The Child with a Rash

Lydia Burland

Learning Outcomes

By the end of the session students should; Be able to recognise common rashes

presenting in childhood Know about common associations and red flag

symptoms Be able to discuss initial management options

and explain to parents Be able to answer questions on common

infectious diseases and rashes

Case 1

A 3 year old presents with a 2 day history of a pustular rash on his face and hands

He is otherwise well, but keeps picking the scabs causing them to bleed

3 other children at nursery have a similar rash

He is usually fit and well, with no PMH or allergies

Case 1

What are your differential diagnoses?

ImpetigoContact dermatitisInfected eczemaEczema herpeticumScabiesBullous pemphigoid

Case 1: Impetigo

Very common superficial skin infection

Usually due to staph. aureus or beta-haemolytic strep.

Two forms: bullous or non-bullous (70%)

Most common in pre-school children and warm (sweaty) environments

Risk factors: poor hygiene and skin conditions

Case 1: Impetigo

Non-bullous:– Initial vesicles, developing into honey-crusted plaques– Minimal surrounding erythema– Spreads rapidly– Often regional lymphadenopathy

Bullous:– Thin membranes that rupture spontaneously– More common with underlying eczema

Diagnosis is clinical, though you can swab vesicular fluid for MC+S

Case 1: Impetigo

Conservative measures:– Avoid itching/touching – Avoid towel sharing

Topical treatments:– Fusidic acid– Mupirocin (for MRSA carriers)

Systemic treatment:– Flucloxacillin– Clarithromycin (for penicillin allergy)

Case 1: Impetigo

Complications include:– Cellulitis– Lymphadenitis– Staphlococcal scalded skin syndrome– Scarlet fever– Post-streptococcal glomerulonephritis

Re-infection may occur in household contacts

Case 2

A 9 year old presents with a 3 day history of cough, coryza and mild pyrexia

In the last 24 hours a non-blanching macular rash has developed on his buttocks/legs

He also has non-specific abdominal pain, and pain/swelling of his knees and ankles

He has a PMH of asthma, and is allergic to nuts

Case 2

Obs: HR 123, RR 32, T37

OE: Alert, but cryingCoryzal, pink left TMHS I + II + 0, chest clearAbdo soft, generally tender, no masses

Case 2

Florid, non-blanching purpuric rash on LL

Pain and swelling of ankles bilaterally, with limited ROM

What’s the diagnosis?

Case 2: HSP

Henoch-Schonlein purpura

IgA mediated hypersensitivity vasculitis

90% of cases in childhood, peak 4-6 years

Risk factors;Recent infection VaccinationsEnvironmental exposure

Case 2: HSP

50-90% have preceding URTI

Rash starts as erythematous macules

Within 24 hrs becomes raised and purpuric

Lesions may coalesce and resemble bruises

Associated symptoms;Abdo pain DiarrhoeaJoint pain HaematuriaScrotal pain Headaches

Case 2: HSP

HSP is self-limiting

Management includes NSAIDs +/- steroids

Complications;Renal involvement IntussusceptionGI bleeding Pulmonary haemorrhage

Prognosis is excellent, however 25% may have recurrent symptoms

Case 3

A 17 year old mum brings her 3 month old daughter in with ‘nappy rash’

It’s been present for ‘weeks’ and is getting worse

She has been putting on regular sudocrem

What are the differentials for nappy rash?

Case 3

Case 3: Nappy Rash

Very common under 18 months

Risk factors include;Immunodeficiency DiarrhoeaIrritant soaps/detergents AtopyPoor nappy hygiene

Causes include;

1. Contact dermatitis

2. Candida infection

3. Superimposed bacterial infection

Case 3: Nappy Rash

1. Contact dermatitisErythema sparing skin foldsBorders not well defined

2. Candida infectionErythema with well defined, raised bordersNo sparing of skin foldsSatellite lesions

3. Superimposed bacterial infectionIncreased erythema and purulent discharge

Case 3: Nappy Rash Management includes;

