Infectious Rashes in Paediatrics
[Link]/infectious-rashes-in-paediatrics
Audrey Ho March 15, 2015
This article provides an overview of common paediatric rashes,
including appearance, causes, relevant investigations and
management.
For more examples of skin rashes on black and brown skin, see the
Mind the Gap handbook and Skin Deep website.
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Meningococcal rash
A meningococcal rash is a sign of meningococcal disease.
Cause: Neisseria meningitidis
Appearance: non-blanching purpuric or petechial rash. All
children presenting with this assumed to have meningococcus
until proven otherwise.
Other symptoms: pyrexia, malaise, meningitis (20-30%)
Management: immediate admission to hospital, resuscitation
and administration of broad-spectrum antibiotics
Complications: septicaemia, meningitis
For more information, see the Geeky Medics guide to meningitis.
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Figure 1. Meningococcal rash
Steven-Johnsons syndrome / toxic epidermal
necrolysis
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis
(TEN) are rare, acute, and potentially fatal skin reactions that cause
sheet-like skin detachment and mucosal loss.
Causes: drugs, chemicals (burns), infections, systemic
illnesses
Appearance: widespread blisters/bullae over
erythematous/macular/haemorrhagic skin. Can also have
haemorrhagic erosions on mucus membranes.
Progression: blisters start on the face before spreading to
other areas
Associated symptoms: fever, arthralgia, myalgia,
conjunctivitis, pneumonitis
Management: supportive (hydration/maintain airway), identify
and remove causative agent, dermatology and critical care
input
For more information, see the Geeky Medics guide to Stevens-
Johnson Syndrome and Toxic Epidermal Necrolysis.
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Figure 2. Steven Johnson Syndrome
(adult patient)
Impetigo
Impetigo is a superficial bacterial infection affecting the skin, most
commonly in young children.
Cause: Staphylococcal aureus or streptococcal skin infection
Appearance: erythematous macules (may progress to be
vesicular/bullous) on face, neck or hands
Epidemiology: infants and young children
Management: topical (fusidic acid, mupirocin) or systemic
(flucloxacillin or clarithromycin)
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Figure 3. Impetigo
Kawasaki disease
Kawasaki disease is an acute systemic vasculitis that affects
young children.
Cause: autoimmune-mediated (medium-sized blood vessel
vasculitis)
Symptoms: fever > 5 days, conjunctivitis, polymorphous
exanthem, fissuring of lips, strawberry tongue (Figure 4),
diffuse erythema of oral and pharyngeal mucosa, periungual
desquamation of fingers and toes, erythema of palms and
soles
Other features: arthralgia, septic meningitis, coronary artery
aneurysm, vasculitis and other cardiac conditions (congestive
heart failure, myocarditis, arrhythmias, mitral insufficiency,
acute MI)
Investigations: echocardiography (needs follow up 6 weeks
later), inflammatory markers (ESR and CRP), alpha-1
antitrypsin
Management: high dose intravenous immunoglobulin, aspirin
For more information, see the Geeky Medics guide to Kawasaki
disease.
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Figure 4. Strawberry tongue
Staphylococcal scalded skin syndrome
Staphylococcal scalded skin syndrome is a blistering skin disease
caused by the exfoliate staphylococcal toxin.
Cause: exfoliative staphylococcal toxin
Appearance: blistering initially, then desquamation affecting
flexural areas, buttocks, hands, or feet
Epidemiology: typically occurs in children under three years
old
Associated symptoms: fever, irritability, diffuse blanching
erythema around the mouth, desquamation as above, positive
Nikolsky’s sign (the epidermal layer easily sloughs off when
pressure is applied)
Management: hospital admission, supportive care, analgesia
and intravenous antibiotics (flucloxacillin is first-line)
Figure 5. Staphylococcal scalded skin
syndrome
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Eczema herpeticum
Eczema herpeticum is a complication of atopic eczema that
occurs with infection of the herpes simplex virus (HSV).
Cause: type I HSV co-infection with active atopic eczema
Primary infection: in pre-school children, presenting with a
sore throat, pyrexia, stomatitis, vesicles or ulceration in the
oral cavity and face
Secondary infection: a cluster of itchy and painful blisters on
the face and neck. New blisters have umbilication, old blisters
crust and form sores.
Management: oral acyclovir, systemic antibiotics for
secondary bacterial infection
Figure 6. Eczema herpeticum
Erythema nodosum
Appearance: red or violet subcutaneous nodules located
pretibially
Causes: streptococcal pharyngitis, idiopathic, sarcoidosis,
primary tuberculosis, inflammatory bowel disease, drug
reactions
Management: usually self-limiting or resolves with the
treatment of the underlying disorder
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Figure 7. Erythema nodosum
Erythema multiforme
Erythema multiforme (EM) is a type IV hypersensitivity reaction
that presents with a skin rash.
It is typically triggered by an infection (most commonly herpes
simplex virus), however, it can also develop secondary drug
reactions. EM typically affects those aged between 20 to 40.
Causes: HSV (90%), mycoplasma pneumonia, medications,
autoimmune disease, sarcoidosis
Appearance: target-like lesions on the skin. Progresses to
erosions of bullae which can involve oral, genital or mucosal
areas.
