rash

1. Approach to a child with
Rash
Rojan Adhikari
Animesh Rajbhandari

2. Rash - Terminology
 Rash: Any change in colour and texture of skin.

3. Primary skin lesions
Fundamental morphological
changes
 Macule: Flat, non-palpable
circumscribed area of change in
skin colour <10mm in diameter
eg: flat nevi
 Patch: circumscribed flat
discoloration > 1cm in diameter
eg vitiligo, tinea versicolor

4.  Papule: small, circumscribed elevation of skin <1cm
in diameter
Eg. Measles
 Plaque: Palpable, plateau-like elevation of skin >1cm
in diameter Eg. Psoriasis
 Nodule: Palpable, solid, round or ellipsoidal lesion
(with depth) <1cm in diameter, in the dermis or
subcutaneous fat. Eg. Erythema nodosum
 Tumour: >1cm diameter Eg. Nevus
Primary skin lesions:

5.  Vesicle: Circumscribed, elevated
lesion <1cm in diameter,
containing serous (clear) fluid eg.
HSV
 Bulla: Blisters of diameter >1cm
Eg. Pemphigus
 Pustule: a superficial, elevated
lesion with pus eg. Folliculitis
Primary skin lesions:

6.  Petechiae: small, pinpoint <2mm
red, non-blanching macule from
extravasated blood
 Purpura: larger red, brown or
purple raised, non-blanching patch
or plaque of extravasated blood
 Ecchymoses: When extensive
 Hematoma: Raised ecchymoses
Eg. Bleeding disorders
Primary skin lesions:

7.  Wheal: An elevated, transient,
compressible papule or plaque
of dermal edema Eg. Urticaria
 Exanthem: Eruption on skin
with inflammatory changes
 Enanthem: Eruption on
mucous membrane
Primary skin lesions:

8. Secondary skin lesions:
 Scale: Dry flake of stratum
corneum
 Crust: a dry mass of exudate,
serum, dried blood, scales, pus
 Ulcer: a clearly defined, deep
erosion of the epidermis and at
least papillary dermis

9.  Scar: a permanent skin change resulting
from formation of fibrous tissue after
destruction of epidermis and cutis
 Excoriation: loss of substance of skin
due to scratching
 Fissure: linear crack in skin surface
reaching dermis
 Lichenification: Thickening of skin with
coarsening of skin markings
Secondary skin lesions:

10. Etiological Classification of rash:
 Infections:
 Viral – Measles, rubella, Coxsackie, CMV, Herpes simplex,
Varicella zoster, EBV, adenovirus, enterovirus, echovirus
 Bacterial – Meningococcal, Streptococcal, Staphylococcal,
Pseudomonas, Pneumococcal, Mycobacterial
 Fungal – Dermatophytosis, Candidiasis
 Rickettsial
 Parasitic - Hookworm, Toxoplasma gondii
 Protozoal – Post Kala azar Dermal Leishmaniasis
 Infestation: Scabies, Pediculosis

11. Etiology (Cont..)
 Eczema :
 Contact dermatitis (Irritant, allergic)
 Atopic dermatitis
 Photodermatitis (Polymorphic light eruption,
Phototoxicity or Photoallergy)
 Phytodermatitis
 Seborrheic dermatitis
 Nummular eczema
 Drug eruptions: Exanthematous eruption, Fixed
drug eruptions, Erythema multiforme, Urticaria,
Photosensitivity

12. Etiology (Cont..)
 Nutritional causes: Kwashiorker (Flaky paint
dermatosis), Deficiency of Vit. A (Phrynoderma
– skin scaly and toad-like), Zinc (Acrodermatitis
enteropathica), Niacin (Pellagra), Riboflavin
(Cheilosis, seborrheic dermatitis),
Hypopigmentation (Copper, biotin deficiency)
 Endocrinal disorders: Addison’s disease,
Diabetes mellitus

13. Others:
 Immunological:
 Connective tissue disorders: SLE, Dermatomyositis,
Scleroderma, Mixed connective tissue disorders
 Papulosquamous disorders: Psoriasis, lichen planus, pityriasis
rosea
 Bullous disorders: Pemphigus vulgaris, bullous pemphigoid,
Chronic bullous disorders of childhood
 Neurocutaneous syndromes: Neurofibromatosis,
Tuberous sclerosis
 Disorders of pigmentation: Vitiligo, Albinism
 Disorders of keratinisation: Ichthyosis
 Urticaria
 Acne
 Neoplasms

