Pediatric Rash

Erythema Multiforme


“Rash” seems to be a ubiquitous complaint some days in the Ped ED.  Knowing that the skin is the largest organ, it seems only appropriate that we should take these complaints seriously. Unfortunately, often I feel a little inadequate when trying to decipher the code of the Pediatric Rash.  Below is a simple approach I use to help ensure I don’t over-diagnose viral exanthem.


Pediatric Rash Step 1: Sick or Not Sick

  • This speaks for itself.
  • Sick? 
    • Treat aggressively!
    • The skin findings may help clue you in to the source of the sickness, but don’t let pontification of the unusual rash delay your rapid administration of necessary care!
  • Not Sick?
    • Don’t be cavalier, just yet!
    • Not appearing sick is reassuring, but kids can be deceptive!
    • Remain vigilant and move to Step 2.


Pediatric Rash Step 2: Evidence of Badness?

  • Naturally, our default is always to be concerned for badness and, thus, we need to look for evidence of serious, systemic illness first.
  • Finding any of the following characteristics does not necessarily define “badness” as being present, but it should make you think more carefully of that possibility.
  • Actively look for:
    • Petechiae
      • Is this ITP?
      • Are these petechiae associated with coughing/vomiting and above the nipple line or are they below the nipple line and concerning for Meningococcemia?
    • Purpura
      • Does this fit the “illness script” of HSP?
      • Platelet disorders? TTP?
      • DIC?
      • Unfortunately, must also consider Abuse.
    • Vesicles
      • HSV
      • Chickenpox (yes, it is still around)
    • Bullae
      • Burns to Bullous Impetigo. Lots to consider.
    • Target Lesions
      • Erythema Multiforme?
      • Spectrum of Stevens Johnson Syndrome / Toxic Epidermal Necrolysis?
      • Erythema Marginatum concerning for Rheumatic Fever?
    • Urticaria
    • Desquamation
  • If none of these characteristics exist, move to Step 3.


Pediatric Rash Step 3: Look at the Mucous Membranes Again!

  • Let’s be honest, looking in a kid’s mouth can be challenging, but this step is very important!
    • For instance, ITP with Wet Purpura (mucous membrane involvement) may be a clue to greater risk of spontaneous bleeding.
    • Certainly, finding Koplick’s Spots would alter your plans.
    • Even finding herpangina or gingivostomatits may impact your plan!
  • While wiping the sweat off of your brow and allowing the parent’s muscle fatigue to resolve, move onward to step 4.


Pediatric Rash Step 4: Look for “Common Pediatric Rashes”

  • If Steps 1-4 have not lead to a diagnosis or a high level of concern, then move onward to step 5.


Pediatric Rash Step 5: Admit You Aren’t Sure

  • This is the hardest part… admitting to the family that you are not sure what the cause of the rash is can be challenging.
  • We are not admitting defeat… we are appropriately avoiding the addition of an incorrect “label” (diagnosis) to the patient.
    • Announce your reassurance in the lack of the concerning characteristics…
    • Acknowledge that rashes often evolve over time…
      • In the next several hours to days, your ability to make a more accurate diagnosis may change.
      • Give good anticipatory guidance on what specific things they need to monitor for and encourage repeat evaluation in the next 12-24 hours.



Dinulos JG1. What’s new with common, uncommon and rare rashes in childhood. Curr Opin Pediatr. 2015 Apr;27(2):261-6. PMID: 25689452. [PubMed] [Read by QxMD]

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Sean M. Fox
I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.
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  2. would you mind me using this useful stepwise approach in an info graphic for our clinical area?

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  4. […] pediatric rashes can be a challenge (and we have discussed my “Approach to the Pediatric Rash” previously).  One “rash,” however, deserves particular attention as it is not a […]

  5. […] unusual dermatologic eruptions are also quite prevalently encountered when caring for children (see Approach to Rash).  While individually each category is fun to think about, the excitement more than doubles when […]

  6. […] of us (ok, maybe it is just me).  We have previously covered an approach to the evaluation of the Pediatric Rash.  We have also covered a variety of common causes of pediatric rashes (ex, Scabies, Tinea, Diaper […]

  7. […] everyone is not the answer, remaining vigilant can help you find subtle, ominous clues (ex, Derm Exam). That odd rash in the setting of fatigue may lead you to diagnose an Aplastic […]

  8. […] ailments, but the we cannot avoid them, so it is best to address them directly. We have discussed a general approach to pediatric rashes and have covered some specific ones as well (ex, Atopic Dermatitis, Molluscum, Scalded Skin, […]

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