Regular nappy changes (6-12/day)Thorough cleaning with water/baby wipes‘Naked’, nappy-free timeBarrier creams (zinc, metanium)

Topical anti-fungals for candida infection (e.g. Clotrimazole, Miconazole)

Topical antibiotics for bacterial infection (e.g. Fusidic acid)

Topical steroids may also be used in severe cases(e.g. 0.5% hydrocortisone)

Case 4

A 3 year old presents with 24 hrs of D+V

Initially vomiting 4-5x day, mostly post feeds

Now watery, offensive stools 12x day

Low grade pyrexia 37.9, but otherwise well in himself

What investigations are needed?Does he need admitting?

Case 4

Obs: HR 105, RR 43, Sat 99%, T 37.8

OE: Alert and playingMoist mucous membranes, CRT <2sHS I + II + 0, chest clearAbdo soft but diffuse discomfortNo masses or guarding

Is he dehydrated?What should we do with him next?

Case 4

NICE fluid challenge = 50mls/kg over 4 hours

He manages to drink 22mls every 10 minutes without vomiting over the next 2 hrs

His obs remain stable throughout and he is discharged home with safety netting advice

Stool culture has been sent

Case 4: Gastroenteritis

Diarrhoea +/- vomiting is very common in childhood

Risk factors include;Poor hygiene Lack of sanitationImmunodeficiency Undercooked meat

Causes include;Rotavirus (>50%) CampylobacterSalmonella NorovirusShigella E. coli

Case 4: Gastroenteritis Investigation depends on presenting features, but may

include;Stool MC+S FBC/U+E/cultures

Management involves;Appropriate hand hygieneOral rehydration where appropriateAbx only in septicaemia, salmonella + C DiffAvoid anti-diarrhoeals Safety netting advice

Majority resolve within 5-7 days

Breastfeeding and rotarix vaccine are preventative

Summary

Infectious diseases and rashes are common in childhood

For your exams;Recognise key rashes (google/patient.co.uk)Know about causative organismsBe able to recommend treatmentBe able to advise families re: infectivityKnow about important complications

Questions

Questions: MCQs

1. The most common cause of gastroenteritis is...?

a. E. Coli b. Adenovirusc. Salmonella d. Rotavirus

2. The most common cause of opthalmia neonatorum is...?

a. Chlamydia T. b. N. gonorrhoeaec. Haemophilus inf. d. Staph. aureus

Questions: MCQs

3. Bullous impetigo is most commonly caused by...?

a. Group A strep. b. Β-haemolytic strep.c. Staph aureus d. Haemophilus inf.

4. HSP is...?b. IgA mediated b. IgG mediatedc. Common in adults d. Secondary to staph. aureus

Questions: EMQ 1

a. Erythema toxicum e. Chicken poxb. Kawasaki disease f. Glandular feverc. Measles g. Mumpsd. Rubella h. Milia

1. A 2 day old baby has erythematous macules and occasional pustules on his trunk. He is otherwise well.

2. An unimmunised 3 year old presents with a rash that started on her head, and has since spread down her body. She also has a cough and bilateral conjunctivitis. There are white ‘spots’ seen inside her mouth.

Questions: EMQ 1

a. Erythema toxicum e. Chicken poxb. Kawasaki disease f. Glandular feverc. Measles g. Mumpsd. Rubella h. Milia

3. A 7 year old presents with fever and rash. The rash was initially vesicular but has now crusted over.

4. An unimmunised 3 year old presents with a pink rash and lymphadenopathy. The rash started behind her ears and has spread to her trunk.

Questions: EMQ 1

a. Erythema toxicum e. Chicken poxb. Kawasaki disease f. Glandular feverc. Measles g. Mumpsd. Rubella h. Milia

5. A newborn has several tiny raised, pearly-white papules on either side of his nose.

6. A 15 year old boy presents with several weeks of lethargy and low fever. He has a sort throat and did have a fine macular rash that has now gone.

