can Expect
● Treatment with 10 days of Amoxicillin (or equivalent) to
treat the underlying strep infection
● No additional treatment is warranted for the rash
● Itching and desquamation may last for a week or more
● Child may return to school/ group activities 24h after
initiation of antibiotics
Scarlet fever is a self-limited condition. Treatment with
antibiotics is thought to prevent development of rheumatic
fever (arthritis, carditis), and other complications of strep
infection**.
**controversial!
Look alike rashes… round 2!
Case 1
Case 2
Case 1
Case 2
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Put it in words...
Case 1
Case 2
● polymorphous welts or wheals
● circumscribed with central
clearing
● itchy (worse at night)
● raised or flat lesions
● erythematous
● blanching
● non-tender
● acute or chronic
●
●
●
●
●
●
●
●
●
●
●
●
polymorphous
macules and papules
raised
erythematous
target lesions
symmetric involvement
+/- mucosal involvement
involves hands and feet but may
be diffuse
+/- itchy
blanching
non-tender
acute or chronic
Additional typical features
Case 1
Case 2
Additional Typical Features
Case 1
●
●
●
General: well appearing, intensely pruritic
HEENT: +/- angioedema of face/lips
○ NO MUCOUS MEMBRANE
INVOLVEMENT
Body:
○ any area may be affected
○ migratory within minutes to hours
leaving behind no change in the skin
○ compressed skin (waistband, axillae,
etc) disproportionately affected
○ no clear progression
○ +/- dermatographia
Case 2
●
●
●
●
●
General: well appearing, painless, usually
not itchy, nontender
HEENT: may have ulceration or painful
lesions in mouth or affecting eyes
Body:
○ palm and soles involved
○ extensor surface involvement
○ fixed lesions
○ centripetal spread
dusky central area +/- blister with a dark
red ring, surrounded by pale edema, with
erythematous halo (TARGET)
after healing, lesions may remain
pigmented for months before clearing
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Case 1: Urticaria (Hives)
Cutaneous mast cells activation releases histamine
○ histamine = vasodilation and itching
○ vasodilation = angioedema
● Acute ( < 6 weeks) vs. chronic ( > 6 weeks)
● Etiology: often unknown
○ infectious (viral, bacterial, parasite)
○ IgE allergy (medication, sting, latex, food, allergy, transfusion)
○ Direct mast cell activation
○ NSAIDS
○ Cold, pregnancy,
● Ask about medications, exposures, recent or concurrent illness
● NO SPECIFIC LABORATORY TESTING
● Only serious if progressing to fulminant allergic reaction with airway
compromise
Urticaria Triage
Contagious?
no
Isolation precautions?
none
Call the primary care
provider?
yes
Go to the ED?
No, unless there is
angioedema, SOB,
airway compromise
Call an ambulance?
Only with SOB and
airway compromise
What Parents Can Expect
Benadryl for itching
Steroids for severe itching, angioedema, or wheezing
+/- famotidine (H2 receptor antagonist)
Epinephrine in the setting of severe allergic reaction with airway edema,
hypoxia, hypotension
● Depending on what caused the urticaria, symptoms can last days to weeks
● Itching always worse at night
●
●
●
●
The large majority of these cases are self-limited, mild, and will resolve on their
own. Symptom control with antihistamines is the primary treatment followed by
removal of the trigger for the urticaria if possible.
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3/31/2015
Case 2: Erythema Multiforme
Acute, immune-mediated, typically associated with HSV infection or
bacterial infection, self-limited. Can be re-current.
● Children with mycoplasma pneumonia
● May be medication related
● ? genetic predisposition
● lesions appear over 3-5 days and resolve over 2 weeks
● NO SPECIFIC LABORATORY TESTING
● Major = mucous membrane involvement
● Minor = only skin
On the spectrum including Steven’s Johnson Syndrome (SJS) and TEN, only
serious when there is disease progression. Watch for ocular involvement
and refer to ophthalmology if the patient complains of eye involvement.
Erythema Multiforme Triage
Contagious?
no
Infectious precautions?
no
Call the primary care
provider?
yes
Go to the ED?
