Introduction
Rashes in children are common and can be difficult to diagnose based on appearance alone. Assessing the full clinical picture will help you form an appropriate management plan.
The Royal College of Emergency Medicine (RCEM) splits childhood rashes into 3 main categories1:
- Potentially worrying (i.e. potential emergencies)
- Named rashes (rashes that can easily be identified by the trained eye)
- ‘Everything else’
*Sometimes you may hear the word “exanthems” in relation to paediatric rashes. This typically refers to non-specific widespread viral rash. Older sources may refer to the six viral exanthems as “First disease”, “Second disease” etc.
Potentially Worrying Rashes
Meningococcal Septicaemia
An infection in the bloodstream caused by Neisseria meningitidis. This is a medical emergency.
*this is not to be confused with Meningitis (the inflammation of the meninges) which can be caused by meningococcal septicaemia
Key Features2
- Feverish child that appears generally unwell
- Cold hands/feet
- Leg pain
- Confusion
- General signs of shock
- Non-blanching purpuric rash
Management
General management will include keeping the patient stable and giving IV antibiotics ASAP (typically Ceftriaxone).
Staphylococcal Scalded Skin Syndrome (SSSS)
A skin condition caused by Staphylococcus aureus. Heat and fluid loss occurs due to damaged skin. Be cautious in treatment (e.g. cannulation) as the skin can be very fragile (like tissue-paper).
Key Features3,4
- Preceding mild infection (e.g. nappy rash, red sticky eye, impetigo, cellulitis).
- Initially miserable, lethargic, feverish child.
- Tissue paper-like skin with wrinkling followed by bullae (fluid-filled blisters) in the groin, armpits, and orifices (e.g. nose, ears).
- Painful, blistering, tender, widespread red rash that resembles a burn or scald.
Management
This is usually managed in secondary care. IV fluids are needed to counteract excess losses through the skin. Systemic antibiotics may be given to eradicate Staphylococcus and prevent complications caused by the loss of the protective skin barrier (e.g. sepsis).
Eczema Herpeticum
A recognized complication of atopic eczema, caused by Herpes simplex virus 1 (HSV 1) infection. This is a dermatological emergency.
Key Features5,6
- Fever
- Lymphadenopathy
- Child feels unwell
- Localised areas of itchy, painful blisters (most often face & neck). They may be:
- Yellow or white pus-filled (purulent).
- Oozing, weeping, or bleeding.
- Crusted over.
Management
Children should be admitted and treated with an antiviral (typically acyclovir). Secondary bacterial skin infection may also occur, in which case systemic antibiotics will be added to the treatment plan.
IgA Vasculitis (Henoch-Schonlein Purpura – HSP)
An immune-mediated systemic vasculitis that can affect the skin, joints, and kidneys. This is usually self-limiting.
Key Features7
- Classical triad: palpable purpura, abdominal pain, arthritis.
- Initially an urticarial (raised, itchy rash like one in an allergic reaction), but quickly becomes maculopapular and purpuric.
- Rash typically covers buttocks & extensor surfaces of arms and legs.
- Associated haematuria (microscopic or macroscopic).
- Usually preceded by an URTI.
Fig. 1 Vasculitic rash of Henoch-Schönlein Purpura
Fig 2. Vasculitic rash on leg
Management
In these patients it’s important to monitor blood pressure and check urinalysis regularly to monitor kidney function (typically done by a GP).
Children with IgA Vasculitis should be admitted to hospital if they have:
- blood in the stool, urine, or vomit
- worsening abdominal pain (intussusception is a complication)
- increasing proteinuria
- headaches, vision changes, or behavioural changes
- heavy breathing
Named Rashes
Chickenpox
Highly contagious, self-limiting disease caused by primary infection by Varicella-Zoster Virus (VZV). Children must not attend nursery/school until all vesicles have crusted over.8
Key Features7
- Incubation period between exposure and first skin lesion is 10-14 days.
- A temperature of 38-39°C for the first 4 days of illness.
- General fatigue and malaise.
- Highly pruritic lesions.
- Lesions pass through the phases of (1) papules (2) vesicles (3) pustules (4) crust
Fig. 3 Chickenpox rash on back
Fig. 4 Chickenpox rash on face
Management
Management is typically supportive (fluids, analgesia, bed rest). Calamine lotion can be purchased over the counter to help with itching. Systemic antihistamines can also help.
Broken lesions can become infected from scratching, causing secondary bacterial infection. Advise parents to check for pain and changes in the rash. Fever should settle after the first few days – if it doesn’t this could be a sign of secondary bacterial infection.
Be aware that chickenpox has a low threshold for admission in the immunocompromised and neonates.
Measles
Self-limiting childhood infection caused by Morbillivirus. The MMR (Measles, Mumps, and Rubella) vaccine has made the disease less common, however, decreasing uptake of vaccination has made measles a growing concern.
Key Features7
- Prodrome of 2-4 days with fever and coryzal symptoms.
- Koplik spots (small, red spots with blue-white specks) on the buccal mucosa.
