Common Childhood Rashes in General Practice

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Common Childhood Rashes in General Practice

• Aimee Lettis

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Why look at rashes?

• 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

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Approach to rashes

• History
• History
• History
• Then examine!
• Investigations rarely needed/ appropriate

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Erythema toxicum

• Features
• Red blotches with central white vesicle
• Each spot lasts about 24 hours, moves from place
  to place
• Spots are sterile and baby is well
• Management
• Reassurance
• Only do swab if suspect sepsis

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Milia

• Features
• Tiny pearly-white papules on nose /- palate
• Blocked sebaceous ducts
• Management
• Reassure, spots disappear spontaneously in few
  weeks

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Benign Neonatal Pustular melanosis

• Features
• Blotchy macular erythema, with tiny yellow-white
  papules/pustules
• Pustules rupture easily leaving pigmented macules
• Mainly in pigmented skin
• Appear at birth/1st day of life
• Completely innocent, no treatment needed
• May persist for 2-3 months

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Mongolian blue spot

• Features
• Bluish discolouration of skin, usually over
  buttocks/lower backs
• Usually affects dark-skinned babies
• Usually disappear by 1 year, harmless

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Umbilical granuloma

• Features
• 3-10mm size
• Round wet pedunculated lesions
• Inflammation of granulation tissue not yet
  epithelialized
• Differential diagnosis
• Patent urachus, polyp
• Treatment
• Observation usually sufficient best
• Silver nitrate
• Beware of burning surrounding skin
• Tie off

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Napkin dermatitis

• Features
• Usually die to irritant contact dermatitis which
  spares groins
• Treat with barrier cream, frequent nappy changes

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Napkin rash Other causes

• Satellite lesions and skin-fold involvement may
  indicate candida
• Look for mouth lesions as well
• Treat with anti-fungal cream
• Seborrhoeic dermatitis
• Also involves skin creases
• Look for cradle cap, rash elsewhere
• Treat body with emollients/hydrocortisone
• Treat scalp with olive/baby oil or 2 salicyclic
  acid in aqueous cream, washed out with baby
  shampoo
• Other rarer causes eg. Acrodermatitis
  enteropathica

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Staphylococcal scalded skin syndrome

• Features
• Sick baby, acute onset
• Shedding of sheets of skin, underlying red/wet
  areas
• Management
• Emergency admission
• Requires iv antibiotics/fluid rehydration

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Atopic eczema

• Affects 15-20 school children
• Usually starts lt6/12 (75)
• Considerable impact on QOL
• May be associated with food allergy in young
  children
• Remission occurs by 10 years in 2/3 by 15 years
  in 75
• Some have worsening symptoms in teenage/relapse
  later in life

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Atopic eczema

• Presentation
• Infants
• Itchy exudative rash on face /- hands, sleep
  disturbance usual
• More then ½ affected are symptom-free by 18/12
• Children gt18/12
• Rash involves antecubital popliteal fossae,
  neck, wrists ankles
• Lichenification, excoriation dry skin common
• May have typical infraorbital folds (Morgans
  folds)
• May be associated sleep disturbance/behavioural
  problems

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Atopic eczema

• Diagnosis
• Itchy skin PLUS at least 3 of
• Itching around skin creases or neck
• Visible flexural eczema (or cheeks/forehead
  outer limbs lt18/12)
• History of asthma/hayfever (or in first degree
  relative if lt18/12)
• Generally dry skin
• Onset in 1st 2 years of life

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Potential triggers

• Irritants
• Soaps detergents
• Skin infections
• Stress/humidity/extremes of temperature
• Avoid if possible, cotton clothing best
• House dust mites/pets
• Avoidance may be helpful but difficult
• Food allergy/intolerance
• Egg/milk/soy etc.
• Moderate-severe eczema, resistant to treatment
• Few with eczema benefit from dietary change