Questions: EMQ 2

a. Staph. Aureus e. Varicella zosterb. Epstein-Barr virus f. E. Coli 0157c. Herpes simplex g. Pox virusd. Strep. Pyogenes h. Campylobacter

1. A 15 year old presents with an itchy maculopapular rash. He has just started antibiotics for tonsillitis.

2. A 7 year old with known eczema presents with rapidly worsening eczema that is painful. On examination you see multiple vesicles.

Questions: EMQ 2

a. Staph. aureus e. Varicella zosterb. Epstein-Barr virus f. E. Coli 0157c. Herpes simplex g. Pox virusd. Strep. pyogenes h. Campylobacter

3. A 4 year old presents with firm, circular papules on his torso. They are painless and have an umbilicated centre.

4. A 4 year presents with haematuria. He has had 7 days of diarrhoea, which has contained blood for the last 3 days.

Questions: EMQ 2

a. Staph. aureus e. Varicella zosterb. Epstein-Barr virus f. E. Coli 0157c. Herpes simplex g. Pox virusd. Strep. pyogenes h. Campylobacter

5. A 2 year old comes back from nursery with 2 peri-oral vesicles. The next day they have burst and left a honey-coloured scab.

6. A 12 year presents with 24 hrs of D+V. He is concerned as he has passed fresh blood per rectum.

Questions: Images

1. A child presents with a very itchy rash.

a. What is the diagnosis?

b. What treatment should be given?

c. What advice should the family be given?

Questions: Images

2. Mum notices the following in her babies mouth.

a. What is the diagnosis?

b. What treatment should be given?

Questions: Images

3. A child presents with a rash.

a. What is the diagnosis?

b. What treatment should be given?

c. What advice should the family be given?

Questions: Images

4. A child presents with a rash. He is otherwise well.

a. What is the diagnosis?

b. Does family need to keep them off school?

Answers

Answers: MCQs

1. The most common cause of gastroenteritis is...?

a. E. Coli b. Adenovirusc. Salmonella d. Rotavirus

Rotavirus is responsible for >50% of all cases of gastroenteritis. It is self-limiting and no treatment is required.

Answers : MCQs

2. The most common cause of opthalmia neonatorum is...?

a. Chlamydia T. b. N. gonorrhoeaec. Haemophilus inf. d. Staph. Aureus

Opthalmia neonatorum is conjunctivitis in the first 28 days of life.

Chlamydia is the most common causative organism, usually presenting 5-14 days after birth.

Answers : MCQs

3. Bullous impetigo is most commonly caused by...?

a. Group A strep. b. Β-haemolytic strep.c. Staph aureus d. Haemophilus inf.

The majority of impetigo is non-bullous and is caused by beta haemolytic strep or staph aureus.

If impetigo is bullous, it is almost always due to staph aureus infection.

Answers : MCQs

4. HSP is...?a. IgA mediated b. IgG mediatedc. Common in adults d. Secondary to staph. Aureus

HSP is an IgA mediated vasculitis most common in children. The underlying cause is unknown but it may follow recent infection or vaccinations.

When it does occur in older children or adolescents the disease tends to be more severe and associated with more renal complications.

Answers: EMQ 1

1. A 2 day old baby has erythematous macules and occasional pustules on his trunk. He is otherwise well.

a. Erythema toxicum

Erythema toxicum neonatorum is a non-infective rash occurring in the first 28 days of life.

It is self limiting.

Questions: EMQs

2. An unimmunised 3 year old presents with a rash that started on her head, and has since spread down her body. She also has a cough and bilateral conjunctivitis. There are white ‘spots’ seen inside her mouth.

c. Measles

Measles is due to morbillivirus infection transmitted by airbourne respiratory droplets. It presents with a rash, most commonly starting on the head and spreading downwards, coryza, conjunctivitis and koplik spots.Measles is usually self-limiting, but may be complicated by pneumonia and encephalitis. It is a notifiable disease.

