- Feb 5th, 2016
- Sean M. Fox
Originally published at Pediatric EM Morsels on October 16, 2015. Reposted with permission.
Follow Dr. Sean M. Fox on twitter @PedEMMorsels
“Rash” seems to be a ubiquitous complaint some days in the Ped ED. Knowing that the skin is the largest organ, it seems only appropriate that we should take these complaints seriously. Unfortunately, often I feel a little inadequate when trying to decipher the code of the Pediatric Rash. Below is a simple approach I use to help ensure I don’t over-diagnose viral exanthem.
Pediatric Rash Step 1: Sick or Not Sick
- This speaks for itself.
- Treat aggressively!
- The skin findings may help clue you in to the source of the sickness, but don’t let pontification of the unusual rash delay your rapid administration of necessary care!
- Not Sick?
- Don’t be cavalier, just yet!
- Not appearing sick is reassuring, but kids can be deceptive!
- Remain vigilant and move to Step 2.
Pediatric Rash Step 2: Evidence of Badness?
- Naturally, our default is always to be concerned for badness and, thus, we need tolook for evidence of serious, systemic illness first.
- Finding any of the following characteristics does not necessarily define “badness” as being present, but it should make you think more carefully of that possibility.
- Actively look for:
- Is this ITP?
- Are these petechiae associated with coughing/vomiting and above the nipple line or are they below the nipple line and concerning forMeningococcemia?
- Chickenpox (yes, it is still around)
- Burns to Bullous Impetigo. Lots to consider.
- Target Lesions
- Erythema Multiforme?
- Spectrum of Stevens Johnson Syndrome / Toxic Epidermal Necrolysis?
- Erythema Marginatum concerning for Rheumatic Fever?
- Is this anaphylaxis?
- Is it serum sickness?
- Sloughing your skin is generally not good.
- Staph Scalded Skin Syndrome? Kawasaki Disease?
- If none of these characteristics exist, move to Step 3.
Pediatric Rash Step 3: Look at the Mucous Membranes Again!
- Let’s be honest, looking in a kid’s mouth can be challenging, but this step is very important!
- For instance, ITP with Wet Purpura (mucous membrane involvement) may be a clue to greater risk of spontaneous bleeding.
- Certainly, finding Koplick’s Spots would alter your plans.
- Even finding herpangina or gingivostomatits may impact your plan!
- While wiping the sweat off of your brow and allowing the parent’s muscle fatigue to resolve, move onward to step 4.
Pediatric Rash Step 4: Look for “Common Pediatric Rashes”
- Now, you get to demonstrate your Pediatric Rash Prowess by looking for those “classic” pediatric skin eruptions.
- Pityriasis Rosea
- Erythema infectiosum
- Perianal Strep
- Impetigo and Bullous Impetigo
- Atopic Dermatitis
- Popsicle Panniculitis
- Hand-Foot-Mouth Disease
- Diaper Dermatitis and Fungal Infection?
- If Steps 1-4 have not lead to a diagnosis or a high level of concern, then move onward to step 5.
Pediatric Rash Step 5: Admit You Aren’t Sure
- This is the hardest part… admitting to the family that you are not sure what the cause of the rash is can be challenging.
- We are not admitting defeat… we are appropriately avoiding the addition of an incorrect “label” (diagnosis) to the patient.
- Announce your reassurance in the lack of the concerning characteristics…
- Acknowledge that rashes often evolve over time…
- In the next several hours to days, your ability to make a more accurate diagnosis may change.
- Give good anticipatory guidance on what specific things they need to monitor for and encourage repeat evaluation in the next 12-24 hours.
Dinulos JG1. What’s new with common, uncommon and rare rashes in childhood. Curr Opin Pediatr. 2015 Apr;27(2):261-6. PMID: 25689452. [PubMed] [Read by QxMD]