14. Morphological Classification
1. Maculopapular
 Viral exanthem- measles, rubella, rubeola, erythrema infectiosum ,
roseola infantum, coxsackievirus, echovirus, adenovirus, CMV,
Hepatitis B infection
 Bacterial- Streptococcus pyogenes (Scarlet Fever), Staphylococcus
aureus (TSS)
 Other Infections- Secondary Syphilis, Lyme disease
 Kawasaki disease
 Drug Eruption- penicillin, tetracycline, sulfonamides, barbiturates,
NSAIDS, salicylates
 Erythema Multiforme due to herpes virus, EBV, Adenovirus,
Chlamydia, Salmonella, Mycobacteria, Histoplasma
 SLE

15. Morphological classification:
2. Vesiculobullous:
 Viral -(HSV, Coxsackie, Enterovirus, Varicella & Herpes Zoster)
 Bacterial –Staphylococcal infection, Bullous Impetigo, Grp A
streptococcal and pseudomonas infection
 Drug Reaction, Allergic Contact Dermatitis, Insect Bite
 Autoimmune blistering diseases of the skin
Intraepidermal bullous diseases: Pemphigus vulgaris
Sub epidermal bullous diseases: Bullous Pemphigoid,Chronic
Bullous Disease of Childhood

16. 3. Nodules:
 Fungal diseases, atypical Mycobacterial and
Pseudomonal infections, Molluscum contagiosum
 Erythema nodosum due to Streptococcus,
Mycobacterium tuberculosis and leprae, Yersinia,
Hepatitis C, Sarcoidosis, drugs
Morphological classification:

17. 4. Diffuse erythematous with peeling or
desquamation
 Scarlet fever, Toxic shock syndrome, Kawasaki
disease, SSSS, Stevens Johnson syndrome
5. Petechial/Purpuric/Hemorrhagic rashes:
 Infections- Meningococcal, Pneumococcal, EBV, Echo virus, CMV,
Rickettsial infections, Malaria and Listeria infection
 Thrombocytopenia – ITP, DIC, Hypersplenism, Platelet dysfunction,
Marrow failure-Leukemia, Marrow infiltrative disorders, Storage disorder,
Myelodysplastic syndromes, Aplastic anemia
 Disorders of blood vessel – HSP, Ehlers-Danlos syndrome
 Drugs
 Trauma/child abuse
Morphological classification:

18. Neonatal Rashes
 Benign:
 Sebaceous hyperplasia
 Erythema Toxicum
 Milia
 Salmon patch
 Mongolian spots
 Transient neonatal pustular melanosis

19. Non infectious
 Acrodermatitis enteropathica
 Epidermolysis bullosa
 Neonatal pemphigus vulgaris
 Urticaria pigmentosa
Infectious usually mild
 Neonatal candidiasis
 Impetigo neonatorum
 Scabies
Neonatal Rashes

20. Infectious usually serious
 Bacterial infections
 Chlamydia trachomatis, E.coli, H.influenzae,
Klebsiella pneumoniae,
 Listeria, Pseudomonas, Staphylococcal,
Streptococcal infection
 Syphilis
 Congenital candidiasis
 Staphylococcal Scalded Skin Syndrome
 Viral infection- CMV, Varicella, Herpes
Neonatal Rashes

21. History:
 Age
 When? Duration: Acute/chronic
 Where it started?
Disease Site of first appearance
Measles Face – behind ears, near
hairline
Rubella Face
Erythema infectiosum Cheeks
Scarlet fever Neck
Exanthem subitum Trunk

22.  Evolution and progression: Extension, exacerbation,
remission, recurrence Eg. In Chickenpox –pleomorphic,
in crops, centripetal
 Distribution: Flexural (Atopic dermatitis), Extensor (HSP),
Areas exposed to sunlight or to chemicals
 Type of lesion : Colour (Red, yellow, bluish), Fluid-filled,
purulent
 When it begins to disappear: Typhoid, Urticaria – few
hours, Exanthem subitum – 24hrs, Measles – 4-5 days
 Aggravating factors: (Photosensitivity, Urticaria, Eczema)
eg. Food, Contact with any chemicals/plants/other
substances, Sunlight, Heat/cold, sweating
History (cont..)

23. History (cont..)
 Treatment history
 Nutritional history
 Past history of similar episodes, history of asthma,
urticaria
 Similar history in close contacts: Viral exanthem,
scabies
 Family history +ve: Atopic dermatitis, Psoriasis
 Risk factors for HIV in parents
 Social factors: Child abuse

24.  h/o Occupation, H/o contact with allergens,
irritants,
 h/o pets in home
 H/o insect bite
 H/o Drug intake (penicillin, sulpha drugs )
 H/o immunosuppressive conditions
 H/o Trauma
 Cosmetic problem
History (cont..)

