Download The Child with a Rash

The Child with a Rash
Lydia Burland
Learning Outcomes
By the end of the session students should;
 Be able to recognise common rashes
presenting in childhood
 Know about common associations and red flag
symptoms
 Be able to discuss initial management options
and explain to parents
 Be able to answer questions on common
infectious diseases and rashes
Case 1
 A 3 year old presents with a 2 day history of a
pustular rash on his face and hands
 He is otherwise well, but keeps picking the scabs
causing them to bleed
 3 other children at nursery have a similar rash
 He is usually fit and well, with no PMH or
allergies
Case 1
 What are your
differential diagnoses?
Impetigo
Contact dermatitis
Infected eczema
Eczema herpeticum
Scabies
Bullous pemphigoid
Case 1: Impetigo
 Very common superficial skin infection
 Usually due to staph. aureus or beta-haemolytic
strep.
 Two forms: bullous or non-bullous (70%)
 Most common in pre-school children and warm
(sweaty) environments
 Risk factors: poor hygiene and skin conditions
Case 1: Impetigo
 Non-bullous:
–
–
–
–
Initial vesicles, developing into honey-crusted plaques
Minimal surrounding erythema
Spreads rapidly
Often regional lymphadenopathy
 Bullous:
– Thin membranes that rupture spontaneously
– More common with underlying eczema
 Diagnosis is clinical, though you can swab
vesicular fluid for MC+S
Case 1: Impetigo
 Conservative measures:
– Avoid itching/touching
– Avoid towel sharing
 Topical treatments:
– Fusidic acid
– Mupirocin (for MRSA carriers)
 Systemic treatment:
– Flucloxacillin
– Clarithromycin (for penicillin allergy)
Case 1: Impetigo
 Complications include:
– Cellulitis
– Lymphadenitis
– Staphlococcal scalded skin syndrome
– Scarlet fever
– Post-streptococcal glomerulonephritis
 Re-infection may occur in household contacts
Case 2
 A 9 year old presents with a 3 day history of
cough, coryza and mild pyrexia
 In the last 24 hours a non-blanching macular rash
has developed on his buttocks/legs
 He also has non-specific abdominal pain, and
pain/swelling of his knees and ankles
 He has a PMH of asthma, and is allergic to nuts
Case 2
 Obs: HR 123, RR 32, T37
 OE:
Alert, but crying
Coryzal, pink left TM
HS I + II + 0, chest clear
Abdo soft, generally tender, no masses
Case 2
 Florid, non-blanching
purpuric rash on LL
 Pain and swelling of
ankles bilaterally, with
limited ROM
What’s the diagnosis?
Case 2: HSP
 Henoch-Schonlein purpura
 IgA mediated hypersensitivity vasculitis
 90% of cases in childhood, peak 4-6 years
 Risk factors;
Recent infection
Environmental exposure
Vaccinations
Case 2: HSP
 50-90% have preceding URTI
 Rash starts as erythematous macules
 Within 24 hrs becomes raised and purpuric
 Lesions may coalesce and resemble bruises
 Associated symptoms;
Abdo pain
Joint pain
Scrotal pain
Diarrhoea
Haematuria
Headaches
Case 2: HSP
 HSP is self-limiting
 Management includes NSAIDs +/- steroids
 Complications;
Renal involvement
GI bleeding
Intussusception
Pulmonary haemorrhage
 Prognosis is excellent, however 25% may have
recurrent symptoms
Case 3
 A 17 year old mum brings her 3 month old
daughter in with ‘nappy rash’
 It’s been present for ‘weeks’ and is getting
worse
 She has been putting on regular sudocrem
What are the differentials for nappy rash?
