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Emergency And Acute Medicine – Rash, Pediatric
Pediatric rashes are common and range from benign self-limited viral exanthems to life-threatening infectious or systemic diseases. Accurate diagnosis relies on identifying lesion morphology, configuration, distribution, associated systemic findings, and progression over time. Primary lesions include macules (flat color changes), papules (<5 mm elevated lesions), plaques (>5 mm elevated lesions), nodules (deeper solid lesions), wheals (transient edematous lesions), vesicles (<5 mm fluid-filled), bullae (>5 mm fluid-filled), pustules, and purpura or petechiae (nonblanching lesions due to extravasated red blood cells). Secondary changes such as scaling, lichenification, excoriation, erosion, and ulceration reflect progression or manipulation of primary lesions. Color changes may reflect vascular dilation, hemorrhage, pigment alteration, or inflammatory proliferation.
Etiologies vary by morphology. Papulosquamous eruptions are commonly infectious, allergic, or autoimmune. Purpura and petechiae raise concern for platelet disorders, coagulation abnormalities, vasculitis, or overwhelming infection. Vesiculobullous lesions may result from viral infection, drug reactions, or autoimmune disease. Ulcers may reflect infection or vascular insufficiency. Age influences presentation, as distribution and severity differ between neonates, infants, and adolescents.
History should include age, onset, evolution, progression pattern, whether lesions are synchronous or asynchronous, associated symptoms such as fever, pruritus, abdominal pain, or joint pain, and prodromal symptoms such as cough or rhinorrhea. Immunization status, recent travel, insect exposures, medications, and family history are essential. Underlying dermatoses such as atopic dermatitis or psoriasis should be noted.
Physical examination must assess systemic stability. Fever with purpura suggests possible sepsis. Cardiac murmurs may indicate endocarditis. Hepatosplenomegaly can suggest systemic infection or hematologic disease. The rash should be classified as papulosquamous, vesiculobullous, or purpuric, and distribution should be documented, including palm and sole involvement.
Laboratory testing is guided by presentation. Purpuric rashes require complete blood count with platelet count and coagulation studies to evaluate for thrombocytopenia or disseminated intravascular coagulation. Febrile children may require CBC, electrolytes, renal function tests, blood cultures, and lactate if sepsis is suspected. Lumbar puncture is indicated when meningitis or encephalitis is suspected. Viral cultures or titers may assist in diagnosing exanthems. Potassium hydroxide preparations help identify fungal infections in scaling lesions, and scabies scrapings may be performed for pruritic linear lesions. Chest radiography is indicated if pulmonary involvement is suspected.
Differential diagnosis depends on morphology. Maculopapular rashes include viral exanthems such as measles, rubella, roseola, and erythema infectiosum, as well as scarlet fever, Kawasaki disease, and early varicella. Purpuric rashes include meningococcemia, pneumococcemia, gonococcemia, endocarditis, Rocky Mountain spotted fever, Henoch–Schönlein purpura, idiopathic thrombocytopenic purpura, leukemia, and disseminated intravascular coagulation. Scaling red lesions may represent tinea, pityriasis rosea, eczema, seborrheic dermatitis, or secondary syphilis. Vesiculobullous eruptions include varicella, herpes simplex, hand-foot-and-mouth disease, scabies, impetigo, drug hypersensitivity reactions, toxic epidermal necrolysis, and staphylococcal scalded skin syndrome.
Management prioritizes stabilization in children with systemic instability. Any child with purpura and fever requires immediate evaluation and empiric intravenous antibiotics targeting meningococcemia and other invasive bacterial infections. Airway support, intravenous access, fluid resuscitation, and vasopressors may be required in shock. Diphenhydramine is appropriate for suspected allergic reactions. Specific antimicrobial therapy should be directed toward the underlying cause. Acetaminophen may be used for fever control.