If having eye or severe
mucous membrane
involvement
Call an ambulance
no
What Parents Can Expect
This is a pretty rare disease, most commonly caused by
infection or medication. This is a cell mediated
response that occurs after the body fights off an infection
and the viral antigen is deposited in the skin cell that
becomes the rash.
● Treated with steroids or anti-viral medications
● Self-limited, and should resolve in 2 weeks, but may recur
● Lesions typically do not hurt or itch, and patients are usually otherwise
well.
Is only dangerous if it continues on to Stevens Johnson Syndrome (which is
almost always related to medications) and this can be noted by an ill
appearing child, with skin sloughing, particularly in the eyes and
oropharynx.
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Look alike rashes… round 3!
Case #1
Case #2
Case #1
Case #2
Put it in words...
Case #1:
● 30% children have malaise, low
grade fever, diarrhea,
lymphadenopathy.
● acute, lasts 3 weeks
● pink/brown, small, monomorphic,
flat on top.
● symmetric papular eruption
● acral distribution
○ cheeks
○ buttocks
○ extensors
● +/- itching (can be severe)
● spares mucus membranes and
nails
Case #2:
● patients are otherwise well
● chronic
● flesh colored
● firm dome shaped papules
● trunk, axillae, flexor surfaces,
crural folds
● no oral lesions
● 2-5 mm diameter, shiny, w/
central umbilication
● +/- stalk base
● +/- itching
● spares palms and soles
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Additional Typical Features
Additional Typical Features
Case #1:
● +/- lymphadenitis
● +/- hepatitis, acute or chronic
● children w/ atopic dermatitis at
higher risk
● usually children under 5 y/o, but
can be adults
Case #2:
● 5% of children in the US
● children w/ atopic dermatitis have
higher risk
● spread by skin-skin contact
● Can be seen in adults, usually
sexually transmitted
● may have surrounding small
vessels
Case 1: Gianotti Crosti
Papular acrodermatitis, associated with HBV, EBV (and other viral illnesses).
Unknown pathogenesis. Theory: a delayed hypersensitivity reaction to a viral
infection.
●
●
●
●
●
●
self-limiting
non-scarring
If associated with hepatitis, can lead to chronic hepatitis
Supportive care only
No specific lab testing, but LFTs and HBV panel may be considered
Skin biopsy is non-specific
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Gianotti Crosti Triage
Contagious?
associated viruses are,
GCS is not
Infectious Precautions?
no
Call the primary care
provider?
yes
Go to the ED?
no
Call an ambulance
no
What Parents Can Expect
Children are usually only mildly sick, or not sick at all.
The rash and any symptoms will resolve. The rash may
initially leave skin changes but is non-scarring.
The doctor may test for HBV and follow LFTs if they are
elevated. Very rarely this can translate to chronic
hepatitis.
Supportive care only, give antihistamines or use calamine
lotion for itching as needed.
Case 2: Molluscum Contagiosum
A poxvirus causing skin infection. Often found in children who play contact
sports as it is spread from direct skin-to-skin contact.
Lesions on the eye need to be followed as they can cause conjunctivitis.
Diagnosis can be confirmed with skin biopsy.
Resolves spontaneously, in about 2 - 6 months, rarely is chronic
No lab testing
Older children (where sexual contact cause is suspected) should be
treated to limit the spread of infection
● Treatment is cryotherapy, currettage, or cantharidin (blistering agent)
● Special consideration for those patient with immunocompromise
●
●
●
●
●
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Molluscum Contagiosum Triage
Contagious?
yes
Infectious Precautions?
cover lesions
Call the primary care
provider?
yes
Go to the ED?
no
Call an ambulance?
no
What can parents expect?
This is a common, self-limited disease, that
spontaneously resolves.
There are no lab tests. The rash can be confirmed by
skin biopsy. The rash is only treated in older children
or immunocompromised patients. All of the treatments
involve cutting or burning the discrete lesions to prevent
further spread. I.e. all of the treatments hurt.
To prevent spread at home, cover lesions, and
discourage scratching.
