Selected Pediatric Rashes

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Selected Pediatric Rashes

• Narasinga Rao D.O., FACOEP
• Department of Emergency Medicine
• St.Barnabas Hospital
• Bronx, N.Y.

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Definitions

• exanthem
• widespread, symmetric, erythematous, discrete
• or confluent maculopapules that initially do
  not form scales
• numbered 1 - 6 in order of appearance
• enanthem
• oral lesions that accompany exanthems

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Definitions

• Macule- a flat area of color change

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Macule
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Definitions

• Papule- a solid lesion
• - lt 1 cm in size
• -raised above skin surface

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Papules
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Definitions

• Nodule- solid mass
• - raised
• - gt 1 cm

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Definitions

• Vesicle - a small lesion containing clear
  fluid
• - raised
• - lt 5mm

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Vesicle
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Definitions

• Bulla - a large lesion containing clear fluid
• -raised
• - gt 1 cm

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Bullae
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Definitions

• Pustule - a lesion containing purulent fluid
• -raised

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Pustule
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Definitions

• Plaque a solid lesion
• -raised
• -horizontal gt vertical

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Plaque
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Definitions

• Crust a layer of dried up inspissated secretions

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Definitions

• Scale - a sheet of adherent epidermal cells

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Definitions

• Ulcer - a break in the continuity of the skin

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Case 1
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Case 1

• Mom states the child had a fever , cough , and
  runny nose for 3 to 4 days before the rash
  developed

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Case 1

• The rash started on the face and spread to the
  trunk

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Case 1

• Mom also states that she saw white spots on the
  inside of his cheeks 2 days before the rash
  started

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Kopliks Spots
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Measles (rubeola)

• first disease
• transmitted via respiratory droplets
• highly contagious
• usually benign
• encephalitis occurs in 1 in 2000
• survivors have permanent brain damage and mental
  retardation
• death occurs in 1 in 3000
• higher risk in infants and adults

25
Measles

• measles during pregnancy may affect fetus
• premature labor
• spontaneous abortion
• low birth weight infants
• congenital malformation
• lifelong immunity if given live measles virus
  vaccine at age 15 months

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Measles

• susceptible persons include
• those vaccinated between 1963-1967 with
  inactivated vaccine
• -may develop atypical measles
• -require live virus vaccine
• those who received live virus vaccine before age
  1 year
• those who never received measles vaccine

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Typical Measles

• caused by myxovirus
• usually a winter-spring disease
• incubation period is 10 days (range 7-14 days)
• prodromal period lasts 3-4 days
• brassy cough, coryza, conjunctivitis,
  photophobia, fever get progressively worse
• Kopliks spots----blue-white spots with a red
  halo appear opposite lower molars on buccal
  mucosa
• -appear 24-48 hours before exanthem and remain
  2-4 days
• -pathognomonic enanthem for measles

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Kopliks spots
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Typical Measles

• eruptive phase
• rash begins on day 4 after prodrome and lasts 7
  days
• rash starts as erythematous maculopapules on face
  and behind ears and spreads to trunk and
  extremities
• rash becomes confluent on face and blanches on
  pressure
• rash turns yellow-brown as it fades
• treatment is supportive care
• measles is contagious from prodromal period to 4
  days after rash appears

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Measles
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Measles

• Vaccination
• in developed countries ,all children should be
  immunized with live virus vaccine at age 15
  months
• in areas of recurrent measles transmission
  (counties with 5 cases in preschool children in 5
  consecutive years) vaccination at age 9 months
  and at age 15 months is recommended

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Measles

• Epidemics
• failure to immunize occurs
• vaccine is given with measles immune globulin
• live vaccine exposed to light gt 5 minutes loses
  potency
• vaccine given to infants under 15 months of age
• management
• vaccine gives protection if given within 72 hours
  of exposure
• -infants age 6-12 months --- give single antigen
  measles vaccine

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Measles

• Vaccination
• gt 12 months receive MMR
• revaccinate at age 15 months
• measles immune globulin
• use within 6 days of exposure in high risk
  persons (infants lt 1 year old who are household
  contacts)
• dose is 0.25cc/kg ,maximum of 15cc
• follow with measles vaccine in 3 months

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Atypical Measles

• occurs in recipients of killed vaccine (1963-67)
  when exposed to natural measles
• occurs in young adults
• prodrome followed by rash on wrists, ankles and
  spreads to palms, soles, extremities, trunk in
  2-5 days
• face is spared
• may become vesicular, purpuric, and hemorrhagic

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Atypical Measles

• pulmonary effusions may occur
• self- limited and clears in 2 weeks
• mild desquamation of palms and soles may follow

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Case 2
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Case 2

• Mom states the child has a fever , sore throat,
  vomiting for 1 to 2 days followed by this rash
  which started on the face and neck

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Case 2

• Mom states the tongue looks like a ______.

