Children’s Rashesand things that go ‘itch’ in the night!

Janet YoudCalderdale and Huddersfield NHS Trust

Objectives•To understand the terminology used in describing rashes and skin lesions.

•To illustrate some common rashes seen in children.

Background• Ill children often present with

several symptoms, one of the most common being a rash.

• Any attempt to identify a rash should come after the systematic assessment of a sick child.

SYSTEMATIC APPROACH TO RASH

IDENTIFICATION•History/Examination•Distribution (Body Location)•Morphology of primary and

secondary lesions.•Configuration / Arrangement•Pattern of Distribution•Consult Textbook

History• Associated symptoms, timings and

sequence of onset. Aggravating/relieving factors

• Recent contacts/symptoms in family members/peers

• Social history/pets• Recent travel• Immunisation history• Past medical history• Drug history• Known allergies

Examination• Ensure privacy• Suitable environment• Will need full systems

examination if signs of systemic illness

• Look:– Total skin evaluation (including folds)– Evaluate hair and nails

• Feel:– Subtle changes in texture

Distribution

•Scattered/Generalised: spread throughout the body

•Localised: involve only a selected part

Morphology

MACULE–Derived from the Latin for Stain.

–Used to describe changes in colour or consistency without elevation above the surface of the surrounding skin.

–Typically less than 1cm•e.g. Freckles

PATCHAs a macule but greater than 1cm.

•e.g. Vitiligo or Café au Lait spot

PAPULERaised, palpable skin lesions smaller than 1cm in diameter that may or may not have a different colour from the surrounding skin.

NODULE•As a papule but greater than 1cm.

PLAQUERaised, palpable skin lesion greater than 1cm in diameter. Usually confined to the superficial dermis.•Typically seenin psoriasis.

WHEALSRaised circumscribed, oedematous plaques that usually are pink or pale and tend to be present only temporarily.

VESICLEA raised lesion of less than 1cm that contains clear serous fluid.•Typical of herpes simplex.

BULLAEAs a vesicle but greater than

1cm. It may be superficial within the epidermis or may be situated in the dermis below.•Commonly Seen in partial Thickness burns.

PUSTULESPapules filled with pus.

•Commonly seen in patients with acne.

PURPURAGeneral name for the escape of red blood cells into the skin.Petechiae are less than 0.5cm

Secondary Lesions•Excoriations

–Scratch marks

Secondary Lesions•Lichenification

–Typical thickening of the skin. Often seen in patients with chronic pruritus.

Secondary Lesions•Crusts

–Raised lesions produced by dried serum and blood cell remnants.

Secondary Lesions•Erosions

–Depressed lesions produced whenever the epidermis is either removed or sloughed. They are moist, usually red and well circumscibed. Classically seen in chicken pox after rupture of a vesicle.

Secondary Lesions•Ulcers

–Depressed lesions produced whenever not only the epidermis but also part of (or all of) the dermis is gone.

Secondary Lesions•Fissures

–Depressed lesions that present as narrow and linear skin cracks. They penetrate through the epidermis and reach at least part of the dermis.

Terms to describe configuration•Annular: Ring shaped

Terms to describe configuration•Linear: Lesions arranged in

a line

Terms to describe configuration•Reticular: Net-like clusters

Pattern of distribution•Clustered: Grouped

•Confluent: Multiple lesions that blend together

•Dermatomal: Distributed along neurocutaneous dermatomes

Information• 1-2 day history of general malaise

and low grade pyrexia.• Initially noticed itchy, scattered

rash of discrete lesions of varying morphology. Some are macular papular, that develop to vesicles.

• Within 24 hours developed some secondary crusts, whilst new lesions continued to erupt over then next 4-5 days.

• There are some ulcers within the mouth.

Chicken Pox

Information•3 day history of high fever,

cough, red and watery eyes. Child miserable.

•Developed non-itchy, scattered, maculopapular confluent rash. Started at the hairline and worked down.

•Koplick spots are noted on buccal mucosa.

Measles

Information•Tiny pink macules starting

on face and working down the body, associated with low grade pyrexia and slight post-auricular lymphadenopathy. Rash fades quickly.

Rubella

Information•Systemically well child with

discrete papules (1-5 mm) with a central dimple, clustered and localised to chest and abdomen.

Molloscum Contagiousum

Information•Tingling skin sensation

followed by clustered or isolated vesicles, localised to specific area, commonly face/lips. Develop secondary crusts. Resolve 5-14 days.

Herpes Simplex

Information•Localised flaccid blisters

rupture and form ‘golden’ crusts. Spreading occurs readily. Most commonly seen around the nose and mouth.

Impetigo

Information•Rapid onset (hours) flu-like

symptoms. May have scattered non-itchy maculopapular rash followed by development of petechiae and purpura.

Meningococcal Septicaemia

Information•Child presents with non-

itchy purpuric rash localised to legs and buttocks. May also have haematuria +/- abdominal pain. He is otherwise well.

Henoch-Schonlein Purpura

Information•Sudden onset widespread wheals following ingestion of strawberrries.

Urticaria

Information•Localised very itchy

oedematous and erythematous lesion may develop to vesicles followed by secondary crusting and scaling.

Contact dermatitis

Information• Intensely itchy, localised

papules and vesicles, some ‘burrows’ may be seen. Often secondary excoriation noted. Commonly found between fingers and on flexor surfaces at elbows, knees and groins.

Scabies

Information•Papular and vesicular rash

noted behind ears and on back of neck. This may lead to secondary excoriation and crusting.

Head Lice (Pediculosus Capitis)

Pitfalls•Beware ‘labelling’ any rash. If in doubt describe it.

•Assess the child properly and treat according to symptoms. Some very sick children have no rash. Some spectacular rashes are of little significance.

Summary• Understanding the terminology

will help you to document your findings.

• Repeated examination of rashes will aid your recognition.

• Consult the textbooks and experts before commencing treatment.