1. Approach to the patient with
rash
Dr AJIT GADEKAR

2. High yield facts
• Primary lesions are uncomplicated
abnormalities which represent initial
pathologic change.
• Secondary changes reflect progression of
disease eg excoriation , infection
, keratinization.
• Physician must search for the primary lesion

3. High yield facts
• Look at the morphology and grouping to reach
the diagnosis
• Clinician must know the pattern of emergency
dermatologic conditions
• Clinician must communicate to the patient
that there are times when it is difficult to
narrow the final diagnosis to single entity

4. Aim
• To classify benign vs malignant
• To know which need urgent care from those
which do not

5. History : series of questions
• What do the patient think is causing rash?
• Where did the lesions originate?
• When did the lesion first develop? & what has
been the progression of rash
• Was there any prodrome to the lesions?
• What are the associated symptoms?

6. History : series of questions
• Does it itch , hurt etc?
• What treatment was applied if any?
• Is there h/o atopy in family?
• What medication do they take regularly or
intermittently?
• What kind of exposure do they have?
• Family history of skin related disorder?

7. Physical
• Diagnosis relies heavily on careful inspection
of the skin.
• Examine in well-lit area where one can
examine the entire skin surface
• Entire eruption should be visualized to
evaluate distribution and configuration
• Most important objective is to characterize
the morphology of the primary lesion
• Description of rash should include
morphology, color, configuration and
distribution

8. Morphology : primary & secondary
lesions
• Primary lesions are uncomplicated
abnormalities which represent initial
pathologic change
• Secondary changes reflect progression of
disease such as excoriation , infection or
keratinization
• Morphologic expression of dermatologic
condition is basic entity on which all diagnosis
are founded

9. Primary lesions
• Macule : circumscribed flat discoloration
< 1cm in diameter eg ash-leaf spots,
flat nevi and freckle
• Patch : circumscribed flat discoloration
> 1cm in diameter eg vitiligo, tinea
versicolor. Often have fine scale
(pityriasis alba)
 Papule : circumscribed superficial solid
elevated lesion < 1cm ,eg warts, elevated nevi
insect bites molluscum contagiosum.

10. Primary lesions
• Plaque : > 1cm elevated flat top superficial
lesion eg psoriasis and pityriasis rosea.
• Vesicle : fluid filled lesion < 1cm in diameter
eg herpes simplex and varicella
• Bulla : fluid filled lesion > 1cm in diameter
eg ssss and bullous impetigo
• Pustule: vesicle with purulent exudates
eg acne , folliculitis

11. Primary lesions
• Nodule : lesion < 1cm in diameter with depth
eg secondary / tertiary syphilis
• Tumor : > 1cm solid lesion with depth
• Petechiae : pinpoint < 1cm flat red spots under
the skin surface
• Purpura : > 1cm visible collection blood eg itp
• Wheal : transient edematous papule or plaque
with pale center and pink margin, peripheral
erythema eg hives and insect bites

12. Secondary lesions
• Scales : dry and greasy masses of keratin
ranging from fine and delicate to coarse
, implies pathologic process in epidermis
• Crust : dried exudates ( pus or blood)
• Excoriation : linear abrasion caused by
scratching
• Fissure : linear crack or cleavage on skin with
sharply defined margins

13. Secondary lesions
• Ulcer :depressed lesion with epidermal &
dermal loss
• Scar : permanent lesion result from process of
repair by replacing connective tissue
• Lichenification : area of increased epidermal
thickness with accentuation of skin

14. Diagnostic features of lesion
• Distribution
• Configuration
• Color
• Texture sandpaper texture in scarlet fever
• Positive nikolskys sign epithelial shearing
caused by lateral pressure to unblistered skin

15. Distribution

17. Configuration
• General shape or the pattern in which the
lesion are arranged
• Lesions may be grouped into a pattern eg
grouped papule in molluscum contagiosum
• Form specific shape annular plaque of tinea
corporis
• Herpes simplex typically present in grouped
vesicles