Case 3
Case 3: Nappy Rash
 Very common under 18 months
 Risk factors include;
Immunodeficiency
Irritant soaps/detergents
Poor nappy hygiene
Diarrhoea
Atopy
 Causes include;
1. Contact dermatitis
2. Candida infection
3. Superimposed bacterial infection
Case 3: Nappy Rash
1. Contact dermatitis
Erythema sparing skin folds
Borders not well defined
2. Candida infection
Erythema with well defined, raised borders
No sparing of skin folds
Satellite lesions
3. Superimposed bacterial infection
Increased erythema and purulent discharge
Case 3: Nappy Rash

Management includes;
Regular nappy changes (6-12/day)
Thorough cleaning with water/baby wipes
‘Naked’, nappy-free time
Barrier creams (zinc, metanium)

Topical anti-fungals for candida infection
(e.g. Clotrimazole, Miconazole)

Topical antibiotics for bacterial infection
(e.g. Fusidic acid)

Topical steroids may also be used in severe cases
(e.g. 0.5% hydrocortisone)
Case 4
 A 3 year old presents with 24 hrs of D+V
 Initially vomiting 4-5x day, mostly post feeds
 Now watery, offensive stools 12x day
 Low grade pyrexia 37.9, but otherwise well in
himself
What investigations are needed?
Does he need admitting?
Case 4
 Obs:
HR 105, RR 43, Sat 99%, T 37.8
 OE:
Alert and playing
Moist mucous membranes, CRT <2s
HS I + II + 0, chest clear
Abdo soft but diffuse discomfort
No masses or guarding
Is he dehydrated?
What should we do with him next?
Case 4
 NICE fluid challenge = 50mls/kg over 4 hours
 He manages to drink 22mls every 10 minutes
without vomiting over the next 2 hrs
 His obs remain stable throughout and he is
discharged home with safety netting advice
 Stool culture has been sent
Case 4: Gastroenteritis
 Diarrhoea +/- vomiting is very common in
childhood
 Risk factors include;
Poor hygiene
Immunodeficiency
Lack of sanitation
Undercooked meat
 Causes include;
Rotavirus (>50%)
Salmonella
Shigella
Campylobacter
Norovirus
E. coli
Case 4: Gastroenteritis
 Investigation depends on presenting features, but may
include;
Stool MC+S
FBC/U+E/cultures
 Management involves;
Appropriate hand hygiene
Oral rehydration where appropriate
Abx only in septicaemia, salmonella + C Diff
Avoid anti-diarrhoeals
Safety netting advice
 Majority resolve within 5-7 days
 Breastfeeding and rotarix vaccine are preventative
Summary
 Infectious diseases and rashes are common in
childhood
 For your exams;
Recognise key rashes (google/patient.co.uk)
Know about causative organisms
Be able to recommend treatment
Be able to advise families re: infectivity
Know about important complications
Questions
Questions: MCQs
1. The most common cause of gastroenteritis
is...?
a. E. Coli
c. Salmonella
b. Adenovirus
d. Rotavirus
2. The most common cause of opthalmia
neonatorum is...?
a. Chlamydia T.
b. N. gonorrhoeae
c. Haemophilus inf. d. Staph. aureus
Questions: MCQs
3. Bullous impetigo is most commonly caused
by...?
a. Group A strep.
c. Staph aureus
b. Β-haemolytic strep.
d. Haemophilus inf.
4. HSP is...?
a. IgA mediated
b. IgG mediated
c. Common in adults d. Secondary to staph. aureus
Questions: EMQ 1
a.
b.
c.
d.
Erythema toxicum
Kawasaki disease
Measles
Rubella
e. Chicken pox
f. Glandular fever
g. Mumps
h. Milia
1. A 2 day old baby has erythematous macules and
occasional pustules on his trunk. He is otherwise well.
2. An unimmunised 3 year old presents with a rash that
started on her head, and has since spread down her
body. She also has a cough and bilateral conjunctivitis.
There are white ‘spots’ seen inside her mouth.
Questions: EMQ 1
a.
b.
c.
d.
Erythema toxicum
Kawasaki disease
Measles
Rubella
e. Chicken pox
f. Glandular fever
g. Mumps
h. Milia
3. A 7 year old presents with fever and rash. The
rash was initially vesicular but has now crusted
over.
4. An unimmunised 3 year old presents with a pink
rash and lymphadenopathy. The rash started
behind her ears and has spread to her trunk.
Questions: EMQ 1
a.
b.
c.
d.
Erythema toxicum
Kawasaki disease
Measles
Rubella
e. Chicken pox
f. Glandular fever
g. Mumps
h. Milia
5. A newborn has several tiny raised, pearly-white
papules on either side of his nose.
6. A 15 year old boy presents with several weeks of
lethargy and low fever. He has a sort throat and
did have a fine macular rash that has now gone.