25. Disease Rash on day
Varicella (Low grade fever, malaise, loss of
appetite)
1
Scarlet fever 2
Small Pox 3
Measles (Moderate fever, dry cough, coryza,
excessive lacrimation, fever rises)
4
Typhus (high fever, chills, headache), Infectious
mononucleosis (Fever, malaise, sore throat)
5
Dengue hemorrhagic fever 6
Typhoid (step-ladder pattern fever, toxic) 7
•Associated symptoms:
•Prodrome:

26. Associated symptoms:
 Rashes with fever: Infections, Drug fever, HSP, SLE, JRA, Kawasaki
disease, Malignancy, IBD
 Fever, headache, vomiting: Meningococcemia
 Pruritus:
Urticaria, Contact dermatitis, Atopic dermatitis, Insect bite, Scabies,
Pediculosis, Fungal infection (tinea versicolor, tinea corporis), Lichen
planus,
Drugs (Cefaclor, aspirin, penicillin),
Obstructive jaundice, Chronic renal failure
 Pain: Herpes Zoster, Polyarteritis nodosa
 Loss of sensation: Leprosy

27.  Mucosal involvement: Koplik spots in Measles, Oral ulcers
in SLE, Steven-Johnson syndrome
 Joint involvement: HSP, SLE, Psoriasis (Dactylitis),
Meningococcemia, Sjogren’s syndrome
 Nail changes: Tinea, Candidial, Bacterial, Psoriasis
 Bleeding from other sites: Bleeding disorders, DIC
 Abdominal pain - HSP, SLE, IBD
 Seizures, altered mental functions - Meningococcemia, SLE
Associated symptoms:

28.  Rash with ocular features:
 Measles – conjunctivitis
 Kawasaki disease – non-exudative conjunctivitis
 Allergic conjunctivitis
 Herpes simplex, Herpes zoster, Adenoviral
 JRA, IBD, Behcet’s (uveitis)
 Chronic Bullous disease of childhood
(conjunctivitis)
 Vit. A deficiency
Associated symptoms:

29.  Rash with CVS involvement:
 Viral infections (myocarditis)
 Bacterial endocarditis
 Rheumatic fever
 Beri-beri
 SLE (Pericarditis, myocarditis, endocarditis)
 Kawasaki (Coronary artery aneurysm)
 Rash with hepatic involvement:
 Kwashiorkor, Sepsis, Toxins/Drugs, SLE
Associated symptoms:

30. Distribution of rash:
a. Atopic dermatitis: flexural
b. Photodermatitis:
Sun-exposed areas
c. Extensors: HSP

31.  Full exposure in natural light.
 MORPHOLOGY-colour, size, consistency,margins, surface
characteristics.
 DISTRIBUTION-flexor/extensor, sym/asymmetrical,
centrifugal/centripetel.
 If only exposed areas involved?
 Involvement of genitals/mucous membrane.
Examination of rash

32.  Kopliks spot(measles)
 Forchheimer spots (rubella)
 Palatal petechiae
 Pharyngitis.
 Strawberry tongue
 Fissuring of lips.
 Coated tongue.
Oral examination

33.  Lymph nodes.
 Joints.
 CNS involvement.
 Hepatosplenomegaly.
 Heart.
 Eyes
Associated systemic exam

35. MEASLES
 Paramyxovirus.
 IP—8 to 12 days.
 Rash starts from face &
behind ears.
 KOPLIKS SPOTS.
 Diagnosis mostly clinical
 H/o Fever, coryza followed by MP rashes
on 4th
day starting from face – near hairline
spreading to whole body
Common diseases with Rashes

36.  Respiratory infections-otitis media croup,trachitis,bronchiolitis.
 Abdominal pain – appendicitis due to swelling of Peyer
patches/hepatitis/gastroentritis
 Pneumonia
 Myocarditis, glomerulonephritis, thrombocytopenic purpura
 Encephalitis (most serious)
 Late onset: subacute sclerosing pan encephalitis (autoimmune
phenomenon)
 Diarrhoea, malnutrition, Febrile seizures
MEASLES - COMPLICATIONS

37.  No specific treatment
 Hydration, antipyretics
 Avoid intense light (for photophobia)
 IV ribavirin (less role)
 Vitamin A .
single dose of 2 lacs IU oral - >1 yr.
1 lac IU oral - 6 m to 1 yr
if opthalmologic evidence –repeat dose next day & 4
wks later.
 Treatment of complications
MEASLES - TREATMENT

38. Rubella
 RNA Togavirus
 IP—2 to 3 weeks.
 Most contagious-2 days prior to 6
days after rash
 Face → neck → trunk.
 Lymphadenopathy.
 Forchheimers spots(20%)