Management: usually self-limiting, aciclovir is used to treat
HSV infections. Oral antihistamines and corticosteroids can be
used to reduce pruritus.
For more information, see the Geeky Medics guide to erythema
multiforme.
Figure 8. Erythema multiforme
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Measles
Measles is an infectious disease caused by a morbillivirus of the
paramyxovirus family.
Appearance: maculopapular rash lasts 6-8 days
Associated symptoms: fever, coryza, cough, non-purulent
conjunctivitis, Koplik spots
Epidemiology: young children with a seasonal peak in late
winter/spring
Treatment: supportive, can give antibiotics to prevent
secondary infection
Prevention: MMR vaccine at 18 months
Figure 9. Measles rash
Figure 10. Measles rash
Glandular fever (infectious mononucleosis)
Glandular fever (also called infectious mononucleosis) is an acute
viral infection caused by the Epstein-Barr virus (EBV).
Cause: Epstein-Barr virus
Associated symptoms: fever, fatigue, sore throat,
lymphadenopathy
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A maculopapular rash can occur due to being treated with penicillin
whilst infected with EBV (Figure 11).
Figure 11. EBV penicillin rash
Hand, foot and mouth disease
Hand, foot and mouth disease is an acute viral infection caused by
enteroviruses (commonly coxsackieviruses).
Causes: coxsackievirus A16 and enterovirus A71
Appearance: oral vesicles which rupture to form ulcers on
tongue and buccal mucosa (enanthem). Macular,
maculopapular or vesicular exanthema on hands, feet,
buttocks, legs, arms.
Management: supportive, but children with complications may
require hospitalization
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Figure 12. Hand, foot & mouth
disease
Erythema infectiosum (fifth disease)
Erythema infectiosum (fifth disease), also called ‘slapped cheek
syndrome, is a self-limiting viral infection caused by parvovirus
B19.
Cause: parvovirus B19
Symptoms: begins with fever, coryza, headache, nausea and
vomiting
Appearance: malar rash with circumoral pallor (slapped cheek
rash), then a lace-like rash on trunk and extremities follows
Epidemiology: outbreaks among school-aged children
Treatment: supportive as the virus is self-limiting
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Figure 13. Fifth disease
Chickenpox (varicella-zoster)
Chickenpox is a common viral infection, caused by the varicella-
zoster virus (VZV).
Appearance: starts on head and trunk, then spreads
throughout the body. Red macules -> papules -> pustule->
crusting
Epidemiology: between 1 and 6 years, seasonal peaks in
winter and spring
Associated symptoms: headache, anorexia, upper
respiratory tract infection, fever, itching
Treatment: antihistamines, paracetamol, acyclovir, VZIG for
prophylaxis for contact at-risk individual
For more information, see the Geeky Medics guide to chickenpox.
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Figure 14. Chickenpox
Figure 15. Chickenpox
Nappy (napkin) rash
Nappy rash is an irritant contact dermatitis that occurs in the
nappy area. Secondary infection with Candida albicans or bacteria
(Staphylococcal aureus or streptococcus) can occur.
Cause: candida albicans in skin creases. Candida secondarily
infects areas of irritant dermatitis that has been left untreated
for more than 3 days.
Appearance: beefy red plaques, satellite papules, superficial
pustules
Treatment: frequent application of emollients, topical
antifungal agent (e.g. nystatin, clotrimazole or ketoconazole)
Scabies
Scabies is a highly contagious skin infestation caused by a
parasitic mite. It is spread by close contact and is more common
among disadvantaged populations.
Cause: an infestation of the skin by mite Sarcoptes scabiei
resulting in a pruritic eruption
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Appearance: small, erythematous papule with haemorrhagic
crusts on fingers, elbows, axillary folds, thighs, genitalia, feet
Treatment: hygiene advice, topical permethrin, oral ivermectin
For more information, see the Geeky Medics guide to scabies.
Figure 16. Scabies nodules
Tinea corporis
Tinea corporis (also called ringworm) is a dermatophyte (fungal)
infection of the body.
Causes: Trichophyton tubrum, Microsporum canis,
Epidermophyton
Appearance: pruritic, circular, erythematous scaly patch
spreading centrifugally. Central clearing is seen.
Treatment: daily application of topical antifungals. Systemic
therapy indicated in patients with failed topical therapy
(terbinafine, fluconazole or itraconazole).
Figure 17. Tinea Corporis
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Figure 18. Tinea corporis
Tinea capitis
Tinea capitis is a fungal (dermatophyte) infection of the scalp.
Appearance: well-demarcated scaly lesion, can be “grey
patch”, “black dot” and favus
Treatment: systemic treatment with oral
griseofulvin/terbinafine
Figure 19. Tinea capitis
Molluscum contagiosum
Molluscum contagiosum is a contagious dermatological infection
that predominantly affects children.
Cause: Poxvirus
Appearance: flesh-coloured, dome-shaped papules on the
skin
Associated symptoms: usually painless and sometimes
pruritic
Treatment: self-resolving after approximately 18 months
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For more information, see the Geeky Medics guide to molluscum
contagiosum.
Figure 20. Molluscum Contagiosum
Figure 21. Molluscum Contagiosum
References
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Copyright © Geeky Medics
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