Questions: EMQ 2
a.
b.
c.
d.
Staph. Aureus
Epstein-Barr virus
Herpes simplex
Strep. Pyogenes
e. Varicella zoster
f. E. Coli 0157
g. Pox virus
h. Campylobacter
1. A 15 year old presents with an itchy
maculopapular rash. He has just started
antibiotics for tonsillitis.
2. A 7 year old with known eczema presents with
rapidly worsening eczema that is painful. On
examination you see multiple vesicles.
Questions: EMQ 2
a.
b.
c.
d.
Staph. aureus
Epstein-Barr virus
Herpes simplex
Strep. pyogenes
e. Varicella zoster
f. E. Coli 0157
g. Pox virus
h. Campylobacter
3. A 4 year old presents with firm, circular papules
on his torso. They are painless and have an
umbilicated centre.
4. A 4 year presents with haematuria. He has had 7
days of diarrhoea, which has contained blood
for the last 3 days.
Questions: EMQ 2
a.
b.
c.
d.
Staph. aureus
Epstein-Barr virus
Herpes simplex
Strep. pyogenes
e. Varicella zoster
f. E. Coli 0157
g. Pox virus
h. Campylobacter
5. A 2 year old comes back from nursery with 2
peri-oral vesicles. The next day they have burst
and left a honey-coloured scab.
6. A 12 year presents with 24 hrs of D+V. He is
concerned as he has passed fresh blood per
rectum.
Questions: Images
1. A child presents with a
very itchy rash.
a. What is the diagnosis?
b. What treatment should
be given?
c. What advice should the
family be given?
Questions: Images
2. Mum notices the
following in her
babies mouth.
a. What is the
diagnosis?
b. What treatment
should be given?
Questions: Images
3. A child presents with a
rash.
a. What is the diagnosis?
b. What treatment
should be given?
c. What advice should
the family be given?
Questions: Images
4. A child presents with a
rash. He is otherwise well.
a. What is the diagnosis?
b. Does family need to keep
them off school?
Answers
Answers: MCQs
1. The most common cause of gastroenteritis
is...?
a. E. Coli
c. Salmonella
b. Adenovirus
d. Rotavirus
Rotavirus is responsible for >50% of all cases of
gastroenteritis. It is self-limiting and no
treatment is required.
Answers : MCQs
2. The most common cause of opthalmia
neonatorum is...?
a. Chlamydia T.
c. Haemophilus inf.
b. N. gonorrhoeae
d. Staph. Aureus
Opthalmia neonatorum is conjunctivitis in the first
28 days of life.
Chlamydia is the most common causative organism,
usually presenting 5-14 days after birth.
Answers : MCQs
3. Bullous impetigo is most commonly caused
by...?
a. Group A strep.
c. Staph aureus
b. Β-haemolytic strep.
d. Haemophilus inf.
The majority of impetigo is non-bullous and is
caused by beta haemolytic strep or staph aureus.
If impetigo is bullous, it is almost always due to
staph aureus infection.
Answers : MCQs
4. HSP is...?
a. IgA mediated
b. IgG mediated
c. Common in adults d. Secondary to staph. Aureus
HSP is an IgA mediated vasculitis most common in
children. The underlying cause is unknown but it
may follow recent infection or vaccinations.
When it does occur in older children or adolescents
the disease tends to be more severe and associated
with more renal complications.
Answers: EMQ 1
1. A 2 day old baby has erythematous macules
and occasional pustules on his trunk. He is
otherwise well.
a. Erythema toxicum
Erythema toxicum neonatorum is a noninfective rash occurring in the first 28 days of
life.
It is self limiting.
Questions: EMQs
2. An unimmunised 3 year old presents with a rash that started on
her head, and has since spread down her body. She also has a
cough and bilateral conjunctivitis. There are white ‘spots’ seen
inside her mouth.
c. Measles
Measles is due to morbillivirus infection transmitted by airbourne
respiratory droplets. It presents with a rash, most commonly
starting on the head and spreading downwards, coryza,
conjunctivitis and koplik spots.Measles is usually self-limiting, but
may be complicated by pneumonia and encephalitis. It is a
notifiable disease.