- Maculopapular rash that starts from behind the ears; spreads down to the rest of the body.
- Children should stay home from school for four days from the onset of rash.8
Fig. 5 Measles rash
Fig 6. Classic measles rash to face and behind the ears
Fig 7. Classic measles rash to the chest and abdomen
Management
If measles is diagnosed, Public Health England should be notified to via a local Health Protection Team. The disease itself is self-limiting; patients should be advised to rest, drink adequate fluids, and take paracetamol or ibuprofen for symptom relief.
Exotoxin-mediated disease from Group A beta-haemolytic streptococci (GABHS)
Key Features1
- Incubation period of 2-5 days. Sandpaper rash may follow after 12-48 hours.
- Rash typically appears on neck and chest first, trunks and legs later.
- Beings with sore throat, headache, fever, malaise.
- There may be some abdominal pain and cervical lymphadenopathy.
- There may be strawberry tongue and circumoral pallor (white area around the mouth).
Management
This is another diagnosis that must be notified to Public Health England. Most children will not need admission to secondary care unless they are considered high risk (e.g. neonates, immunocompromised, have a concurrent infection). First-line treatment is Phenoxymethylpenicillin (penicillin V) four times a day for 10 days. Amoxicillin is sometimes prescribed as an alternative because it is better tolerated and given three, not four, times a day.
Molluscum Contagiosum
A common skin condition caused by the molluscum contagiosum pox virus (MCV). It is highly contagious and self-limiting. Most commonly spread by direct skin contact.
Key Features9
- Incubation period of 2-8 weeks.
- Firm, smooth papules with a small depression in the center (umbilicated).
- May be white, pink, or brown
- Papules are generally seen in moist areas like the armpit, groin, or genital areas.
Fig. 7 Molluscus contagious nodule
Fig. 8 Molloscum contagiosum rash
Management
This is self-limiting (unless the patient is immunocompromised), requires no treatment and usually resolves by itself within 18 months. Patients should be advised to avoid squeezing lesions to limit the spread of the infection. Emollient and mild topical corticosteroid can be prescribed to help itching.
Hand, Foot, and Mouth Disease
As the name suggests, this causes lesions on the hands, feet, and mouth (sometimes seen on the buttocks and genitalia). The most common cause is the Coxsackievirus A16. Children infected are usually under 5 years of age10
Key Features
- Prodromal period for 12-36 hours; low-grade fever, malaise, and loss of appetite.
- Lesions appear 1-2 days after prodrome.
- Hands & Feet: progression from flat pink patches to small, elongated grey blisters
- Mouth: small vesicles and ulcers in and around the mouth, palate, and pharynx.
- Red papules and macules on the buttocks and genitalia may be present.
Fig. 9 Flat pink patches of Hand, Foot and Mouth disease on the foot
Fig. 10 Blisters of Hand, Foot and Mouth disease
Management
Hospital admission is required only if fever is severe, or there is marked central nervous system involvement (e.g. persistent headache, confusion, weakness, lethargy etc.). In typical cases, self-care measures including good fluid intake, soft food diet (if oral lesions are painful), and ibuprofen or paracetamol are adequate.
Erythema Infectiosum (Slapped Cheek)
Caused by human parvovirus B19 (HPV-B19). Infection can be asymptomatic or cause non-specific coryzal symptoms 7.
Key Features
- Initially low-grade fever, malaise, sore throat, rhinitis and headache. Some patients may also present with symmetrical arthralgia.
- Rash appears after 7-10 days. Textbooks will describe this as a “slapped cheek” appearance – erythema on the cheeks.
- Red macular lesions may appear on the extremities and extensor surfaces.
Fig. 11 Erythema infectiosum in a baby
Fig. 12 Erythema infectious in a child
Management
This is usually mild and self-limiting. Symptom relief is to be used as appropriate. School or nursery should be informed as pregnantwomen, immunocompromised individuals, and those with hematological disorders may develop serious complications.
Atopic Dermatitis (Eczema)
Alterations in the skin barrier provide entrance for allergens, microbes, and other irritants causing an immune response. Genetic predisposition and environmental factors also play a role in the development of eczema. This leads to chronic, itchy skin.
Key Features 11.12
- Main symptom is excessively itchy skin.
- Especially in skin creases (e.g. elbows, knees).
- Generalized dry skin.
- Atopy (asthma or hay-fever; family history of atopy from a 1st degree relative).
Fig 13. Atopic dermatitis in a baby
Fig 14. Atopic dermatitis with excoriation marks
Management
Treatment depends on the severity of disease:
- Mild (areas of dry skin with infrequent itching) – generous amounts of emollients, used frequently and generously.
- Moderate (areas of dry skin, with frequent itching and significant redness) – consider a topical corticosteroid in addition to control flareups, with the addition of a non-sedating antihistamine to control itching.
- Severe (widespread areas of dry skin, constant itching, and redness) – may also need routine dermatology if treatment in primary care shows little effectiveness after 3 month review.