39.  Thrombocytopenia
 Arthritis-clasically small hand joints
 Encephalitis
 Progressive rubella panencephalitis.
 Others – GBS, peripheral neuritis,myocarditis.
Features of congenital rubella syndrome:
 Intrauterine growth retardation, small for gestational age and failure
to thrive
 Nerve deafness
 Microcephaly and mental retardation
 Congenital heart disease (PDA, VSD)
 Cataract, glaucoma, and cloudy cornea
 Thrombocytopenic purpura.
 Hepatosplenomegaly,osteopathy,interstitial nephritis, pneumonitis.
Complications of Rubella

40. PRINCIPLE OF MANAGEMENT
of Rubella
TREATMENT
 No specific therapy
 Routine supportive care
 Congenital Rubella Syndrome baby should
be isolated

41. PREVENTION
 Live attenuated MMR vaccine
 Children at age 12-15 months of life
 In Nepal MR (measles and rubella) is given at 9
and 15 months.
 Pregnant women are contraindicated for rubella
vaccine.
 Pregnant woman should be immunized after
delivery.

42.  Herpes virus varicellae
 IP- 10 to 21 days
 Papules→vesicles →crusting.
 Pleomorphic,flexor surface.
 Spreads centripetally,symmetrical,mucosa & axilla
involved,spares palm & soles,diminishes centrifugally.
 Scab formation after 4-7 days.
 Fever rises with each fresh crop of rash
 Period of communicability is 2 days before
and 7 days after lesions crusted over.
Chickenpox

43.  Secondary bacterial infections (staph/strep) most
common; may be life threatening with toxic shock
syndrome/necrotizing fasciitis
 Varicella gangrenous – thrombocytopenia with
hemorrhagic lesions
 Pneumonia, Myocarditis/pericarditis.
 Hepatitis , Glomerulonephritis,Orchitis
 Arthritis
 Ulcerative gastritis
 Encephalitis (cerebellar ataxia may occur without
encephalitis)
VARICELLA - COMPLICATIONS

44.  Oral acyclovir- indications
 Healthy nonpregnant teenagers and adults
 Children > 1 yr with chronic cutaneous or
pulmonary conditions
 Patients on chronic salicylate therapy
 Patients receiving short or intermittent courses
of aerosolized corticosteroids
 Treatment of complication
Varicella – Treatment

45.  Erythrogenic toxin producing
group A β-hemolytic
streptococci
 1 to 2 days after pharyngitis
 Rash from neck- trunk- extremities,blanches on
pressure.
 Petechiae in linear form.
 More intense along elbow,axilla,groin creases.
 Fade in 4 to 5 days with desquamation 1st
face progressing downwards.
 White and red strawberry tongue
 Treatment –penicillin or erythromycin
Scarlet Fever

46.  < 5 yrs.
 Staphylococcal exfoliation
 Bullous lesions.
 Easy peeling of skin in
thin sheets.
 Positive Nikolsky’s sign
 Diagnosis: Tzanck test, bacterial culture
 Treatment:Penicillin is the drug of choice.
Staphylococcal Scalded-Skin
Syndrome

47.  Superficial infection
of the dermis
 Two types:
 Impetigo contagiosa
 Bullous impetigo
 Etiology
 Group A ß hemolytic streptococcus
 Coagulase positive S. aureus
 Treatment : Erythromycin is the drug of choice.
Impetigo

48.  Multiple crusted
lesion with
erythematous halo
with polycyclic edges.
 Spreads without healing.
Impetigo contagiosa

49. Stevens-Johnson Syndrome
 Starts with fever,target lesions and mucosal
erosions.
 Bulla > Erosions > Crustings.
 Target lesions:Pale red centre with a pale zone
around it which is surrounded by dark red zone.
 Skin tenderness is minimal to absent.
 Pain due to mucosal ulceration.
 Systemic involvement present .
 Treatment : Nursing care , IVIg , Prevention of
secondary infection,care of eyes,mouth,
Systemic steroids.