Answers: EMQ 1

3. A 7 year old presents with fever and rash. The rash was initially vesicular but has now crusted over.e. Chicken pox

Chicken pox is very common and due to varicella zoster virus. It enters via the upper respiratory tract, and presents with fever and malaise, before vesicles appear around day 3-5. They are infective prior to the rash appearing until all the vesicles have scabbed over.

Patients should be advised against itching, and given antipyretics/analgesia as required.

Answers: EMQ 1

4. An unimmunised 3 year old presents with a pink rash and lymphadenopathy. The rash started behind her ears and has spread to her trunk.

d. Rubella

Rubella is usually and mild and self-limiting illness, and presents with a rash starting behind the ears and spreading down the trunk.

The main concern regarding rubella is its effect on the growing foetus.

Answers: EMQ 1

5. A newborn has several tiny raised, pearly-white papules on either side of his nose.

h. Milia

Answers: EMQ 1

6. A 15 year old boy presents with several weeks of lethargy and low fever. He has a sort throat and did have a fine macular rash that has now gone.

f. Glandular fever

Infectious mononucleosis, or glandular fever, is a self limiting infection usually caused by Epstein Barr virus. It presents with fever and malaise over a few weeks to months, sore throat and enlarged tonsils and a transient fine macular rash.

Patients may later develop transient splenomegaly and should be advised against contact sports for the next month to avoid splenic rupture.

Answers: EMQ 2

1. A 15 year old presents with an itchy maculopapular rash. He has just started antibiotics for tonsillitis.

b. Epstein-Barr virus

This is a common presentation of infectious mononucleosis – the child is treated for presumed tonsillitis with amoxicillin, resulting in a florid maculopapular rash.

Answers: EMQ 2

2. A 7 year old with known eczema presents with rapidly worsening eczema that is painful. On examination you see multiple vesicles.

c. Herpes simplex

This describes eczema herpeticum – herpes simplex infection complicating known eczema. It is characterised by fever, painful rash and clusters of vesicles.

Answers: EMQ 2

3. A 4 year old presents with firm, circular papules on his torso. They are painless and have an umbilicated centre.

g. Pox virus

This describes molloscum contagiosum – firm painless papules appearing in crops with an punctate centre. They are caused by pox virus and are self-limiting though may take months to resolve.

Answers: EMQ 2

4. A 4 year presents with haematuria. He has had 7 days of diarrhoea, which has contained blood for the last 3 days.

f. E. Coli 0157

This describes a likely cause of haemolytic uraemic syndrome which most commonly follows e.coli 0157 infection. It tends to occur 6-8 post diarrhoea and presents with haematuria, fever and lethargy.

Blood tests show haemolytic anaemia, thrombocytopenia and renal impairment.

Answers: EMQ 2

5. A 2 year old comes back from nursery with 2 peri-oral vesicles. The next day they have burst and left a honey-coloured scab.

a. Staph. Aureus/d. Strep. Pyogenes

This describes impetigo which may be due to beta haemolytic strep, such as strep pyogenes or staph aureus.

Answers: EMQ 2

6. A 12 year presents with 24 hrs of D+V. He is concerned as he has passed fresh blood per rectum.

h. Campylobacter

Campylobacter is the most common cause of bloody diarrhoea secondary to food poisoning, and is due to eating under meat, especially chicken.

Answers: Images

1. A child presents with a very itchy rash.

What is the diagnosis?Scabies

What treatment should be given?Permethrin or malathion

What advice should the family be given?

Wash all bedding and clothes

Answers : Images

2. Mum notices the following in her babies mouth.

What is the diagnosis?Oral candidiasis

What treatment should be given?

Oral antifungal, i.e. Nystatin or daktarin

Answers : Images

3. A child presents with a rash.

What is the diagnosis?Chicken pox

What treatment should be given?Supportive (unless immunosupressed)

What advice should the family be given?

Contagious until all vesicles scab overAvoid pregnant women

Answers : Images

4. A child presents with a rash. He is otherwise well.

What is the diagnosis?Molloscum contagiosum

Do parents need to keep them off school?No, infectivity is very low

Any questions?

Thanks for listening