Eczematous lesions may also become infected. These may or may not be treated with antibiotics depending on risk/benefit analysis of antibiotic treatment versus the risk of antimicrobial resistance.
Everything Else
Sometimes you may hear the word “exanthems” in relation to paediatric rashes. This typically refers to non-specific widespread viral rash. Older sources may refer to the six viral exanthems as “First disease”, “Second disease” etc.
This is the most common viral exanthem often appear as blotchy red/purplish spots. It is a hypersensitivity reaction triggered by infection, commonly HSV, or an adverse drug reaction. This is usually self-limiting.13
Key Features
- ‘Target’ lesions (round shaped with sharp margins) – The center of the lesions will be darker with blistering or crusting.
- Usually on the dorsum of the hands and feet. There may also be oral lesions.
- Mild itching or burning sensation.
Fig. 15 Target lesions of erythema multiforme
Management
Treatment is typically symptomatic but be sure to rule out serious infection (e.g. non-blanching rash in a floppy, inconsolable baby should be referred to a secondary care ASAP).
If a drug reaction is the suspected culprit, discontinue the drug immediately. First time viral infection may only require symptomatictreatment (analgesia, mouthwash, emollients), however recurrent viral infection may require antiviral treatment.
Urticaria (Hives)
Activation of mast cells in the skin result in the release of histamine and other mediators, which cause capillary leakage and swelling of the skin. Acute cases are typically caused by allergens and infections. Chronic causes are thought to be idiopathic or autoimmune.14
Key Features
- Typically “weals” – white or red lesions which can be rings, large patches, or appear in a map-like pattern.
- Lesions are pruritic and transient (come and go within minutes to hours).
- Localised angioedema, typically of the face (eyelids, and perioral regions), hands and feet.
Fig. 16 Urticaria on a child’s abdomen
Fig. 17 Urticaria on a child’s back
Management
In the first instance, be sure to rule out anaphylaxis (serious allergic reaction) which needs to be treated as a medical emergency.
Identify and treat the underlying cause if possible. Advise the patient to avoid triggers and limit potential aggravating factors (e.g. alcohol, caffeine, stress, and medications like NSAIDs and ACE inhibitors that are likely to cause urticaria). A non-sedating antihistamine should be offered for up to 6 weeks. For severe symptoms, oral corticosteroids can be prescribed.
The take home message is that seeing rashes in person is the best way to learn what they look like! It’s also important to be aware of how each rash can manifest itself on varying skin tones.
Within medical education there is a drive to improve representation of skin conditions in all skin tones. Historically, many medical textbooks and resources have focussed on lighter skin tones which can exacerbate inequality and lead to mis/delayed diagnosis in darker skin tones. The team at ‘Don’t Forget The Bubbles’ have set up a ‘Skin Deep’ initiative to improve free open access to dermatological conditions across a range of skin tones. This can be found here.
References
- Common Childhood Exanthems – RCEMLearning [Internet]. RCEMLearning. (2020). https://www.rcemlearning.co.uk/reference/common-childhood-exanthems/
- Guidance | Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management [Internet]. National Institute for Health and Care Excellence. (2015). https://www.nice.org.uk/guidance/cg102/chapter/1-guidance#bacterial-meningitis-and-meningococcal-septicaemia-in-children-and-young-people-symptoms-signs
- Staphylococcal Scaled Skin Syndrome [Internet]. British Association of Dermatology. (2019). https://www.bad.org.uk/patient-information-leaflets/staphylococcal-scalded-skin-syndrome/
- Oakley A, Gomez J. Staphylococcal scalded skin syndrome. DermNet NZ. (2016). https://dermnetnz.org/topics/staphylococcal-scalded-skin-syndrome
- Lin C. Eczema herpeticum. DermNet NZ. (2010). https://dermnetnz.org/topics/eczema-herpeticum
- Starr O, Cox J. Eczema Herpeticum. Info. (2018). https://patient.info/skin-conditions/atopic-eczema/eczema-herpeticum
- Lissauer T, Carroll W, editors. Illustrated textbook of paediatrics E-book. 6th ed. Elsevier; 2021.
- Guidance on infection control in schools and other childcare settings [Internet]. Public Health Agency. (2017). https://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf
- Oakley, A. Molluscum contagiosum. DermNet (2015). https://dermnetnz.org/topics/molluscum-contagiosum
- Oakley, A. Hand foot and mouth disease. DermNet (2016). https://dermnetnz.org/topics/hand-foot-and-mouth-disease
- Stanway A. Atopic dermatitis. DermNet NZ. (2004). https://dermnetnz.org/topics/atopic-dermatitis
- Tidy C. Atopic Dermatitis and Eczema. Info. (2021). https://patient.info/doctor/atopic-dermatitis-and-eczema
- Oakley, A. Erythema multiforme. DermNet (2015). https://dermnetnz.org/topics/erythema-multiforme
- Harding, M. Urticaria. Info. (2016). https://patient.info/doctor/urticaria-pro