50. Viral infections:
Herpes Simplex and Herpes Zoster
Vesicles in perioral
region
-Painful, grouped vesicles in
dermatomal distribution

51. Viral infections:
 Caused by HPV B 19
 Erythema over cheeks
 Followed by itchy
maculopapular rash over trunk
and extensors of extremities
Erythema Infectiosum

52. Parasitic infestation
 Papules and vesicles usually present in
Web spaces, wrist flexors, axilla, groin.
 Head, palms, soles usually spared
 Severe itching usually nocturnal
 Presence of Burrow (Typical)
 Similar h/o in other family members
 Complication – secondary bacterial
infection, AGN, eczema
 Treatment - Scabicide:
1.Permethrine
2.Benzyl Benzoate
3.Gamma benzoate hexachloride
4.Ivermectin.
Scabies

53. Rashes in Diaper area:
 Rashes over the convex
surfaces of diaper area,
 Over flexures
 Beefy red
 Satellite pustules
Irritant contact dermatitisCandidiasis

54. Atopic dermatitis
Acute: Intensely pruritic,
erythematous papules
Subacute:
Erythematous,
excoriated, scaling
papules
Chronic: Lichenification

55. Fungal infections:
Tinea Corporis
Annular
lesion with
central
clearing,
scaling,
pruritic
Tinea pedis – web
spaces involved
(Web spaces
spared in Contact
dermatitis due to
rubber shoes)

56. Rashes as manifestations of
systemic diseases:
SLE
Erythema Marginatum in
Rheumatic fever

57. Rashes of vascular origin:
Salmon Patch
- Vascular ectasia
-Glabella, eyelids, upper lip
Port-wine stain (Sturge-Weber
syndrome) (glaucoma,
leptomeningeal venous angioma,
seizures, C/L hemiparesis, intracranial
calcification)
-Capillary malformation
-Larger, U/L, end along midline, Persist
Hemangiomas:
Rapid growth after birth, slow,
spontaneous involution

58. Henoch Schonlein purpura (HSP)Henoch Schonlein purpura (HSP)
appears as petechiae, palpable purpura over the buttocks & lowerappears as petechiae, palpable purpura over the buttocks & lower
extremities, as well as arthritis, abdominal pain,&extremities, as well as arthritis, abdominal pain,&
glomerulonephritisglomerulonephritis..

59. Investigations according to DiseaseInvestigations according to Disease
Diagnosis – usually clinical
 CBC, PBS– TC (↑ in infections, HSP, Kawasaki,
May be ↓ in SLE), Eosinophilia in Scabies,
Platelets (↓ ITP, DIC, SLE; May be ↑ in IBD,
Kawasaki, HSP)
 ESR - ↑ in infections, connective tissue disorders,
Kawasaki, IBD
 Coagulation profiles (Bleeding spots)
 Gram staining (Bacterial, Candidial)
 Culture for bacteria or fungi (Saboraud Dextrose
agar)
 Serology for infective organisms

60. InvestigationInvestigation
 Direct light microscopy ( with
KOH preparation)
Dermatophytes
Parasitic infestations
 Tzanck smear
HSV infection
Bullous disorders (Acantholytic
epidermal cells)
Immunofluorescence test
HSP (IgA around vessel walls)

61. InvestigationsInvestigations
 Skin tests in allergy –
Intracutaneous, Patch test
 Skin biopsy (HSP, Malignancy)
 Dermatosonography
Tumours and subcutaneous
malignant lesions
Measurement and monitoring of
hemangiomas

62.  Urine R/M/E: Hematuria, Proteinuria (SLE, HSP)
 LP: Meningococcal
 LFT, RFT - ↑ Urea, Creatinine in HSP, SLE
 ANA, RA factor, Anti ds DNA – Connective tissue
disorders
 HIV I & II
 Stool R/M/E: IBD; Stool Occult blood – HSP,
Bleeding disorders
 Creatine Kinase, LDH – Juvenile Dermatomyositis
 Bone marrow examination: ITP, Leukemia
InvestigationsInvestigations

63. Management according to DiseaseManagement according to Disease
Specific management of condition
 Viral fever with rash- acyclovir in chickenpox, or
symptomatic management of rash & fever.
 Bacterial infections- systemic/ local antibiotics
 Oral Cephalexin, Cloxacillin - generalized impetigo
 Topical Mupirocin- Localised impetigo
 Fungal infections- systemic/Local antifungal
agents
 Eczema – Avoid the irritant, allergen,
Antihistaminic, local emollients, local steroids,
Cutaneous hydration

64. Management
 Scabies- 25% Benzyl benzoate or Permethrine 5%
apply usually neck and below. Treat family members
too, wash and dry all clothes
 Drug reactions – Stop the causative agent
 Photosensitivity – Use of sunscreens
 Psoriasis – Steroids, Keratolytic agents (5-10%
salicylic acid),Tar, UVB
 Treatment of the systemic disease

65. References:
 Nelson Textbook of Paediatrics, 18th
edition
 O.P. Ghai Essential Paediatrics, 7th
edition
 Fitzpatrick’s Dematology in General
medicine, 5th
edition.
 Medscape
 emedicine.com

66. Thank You!!!