19. An algorithmic approach

25. True emergencies in the pediatric
dermatologic presentation
• Toxic epidermal necrolysis (TEN)
• Stevens Johnson syndrome (SJS)
• Staphylococcal scalded skin syndrome (SSSS)
• Toxic shock syndrome (TSS)
• Kawasaki disease (KD)
• Anaphylaxis
• Purpura fulminans

26. Toxic epidermal necrolysis (TEN)
• Definition : sudden onset
: generalization in 24 – 48hrs
: widespread blister formation
: confluent erythema
: skin tenderness
: absence of target lesion
: sever form of EM
• Hypersensitivity that result in damage to basal
layer of epidermis

27. Toxic epidermal necrolysis
• Nikolskys sign positive
• Fever , inflammation of eyelid , conjunctivae,
mouth precedes skin lesion
• Complicated by dehydration shock electrolyte
imbalance septicemia

28. Stevens-johnson syndrome
• Erythema , edema of lips , buccal mucosa
• Then devolopes bullae ulceration hemorrhagic
crusting
• Skin lesions are bullae denuded skin .more
widespread than EM
• Skin tenderness is minimal to absent
• Pain from mucosal ulceration is painful
• Systemic involvement present

29. SSSS
• Caused predominantly by phage group 2
staphylococci , strain 71 & 55
• Common in infant and young children's
• Clinical features are mediated by
hematogenous spread in absence of specific
antitoxin antibody to staphylococcal
epidermolytic or exfoliative toxins A or B
• ↓ clearance of these toxin in young infant

30. SSSS
• Range from localized bullous impetigo to
generalized cutaneous involvement with
systemic illness
• Begins as cutaneous scarlentiform erythema
• Desquamative phase begins 5 days after
cutaneous erythema
• Sterile flaccid blisters devolopes diffusely
• Intact bullae are consistently sterile unlike in
bullous impetigo

31. SSSS

32. SSSS
• Nikolskys sign positive .
• Absence of inflammatory infiltrate is
charecteristics
• semisynthetic penicillinase resistant penicillin
should be prescribed as staphylococci are
resistant to penicillin

33. Erythema multiforme
• Characterized by abrupt , symmetric cutaneous
eruption mostly on extensor upper extremities
• EM has numerous morphologic manifestation on
the skin , varying from erythematous macules ,
papules , vesicles , bullae , or urticaria appearing
plaques.
• Classic lesions doughnut-shaped, target like (iris
or bulls eye) papule with erythematous outer
border an inner pale ring dusky purple to necrotic
center

34. Target or iris lesion with dusky zone on
palm with EM due to HSV

35. Early fixed papule with central dusky
zone on dorsum of hand in EM

36. EM etiology
• Infection with HSV is most common.
• HSV labialis & HSV genitalis implicate in 60%
of episode of EM.
• Trigger nearly all episodes of recurrent EM
• HLA B35 / B62 / DR53 is associated with an
increased risk of HSV induced EM (recurrent).

37. Recurrent labial HSV

38. Meningococcemia
• Fever
• Rash typically petechiae & purpura
• Hypotension
• Adrenal failure
• Multiorgan failure
• meningitis feature

39. Anaphylaxis
• Life threatening allergic reaction
• Urticaria
• angioedema
• Wheezing
• dyspnea
• Hypotension
• All these in few seconds to minutes of
exposure

40. Purpura fulminance
• Life threatening hemorhagic disease seen in
setting of sepsis
• Skin lesions lead to perivascular hemorrhage
and necrotic gangrene
• Presentation typically include fever
hypotension DIC

41. Conclusion
• Approach to pediatric dermatology patient in
the ED may appear daunting however with a
systemic approach one can more readily and
successfully arrive at a diagnosis and manage
the patient effectively

42. Thank you…………………………………….