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Case 2

• Eventually desquamation occurs

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Scarlet Fever

• second disease
• group A, beta -hemolytic streptococci and group C
  strep.
• erythrogenic toxin causes rash and systemic
  symptoms
• infection of pharynx or skin
• incubation period is 2-4 days
• prodromal phase
• sudden onset of fever ,pharyngitis followed by
  N/V
• abdominal pain, headache
• strawberry tongue

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Scarlet Fever

• diffuse lymphadenopathy
• eruptive phase
• rash begins 1-2 days after onset of prodrome
• begins on neck and face and spreads to trunk and
  extremities within 48 hours
• palms, soles are spared
• circumoral pallor
• scarlet pinpoint papules (sandpaper rash)
• linear petechial eruptions occur in antecubital
  and axillary folds ( Pastias lines)

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Pastias lines
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Scarlet fever
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Scarlet Fever

• fever, rash subside after 1 week
• desquamation occurs
• transverse groove in nails (Beaus lines)
• Diagnosis is clinical
• Treatment
• reduces incidence of rheumatic fever and
  nephritis
• benzathine PCN G IM or oral PCN V
• -clindamycin or macrolides are effective as well

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Scarlet fever
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Rubella (German Measles)

• third disease
• 3 day measles
• benign viral disease spread by respiratory route
• children and young adults
• most common in spring
• pregnant women may transmit to fetus in first
  trimester
• congenital defects

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Rubella

• incubation period is 18 days (range 14-21 days)
• prodromal phase
• fever, malaise, headache, sore throat may precede
  eruption by a few hours or 1 day
• postauricular and suboccipital lymphadenopathy
  appear 4- 7 days before rash
• 2 of cases have petechiae on soft palate
  (Forschheimers spots) in late prodromal or early
  eruptive phase

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Rubella

• eruptive phase
• begins on neck/face and spreads within hours to
  trunk and extremities
• pink maculopapules, may coalesce on face
• rash fades in 24-48 hours in same order as it
  appeared
• fine desquamation may occur
• No treatment is required

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Rubella
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Case 3
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Case 3

• Mom states the child has fever, sore throat and
  is not eating . After 1 day mom noted little
  bumps in his mouth and hands

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Enteroviruses

• fourth disease (Dukes disease)
• coxsackieviruses and echoviruses are most common
• single stranded RNA viruses
• most prevalent in summer and early fall
• transmission by fecal-oral route and respiratory
  route
• systemic symptoms
• fever, N/V, diarrhea, sore throat, photophobia,
  lymphadenopathy

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Enteroviruses

• rash can be maculopapules, urticarial, vesicular,
  or petechial
• palms and soles may be involved
• rash fades without pigmentation or scaling
• more common in children than adults
• Hand, Foot, and Mouth disease
• acute illness affecting children
• initially--- fever, anorexia, malaise, and sore
  mouth
• painful 4-8 mm vesicles on erythematous base
  develop in 1-2 days on buccal mucosa, soft
  palate, tongue, gingiva-------ulcerate

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Enteroviruses

• Hand, foot and mouth disease
• exanthem starts as red papules which change to
  3-7 mm gray vesicles
• found on palms, soles, dorsum of hands and feet
• heal in 7 - 10 days
• Herpangina
• acute fever 40 C, headache, sore throat,
  dysphagia, anorexia, and occasionally stiff neck
• 2mm yellow-white vesicles with hyperemic border
  on pharynx----- ulcerate
• resolve in 5-10 days

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Coxsackievirus
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Coxsackievirus
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Coxsackievirus
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Enteroviruses

• clinical differentiation of enteroviral disease
  is difficult
• treatment is symptomatic
• adequate hydration
• antipyretics
• viscous lidocaine gel for painful oral lesions
• Magic Mouthwash
• Equal parts of 1 viscous lidocaine,
  diphenhydramine and Maalox ( no more than 2cc/kg
  of the mixed solution)
• Paint the solution on the lesions

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Case 4
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Case 4

• Mom states the child developed a rash on his face
  and it spread to the body over the next 2 days

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Erythema Infectiosum

• fifth disease
• caused by human parvovirus B19
• single stranded DNA virus
• cause spontaneous abortion in first trimester
• -fetal anemia
• virus infects and lyses erythroid precursor cells
• -causes transient aplastic crisis in people with
  hemolytic anemias or anemia secondary to blood
  loss
• mildly contagious, common in spring
• usually affects children 5-15 years old
• incubation period is 13-18 days

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Erythema Infectiosum

• prodromal symptoms
• usually absent
• -pruritis, low grade fever, malaise, and sore
  throat are present in 10
• lymphadenopathy is absent
• eruptive phase
• diffuse erythema on cheeks b/l sparing nasolabial
  fold and circumoral area------- slapped cheek
  appearance
• fades in 4 days
• nonpruritic macular erythema develops in 1-2 days
  after facial rash , on trunks and limbs