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Management

• Conservative measures
• Clothing, wear gloves in bed, short nails
• Avoid triggers
• Dietary measures
• Few improve with dietary manipulation, could try
  if moderate-severe eczema not controlled with
  emollients/steroid cream
• NICE recommends 6-8/52 trial hydrolysed formula
  if lt6/12 bottle-fed
• Dietician advice needed

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Management

• Emollients, eg aqueous cream
• 3-4 x daily at least
• Use as soap substitute emollient
• Bath oil, eg oilatum
• Topical steroid cream
• Start with mild strength and increase only if
  necessary, short-term use only
• Ointments if dry skin, cream if wet
• Antibiotics for secondary infection
• Topical/systemic (severe)
• Wet wraps bandaging
• Sedative antihistamines help sleep

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Complications

• Secondary bacterial infection
• Usually Staph aureus
• Suspect if crusting/weeping/worsening
• Increased incidence molluscum/ warts
• Eczema herpeticum
• Usually need admission for IV aciclovir as can be
  sick
• Growth restriction (severe eczema)

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When to refer?

• Eczema herpeticum (E)
• Severe eczema resistant to treatment (U)
• Infection not cleared in primary care(U)
• Severe social /- psychological problems (S)
• Diagnosis uncertain (R)
• Help with bandaging (R)
• For patch testing (R)
• Growth restriction (R)
• Dietary factors suspected (R)
• EEmergency, UUrgent, SSoon, RRoutine

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Another case of eczema?
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Scabies!!!

• Cause
• Sarcoptes scabei mite
• Features
• Spread by direct physical contact
• Average infection- 12 mites
• Symptoms appear 4-6 weeks after infection
• Intense itching
• Burrows/eczematous rash on examination
• Sides of fingers/hands/wrists/genitalia
• May be widespread especially in infants
• Management
• Malathion lotion 2 applications 1/52 apart
• ALL family members need treatment
• Boil all beeding/towels at same time
• Itching may persist for some time after treatment

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Impetigo

• Cause
• Usually due to Staph aureus
• Features
• Blister bursts to leave golden crusted lesion
• Can occur anywhere, most commonly face
• Very contagious!
• No sharing of towels/flannels etc.
• Management
• Topical/oral Flucloxacillin/erythromycin

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Molluscum contagiosum

• Cause
• DNA pox virus
• Features
• Discrete pearly pink umbilicated papules 1-3mm
  diameter
• If squeezed release cheesy substance
• Usually grouped
• Spread by contact eg. Towels
• Management
• Untreated, resolve over months
• Leave alone or will scar!

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Viral exanthem

• Viral exanthem a skin rash accompanying any
  eruptive disease/fever
• Non-specific rash, child may also have
• Fever
• Runny nose
• Cough
• DV etc.
• Differential diagnosis
• Non-specific or specific viral infection
• Early meningococcal disease
• Scarlet fever
• Kawasaki disease
• Erythema multiforme
• Allergy
• Drug eruption

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Roseola

• Cause
• HHV6/7
• Features
• Affects those aged 6-36 months
• 3-5 days high fever with no obvious source
• Sub-occipital nodes
• Rose-pink macular rash appears once fever settles
• Starts on trunk, may spread to face extremities
• Lasts up to 2 days
• Management
• Treat symptomatically, reassure

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Scarlet fever

• Notifiable disease!
• Cause
• Group A beta-haemolytic Streptococcus
• Features
• Incubation 2-4 days
• Bright red blanching rash (sandpaper)
• First in axilae/groins, then widespread
• Red face with circumoral pallor
• Strawberry tongue (white then red)
• Treatment
• Symptomatic relief
• Penicillin V 7-10 days

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Chickenpox

• Causes
• Varicella zoster virus
• Features
• Very common
• Incubation period 14-21 days
• Prodrome mild fever malaise
• Vesicles on erythematous base
• Change to macule?papule?vesicle?crust
• Last 3-4 days
• Mainly on trunk
• Can appear in mouth/genital region
• Usually no scarring
• Infectious for 1-2 days before rash 5 days
  afterwards