Answers: EMQ 1
3. A 7 year old presents with fever and rash. The rash
was initially vesicular but has now crusted over.
e. Chicken pox
Chicken pox is very common and due to varicella zoster
virus. It enters via the upper respiratory tract, and
presents with fever and malaise, before vesicles appear
around day 3-5. They are infective prior to the rash
appearing until all the vesicles have scabbed over.
Patients should be advised against itching, and given
antipyretics/analgesia as required.
Answers: EMQ 1
4. An unimmunised 3 year old presents with a
pink rash and lymphadenopathy. The rash
started behind her ears and has spread to her
trunk.
d. Rubella
Rubella is usually and mild and self-limiting illness,
and presents with a rash starting behind the ears
and spreading down the trunk.
The main concern regarding rubella is its effect on
the growing foetus.
Answers: EMQ 1
5. A newborn has several tiny raised, pearlywhite papules on either side of his nose.
h. Milia
Answers: EMQ 1
6. A 15 year old boy presents with several weeks of
lethargy and low fever. He has a sort throat and did have
a fine macular rash that has now gone.
f. Glandular fever
Infectious mononucleosis, or glandular fever, is a self limiting
infection usually caused by Epstein Barr virus. It presents with
fever and malaise over a few weeks to months, sore throat
and enlarged tonsils and a transient fine macular rash.
Patients may later develop transient splenomegaly and should
be advised against contact sports for the next month to avoid
splenic rupture.
Answers: EMQ 2
1. A 15 year old presents with an itchy
maculopapular rash. He has just started
antibiotics for tonsillitis.
b. Epstein-Barr virus
This is a common presentation of infectious
mononucleosis – the child is treated for presumed
tonsillitis with amoxicillin, resulting in a florid
maculopapular rash.
Answers: EMQ 2
2. A 7 year old with known eczema presents
with rapidly worsening eczema that is
painful. On examination you see multiple
vesicles.
c. Herpes simplex
This describes eczema herpeticum – herpes
simplex infection complicating known eczema. It
is characterised by fever, painful rash and
clusters of vesicles.
Answers: EMQ 2
3. A 4 year old presents with firm, circular
papules on his torso. They are painless and
have an umbilicated centre.
g. Pox virus
This describes molloscum contagiosum – firm
painless papules appearing in crops with an
punctate centre. They are caused by pox virus
and are self-limiting though may take months to
resolve.
Answers: EMQ 2
4. A 4 year presents with haematuria. He has had
7 days of diarrhoea, which has contained blood
for the last 3 days.
f. E. Coli 0157
This describes a likely cause of haemolytic uraemic
syndrome which most commonly follows e.coli
0157 infection. It tends to occur 6-8 post diarrhoea
and presents with haematuria, fever and lethargy.
Blood
tests
show
haemolytic
anaemia,
thrombocytopenia and renal impairment.
Answers: EMQ 2
5. A 2 year old comes back from nursery with 2
peri-oral vesicles. The next day they have
burst and left a honey-coloured scab.
a. Staph. Aureus/d. Strep. Pyogenes
This describes impetigo which may be due to
beta haemolytic strep, such as strep pyogenes or
staph aureus.
Answers: EMQ 2
6. A 12 year presents with 24 hrs of D+V. He is
concerned as he has passed fresh blood per
rectum.
h. Campylobacter
Campylobacter is the most common cause of
bloody diarrhoea secondary to food poisoning,
and is due to eating under meat, especially
chicken.
Answers: Images
1. A child presents with a very
itchy rash.
What is the diagnosis?
Scabies
What treatment should be given?
Permethrin or malathion
What advice should the family be
given?
Wash all bedding and clothes
Answers : Images
2. Mum notices the
following in her babies
mouth.
What is the diagnosis?
Oral candidiasis
What treatment should be
given?
Oral antifungal, i.e.
Nystatin or daktarin
Answers : Images
3. A child presents with a rash.
What is the diagnosis?
Chicken pox
What treatment should be given?
Supportive
(unless immunosupressed)
What advice should the family be
given?
Contagious until all vesicles scab
over
Avoid pregnant women
Answers : Images
4. A child presents with a
rash. He is otherwise well.
What is the diagnosis?
Molloscum contagiosum
Do parents need to keep
them off school?
No, infectivity is very low
Any questions?
Thanks for listening