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.

 

References

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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