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Erythema Infectiosum
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Erythema Infectiosum

• rash fades over 6 - 14 days with central
  clearing--------- reticular appearance
• palms and soles are rarely affected
• recurrent phase
• eruption may recur in next 2-3 weeks after it has
  faded
• temperature change, emotional upset, sunlight may
  stimulate recurrences
• fever, malaise, N/V, diarrhea, myalgia, arthritis
  may occur
• rash fades without scaling or pigmentation
• treatment is symptomatic, recovery is complete

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Case 5
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Case 5

• Mom states the child had a high fever of 104
  which subsequently went down , but then he
  developed this rash

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Roseola Infantum (Exanthem Subitum)

• sixth disease
• caused by herpesvirus 6
• no seasonal preponderance
• most common in ages 6 months - 4 years
• incubation period is 12 days ( range 5- 15 days)
• Prodromal phase
• sudden onset of fever 103-106 F
• few or minor symptoms
• -cough, coryza, anorexia, vomiting
• occipital lymphadenopathy may be present

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Roseola Infantum

• leukocytosis with onset of fever
• leukopenia with lymphocytosis as fever rises
  until eruption fades
• febrile seizures may occur
• eruptive phase
• rash begins as fever subsides
• pale pink maculopapules on neck, trunk, and
  buttocks
• fades in few hours to 2 days
• no desquamation or pigmentation
• no oral lesions

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Roseola Infantum

• No specific treatment
• acetaminophen to control fever

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Pityriasis Rosea

• mild inflammatory exanthem of unknown cause
• possibly viral etiology
• most common in age 10 - 35 years
• occurs in spring and fall
• NOT contagious
• prodromal symptoms occur occasionally
• malaise, sore throat, headache, arthralgia
• rash evolves over several weeks

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Pityriasis Rosea

• begins with herald patch
• a solitary erythematous lesion with a raised
  border on chest or back
• -2-6 cm in diameter
• 1-2 weeks later
• widespread symmetrical eruption of pink
  maculopapules on trunk----0.5-1.5 cm in diameter
• patches are covered with dry epidermis which
  desquamates
• mucous membranes may have plaques, hemorrhagic
  punctate spots, or ulcers
• lesions may last 3-8 weeks

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Pityriasis Rosea
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Pityriasis Rosea
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Pityriasis Rosea
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Pityriasis Rosea
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Pityriasis Rosea
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Pityriasis Rosea

• healing is complete
• diagnosis is clinical
• diff dx includes viral exanthems, drug eruptions,
  seborrheic dermatitis, tinea corporis, and
  syphilis
• treatment is symptomatic
• oral antihistamines for itch
• emollients for dryness
• thorough cleansing to prevent secondary infection

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Case 6
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Case 6

• Mom states child has a fever of 101 and a rash
  which started on the head and spread to his chest
  and abdomen over 2 days

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Case 6

• Note that the rash is in multiple stages

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Varicella

• chickenpox---varicella zoster virus
• late winter-early spring
• highly contagious
• most frequently in age lt 10 years
• exanthem
• starts on trunk or scalp
• first appears as red macules
• within 24 hours--- teardrop vesicles on an
  erythematous base develop, which dry and crust
  over
• palms and soles are spared

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Varicella
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Varicella

• vesicles may occur on mucous membranes and
  ulcerate
• low grade fever, headache, malaise
• diagnosis is clinical
• Tzanck smear of vesicle will show giant cells
  with inclusion bodies
• complications include encephalitis, pneumonia,
  nephritis, and secondary infection of vesicles

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Varicella

• Treatment is supportive
• antipyretics, antihistamine
• immunocompromised patients require acyclovir and
  varicella zoster immune globulin (VZIG)
• Acyclovir --- 80 mg/kg divided qid for 5 days
• Immunocompromised
• Varicella pneumonia
• Varicella encephalitis

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Varicella

• VZIG ---125 U/10 kg (max 625U) IM
• - passive immunity if within 96 hours
• -immunocompromised children
• -susceptible pregnant women
• -newborns whose mothers had varicella 5 days
  prior to 48 hours after delivery
• -Active immunity
• -universal varicella vaccine at age 12-18
  months

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Case 7
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Case 7

• Mom states she noted yellow pus come out of these
  lesions

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Impetigo Contagiosum

• skin infection with group A beta hemolytic
  streptococci
• common in young children in warm , humid
  conditions
• may arise at sites of insect bites or local
  trauma
• fever and systemic signs are uncommon
• rash starts as erythematous maculopapules
• become vesiculopustular and rupture leaving a
  yellow crust which can spread the infection
• most frequently involve face, neck, and
  extremities

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Impetigo
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Impetigo
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Impetigo Contagiosum

• diagnosis is clinical
• treatment
• wound scrubbing and cleansing
• neosporin topically
• IM benzathine PCN, oral PCN, dicloxacillin, or
  macrolides are an alternative

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Case 8
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Case 8

• Mom states her child has little bubbles filled
  with fluid
• Trivia Who sang Tiny Bubbles ?