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Chickenpox

• Complications
• Always look carefully at child if fever persists
  gt 5 days after appearance rash
• ?secondary bacterial infection
• Pneumonitis
• Encephalitis
• Cerebellar ataxia
• Eczema herpeticum
• Risk to neonates pregnant women 1st trimester
  especially
• Management
• Supportive fluids/paracetamol/calamine lotion
• Admit if complications suspected

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Shingles

• Reactivation of VZV
• Features
• Dermatomal pattern of rash, usually unilateral
• Typically painful, pain may occur first
• Can catch chickenpox from affected individual but
  not shingles!
• Infectious until all lesions scabbed
• Management
• Treat with aciclovir if see in 1st 72 hours
• Refer urgently if eye affected

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Measles

• Features
• Incubation period 8-14 days
• Prodromal illness 3-4 days
• Fever, conjunctivitis, runny nose cough
• Infectious 1-2 days before prodrome
• Later symptoms
• Koplik spots, rash-reddish-purple macules which
  coalesce, spreads downwards
• Management
• Supportive
• Symptoms usually last 10 days

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Measles

• Complications
• Otitis media
• Bronchopneumonia
• Encephalitis (1/1000)
• Myocarditis/pericarditis
• SSPE (rare)
• 30 mortality in developing countries

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Rubella (German measles)

• Features
• Incubation period 14-21 days
• Infectious 5-7 days before rash
• No prodrome
• Rash fine pink maculopapular rash on face then
  trunk limbs
• Fever lymphadenopathy
• May have petechiae on hard palate associated
  arthralgia/arthritis
• Lasts 10 days
• Management
• Supportive

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Rubella (German measles)

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

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Hand, foot mouth disease

• Cause
• Coxsackie viral infection
• Features
• Low grade fever, headache, vesicles on hands
  feet (last 3-10 days)
• Can be widespread
• Mouth lesions-yellow ulcers with red borders
• Can be complicated by aseptic meningitis
• Management
• Supportive

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Parvovirus B9

• Otherwise known as slapped cheek disease or 5th
  disease
• Features
• Incubation period 4-14 days
• Fever in 15-30 for 1-2 days
• Slapped cheek appearance
• Generalised maculopapular rash for 7-10 days
  lace-like
• Management
• Supportive

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Pityriasis rosea

• Cause
• Unknown ?viral
• Features
• Acute self-limiting disorder
• Mainly affects teenagers young adults
• Generalised eruption preceded by herald patch
  2-5cm size
• Smaller lesions have collarette of scale, mainly
  on trunk but can affect upper arms/thighs as well
• Management
• Nil required (unless itchy)
• Fades spontaneously in 4-8 weeks

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Pityriasis vesicolor

• Cause
• Fungal (Pityrosporum orbiculare)
• Features
• Often asymptomatic, may be chronic
• Common in humid/tropical conditions
• Often affects teenagers/young adults
• On untanned white skin, appears pinkish-brown,
  oval/round patches with fine scale
• In tanned/dark skin, hypopigmentation occurs
• Involves trunk/proximal limbs
• Management
• Topical imidazole antifungal
• Selenium sulphide shampoo
• Apply at night wash off in morning x 2 at
  weekly intervals
• Resistant cases systemic imidazole
• Recurrences common

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Purpuric rash

• Most important cause meningococcal disease
• Differential diagnosis
• Henoch-Schlonlein purpura
• Other infections
• Strep/EBV
• Thrombocytopenia

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HSP

• Features
• Well child
• Purpuric rash on legs buttocks, can be bullous
• May be associated arthritis, nephritis gut
  involvement
• FBC/clotting normal
• Should test urine for blood/protein for 3/12

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Tinea corporis

• Otherwise known as ringworm
• Features
• Usually occurs on trunk/limbs
• Single/multiple plaques with scaling erythema,
  especially at edges
• Enlarge slowly clear centrally
• Management
• Imidazole cream/spray/powder
• Terbinafine cream

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The End!

• Any Questions?