Common Childhood Rashes in General Practice

Common problem encountered in General Practice 49.1% pre-school children affected at any one time 29.4% eczema 19.5% seborrhoeic dermatitis 15% Nappy rash 0.9% Tinea Approach to rashes History History History Then examine! Investigations rarely needed/ appropriate

Common skin lesions Macule Papule Nodule Plaque Pustule Vesicle Bulla Petechiae Purpura

circumscribed area of change in normal skin color with no skin elevation solid raised lesion up to 0.5 cm in diameter , variable color larger & deeper than papule confluence of papules circumscribed area of skin containing purulent fluid circumscribed elevated ,fluid filled lesion up to 0.5 cm in diameter larger than vesicle small red or brown macules up to 0.5 cmin diameter that do not blanch on pressure petechiae > 0.5 cm

Differential Dx in Childhood Rash Maculopapular rash Viral exanthems : rubeola , rubella , adenovirus , enterovirus , Epstein-Barr virus Meningococcemia (early) Cutaneous drug eruptions Toxic shock syndrome Erythema multiformis Systemic lupus erythromatosis

Vesiculopapular rash Varicella zoster infection (chicken pox) Herpes simplex virus infection Stevens-Johnsons syndrome Erythema multiforme major Pemphigus vulgaris

Petechial/purpuric rash Meningococcemia Vasculitis : Henoch-Schonlein purpura , hypersensitivity drug reaction Enteroviral infections Epstein-Barr virus Thrombocytopenia SLE Purpura fulminan

VIRAL MACULOPAPULAR RASH ROSEOLA Cause General feature HHV6/7 - Affects those aged 6-36 months - 3-5 days high fever with no obvious source - Sub-occipital nodes Measle virus IP = 8-14 days Prodromal illness 3-4 days - Fever - conjunctivitis - runny nose (coryza) & cough Infectious 1-2 days before prodrome Later symptoms : Koplik spots (appear 1 day before and 1 day after rash appear) MEASLES RUBELLA (GERMAN MEASLES) Rubella virus IP = 14-21 days No prodrome Infectious 5-7 days before rash - Fever & lymphadenopathy (occipital & postauricular) - May have petechiae on hard palate & asscociated arthralgia/arthritis - Lasts 10 days Fine pink maculopapular rash on face then trunk & limbs ERYTHEMA INFECTIOSUM (5TH DISEASE) aka slapped cheek disease Parvovirus B19 IP = 4-14 days - Fever in 15-30% for 1-2 days - Slapped cheek appearance

Rash

**Dx features

Rose-pink macular rash appears once fever settles - Starts on trunk, may spread to face & extremities - Lasts up to 2 days rash appears once fever settles

** Diffuse erythematous maculopapular rash all over the trunk, face and extremities, blotchy and irregular. Coalesce into patches of different size and shapes **Koplics spots : multiple red spots with white dots in the centre resting on inflamed mucous membrane of the hard palate opposite to the upper second molar tooth Supportive Symptoms usually last 10 days Complications: - Otitis media - Bronchopneumonia - Encephalitis (1/1000) - Myocarditis/pericarditis - SSPE (rare) - 30% mortality in developing countries DDx of maculopapular rash (see above)

Generalised maculopapular rash for 7-10 days - lace-like

Managemt

Treat symptomatically Reassurance

Supportive Complications : - Arthritis (esp. adolescents) - Thrombocytopenia (rare) - Encephalitis - Peripheral neuritis - Birth defects in 1st trimester * Hence importance of vaccinating girls!

**Diffuse erythematous patch on the cheeks with circumoral pallor giving slapped cheek appearance Supportive DDx of slapped cheek: - Cushing syndrome - Malar flush (SLE) - Scarlet fever - Corticosteroid (drug)

Roseola Infantum

Measles

Kopliks spot

Erythema Infectiousm

Rubella (German measles)

Rubella (German measles)

Follicular tonsillitis

Scarlet fever

Strawberry tongue

Chicken Pox

Cause General feature

BACTERIAL MACULOPAPULAR RASH Scarlet Fever Group A beta-haemolytic Streptococcus (toxigenic stains) IP = 2-4 days Bright red blanching rash (sandpaper) First in axila/groins, then widespread Red face with circumoral pallor Strawberry tongue (white then red) Hx of strep. Tonsillitis ** rash is pinpoint, red fine granular macules, Bright red blanching rash (sandpaper) mainly on the trunk giving the appearance of goose skin

VIRAL VESICULAR RASH Chickenpox Varicella zoster virus IP = 14-21 days

Very common Prodrome mild fever & malaise Infectious for 1-2 days before rash & 5 days afterwards

Rash

Vesicles on erythematous base - Change to macule papulevesiclecrust - Last 3-4 days - Mainly on trunk - Can appear in mouth/genital region - Usually no scarring - multiple vesicles centripetal in distribution mainly found on the face and trunk and scattered on the extremities. - oval in shape, resting on erythematous base, filled with clear fluid, about 0.5 cm in diameter. - Some vesicles erupted and show crustation Supportive fluids/paracetamol/calamine lotion Admit if complications suspected Complications: - Always look carefully at child if fever persists > 5 days after appearance rash secondary bacterial infection - Pneumonitis - Encephalitis - Cerebellar ataxia - Eczema herpeticum - Risk to neonates & pregnant women 1st trimester especially DDx of vesicular vesicular rash (see above)

**Dx features

**tongue is swallowen, edematous, hyperemic, with prominent papilla with circumoral pallor giving the appearance of red strawberry tongue

Management

Symptomatic relief Penicillin V 7-10 days Dx of streptococcal tonsillitis: (2 out 3) - diffuse erythematous tonsils - pus on top of tonsil - enlarged tender lymphadenopathy DDx of congested tonsil with white spots: - diphtheria - infectious mononucleosis - thrush - milk