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Bullous Impetigo

• local skin infection caused by phage group II
  staphylococci
• produce epidermolytic toxin that causes
  separation of skin at the granular layer causing
  bullae
• occurs primarily in newborn infants and young
  children
• bullae occur most often on extremities
• 0.5-3 cm in diameter
• filled with clear-yellow fluid
• rupture easily

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Bullous Impetigo
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Bullous Impetigo
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Bullous Impetigo

• diagnosis is clinical
• staphylococci cultured from aspirated bullae
  confirm diagnosis
• treatment
• oral antistaphylococcal antibiotics
• local wound cleansing
• neosporin topically
• usually complete recovery

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Case 9
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Case 9

• Mom says HELP! My childs skin is peeling off

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Staphylococcal Scalded Skin Syndrome

• febrile illness of neonates and young children
• generalized, confluent superficial exfoliation of
  skin
• caused by epidermolytic toxin from phage group II
  staphylococcus
• staph. do not occur locally in skin but at a
  distant site ( pharynx, nose, conjunctiva,
  septicemia)

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SSSS

• illness begins with fever, malaise, irritability,
  skin tenderness
• diffuse macular erythroderma of face, neck,
  axillae, and groin
• palms, soles, and mucous membranes are spared
• within 1-3 days--- positive Nikolskys sign
• desquamation follows
• usually heals without scarring

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SSSS
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SSSS
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SSSS

• diagnosis is clinical
• differentiated from TEN by biopsy
• Separation is intraepidermal with minimal fluid
  loss
• Mucous membranes are not involved
• lt 5 mortality

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SSSS

• Treatment
• parenteral antistaphylococcal antibiotics
• fluid resuscitation
• temperature regulation
• wound care
• topical antibiotics and steroids should NOT be
  used
• prognosis for complete recovery is good

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Case 10
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Case 10

• Mom states he has a fever and headaches for 2
  days and then came a rash which started on the
  wrists and ankles and spread to his palms and
  soles and up his arms and legs and to his body

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Case 10

• This was found on the patient

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Rocky Mountain Spotted Fever

• caused by Rickettsia rickettsii
• transmitted by ticks
• multiply in endothelial cells lining small blood
  vessels
• generalized vasculitis accounts for rash,
  headache, mental confusion, terminal heart
  failure and shock
• most common in southeastern United States
• incubation period is 2-12 days
• peak severity within 1-2 weeks
• rash appears on day 2-3

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RMSF
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RMSF

• small erythematous macules begin on wrists and
  ankles and spread to extremities and trunk
• involve palms and soles
• blanch on pressure
• become maculopapular and petechial
• splenomegaly present in 50
• fever subsides in 2-3 weeks with residual
  hyperpigmentation
• overall mortality rate 3-7
• mortality rate for untreated persons ---30

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RMSF
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RMSF
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RMSF

• diagnosis
• clinical---- fever, headache, rash, myalgia
• epidemiologic---- hx of tick exposure
• lab confirmation by antibody titers cannot be
  done until after 10-14 days after onset of
  illness
• leukopenia, thrombocytopenia may occur
• treatment
• under 8 years old or pregnant
• -chloramphenicol 100mg/kg/24 hours upto 3g total
  dose
• over 8 years old
• -doxycycline 2 mg/kg q 12 hours for 5-10 days

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RMSF
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Case 11
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Case 11
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Case 11
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Case 11
120
Scabies

• caused by mite sarcoptes scabei
• dogs and cats may be infested and can be source
  of human infestation
• female mite burrows into stratum corneum within 1
  hour of arrival on skin
• lays eggs and fecal pellets (scybala) in burrow
• -causes itch
• scratching spreads mites to other areas leading
  to intense pruritis
• scratching destroys burrows

121
Scabies

• distribution
• finger webs, wrists, extensor surfaces of
  elbows, knees, sides of hands and feet, axilla,
  buttocks, genitalia, ankles
• vesicular or pustular lesions on palms and soles
  of infants
• diagnosis
• clinical symptoms with intense pruritis
• other family members have symptoms
• skin scrapings with 15 blade of web spaces or
  burrows to look for mites or eggs

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Scabies
123
Scabies

• Treatment
• lindane cream or lotion
• -apply topically for 8-12 hours and wash off
• permethrin cream
• -apply topically for 8-14 hours and rinse
• all family members should be treated
• wash all clothing,, towels, and linens

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Scabies
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