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Pityriasis Rosea
Put it in words:
erythematous
raised/inflamed
ovaloid
central scaling
+/- itching
on back, trunk, proximal
extremities
○ Christmas-tree distribution
● 10-20 year olds
● > 50% cases have a “herald
patch”
●
●
●
●
●
●
What Can Parents Expect?
It is a common, self-limited, non-scarring rash. It may occur after a mild viral
infection. Your child is not contagious, you child can be around others and
go back to school.
Your doctor may use laboratory tests to rule out other causes of rash (such a
syphilis) but there is no test for PR.
Your child may have itching, and this can be controlled with oral or topical
over-the-counter therapies. If your child is very itchy, your doctor may
prescribe a steroid cream.
This rash may take 2-3 months to go away.
For severe cases, (RARE) an antiviral drug called acyclovir may be
prescribed.
Pityriasis Alba
Put it words:
● hypopigemented flat patches
● face, neck, upper trunk, proximal
extremities
● well defined, irregular borders
● highlighted on skin after sun
exposure
● +/- mild itching
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3/31/2015
What Can Parents Expect?
Children 3-16 years old get this. Your child should be
otherwise well. It is caused by a dermatitis that
affected the pigmentation of the skin. Children with
eczema.
Protect these areas from further sun exposure. Your
doctor may prescribe you a mild topical steroid to try and
help the lesion go away more quickly. Use moisturizers
to prevent recurrence.
It is not contagious, there are no lab tests, and skin
biopsy is not useful.
Drug Eruptions:
COMMON:
● Drug-induced exanthum: most common, 90% of drug related rashes. Antibiotics are the most
commong culprit. Rashes are usually morbilliform, macular, or papular.
● Urticaria/angioedema: very itchy, lesions come and go. Angioedema is from the deeper dermis
swelling and is from mast cell activation. Can occur immediately after exposure or be delayed
UNCOMMON:
● Anaphylaxis: most severe type I hypersensitivity reaction. May have: urticaria, laryngeal
edema, nausea/vomiting, wheezing, and shock.
● Hypersensitivity vasculitis: causes palpable purpura, petechiae, fever, arthralgias. Usually 710 days after drug exposure.
○ Labs: elevated ESR
● Exfoliative Dermatitis: erythema followed by scaling of 90% of the skin. May be associated
with DRESS (Drug reaction with eosinophilia and systemic symptoms).
● Stevens-Johnson/TEN
● Erythema Multiforme
● Fixed drug reaction: erythematous plaques with central blister
● Pemphigus: auto-immune mediated, bullous diasease, triggered by various drugs
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References
American Heart Association; Council on Cardiovascular Disease in the
Young; Committee on Rheumatic Fever, Endocarditis, and Kawasaki
Disease (2004). Diagnosis, treatment, and long-term Management of
Kawasaki Disease. Circulation, 110, 2747-2771.
K.S.M. Kane, J.B. Ryder, R.A.Johnson, H.P. Baden, and A. Stratigos (2002)
Color Atlas & Synopsis of Pediatric Dermatology, New York: McGraw-Hill.
Mosier, R. (2012). Vasculitis. In K. Reuter-Rice and B. Bolick (Eds.),
Pediatric Acute Care: a guide for interprofessional practice (pp. 707-709).
Burlington, MA: Jones & Bartlett.
Am Fam Physician. 2006 Dec 1;74(11):1883-1888. “Erythema Multiforme.”
New onset urticaria. Uptodate.com. Clifton O Bingham, III, MD
References
● Romero, Jose (2015) Hand, foot and mouth disease and herpangina: An
overview. www.uptodate.com
● Pichichero, Michael (2014). Complications of streptococcal pharyngitis.
www.uptodate.com
● Pathogenesis, clinical features, and diagnosis of erythema multiforme.
Uptodate.com. David A Wetter, MD
● “Gianotti-Crosti syndrome (papular acrodermatitis).” Antonio A T Chuh, MD,
FRCP, FRCPCH. www.uptodate.com
●
“Molluscum contagiosum.”
. www.uptodate.com
Stuart N Isaacs, MD
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