Admission decisions depend on the underlying diagnosis and systemic involvement. Children with systemic illness, unstable vital signs, staphylococcal scalded skin syndrome, severe varicella, or other high-risk conditions require hospitalization. Stable children with self-limited exanthems may be discharged with close follow-up. Return precautions should include rapidly spreading rash, new petechiae or bleeding, changes in rash morphology, new fever, neck stiffness, or systemic deterioration.
Careful attention to the initial appearance and spread of the rash, along with associated systemic symptoms, is critical. Meningococcemia must always be considered in a child with fever and purpura, as early recognition and treatment are lifesaving.
Pediatric rashes are common and range from benign self-limited viral exanthems to life-threatening infectious or systemic diseases. Accurate diagnosis relies on identifying lesion morphology, configuration, distribution, associated systemic findings, and progression over time. Primary lesions include macules (flat color changes), papules (<5 mm elevated lesions), plaques (>5 mm elevated lesions), nodules (deeper solid lesions), wheals (transient edematous lesions), vesicles (<5 mm fluid-filled), bullae (>5 mm fluid-filled), pustules, and purpura or petechiae (nonblanching lesions due to extravasated red blood cells). Secondary changes such as scaling, lichenification, excoriation, erosion, and ulceration reflect progression or manipulation of primary lesions. Color changes may reflect vascular dilation, hemorrhage, pigment alteration, or inflammatory proliferation.
Etiologies vary by morphology. Papulosquamous eruptions are commonly infectious, allergic, or autoimmune. Purpura and petechiae raise concern for platelet disorders, coagulation abnormalities, vasculitis, or overwhelming infection. Vesiculobullous lesions may result from viral infection, drug reactions, or autoimmune disease. Ulcers may reflect infection or vascular insufficiency. Age influences presentation, as distribution and severity differ between neonates, infants, and adolescents.
History should include age, onset, evolution, progression pattern, whether lesions are synchronous or asynchronous, associated symptoms such as fever, pruritus, abdominal pain, or joint pain, and prodromal symptoms such as cough or rhinorrhea. Immunization status, recent travel, insect exposures, medications, and family history are essential. Underlying dermatoses such as atopic dermatitis or psoriasis should be noted.
Physical examination must assess systemic stability. Fever with purpura suggests possible sepsis. Cardiac murmurs may indicate endocarditis. Hepatosplenomegaly can suggest systemic infection or hematologic disease. The rash should be classified as papulosquamous, vesiculobullous, or purpuric, and distribution should be documented, including palm and sole involvement.
Laboratory testing is guided by presentation. Purpuric rashes require complete blood count with platelet count and coagulation studies to evaluate for thrombocytopenia or disseminated intravascular coagulation. Febrile children may require CBC, electrolytes, renal function tests, blood cultures, and lactate if sepsis is suspected. Lumbar puncture is indicated when meningitis or encephalitis is suspected. Viral cultures or titers may assist in diagnosing exanthems. Potassium hydroxide preparations help identify fungal infections in scaling lesions, and scabies scrapings may be performed for pruritic linear lesions. Chest radiography is indicated if pulmonary involvement is suspected.
Differential diagnosis depends on morphology. Maculopapular rashes include viral exanthems such as measles, rubella, roseola, and erythema infectiosum, as well as scarlet fever, Kawasaki disease, and early varicella. Purpuric rashes include meningococcemia, pneumococcemia, gonococcemia, endocarditis, Rocky Mountain spotted fever, Henoch–Schönlein purpura, idiopathic thrombocytopenic purpura, leukemia, and disseminated intravascular coagulation. Scaling red lesions may represent tinea, pityriasis rosea, eczema, seborrheic dermatitis, or secondary syphilis. Vesiculobullous eruptions include varicella, herpes simplex, hand-foot-and-mouth disease, scabies, impetigo, drug hypersensitivity reactions, toxic epidermal necrolysis, and staphylococcal scalded skin syndrome.
Management prioritizes stabilization in children with systemic instability. Any child with purpura and fever requires immediate evaluation and empiric intravenous antibiotics targeting meningococcemia and other invasive bacterial infections. Airway support, intravenous access, fluid resuscitation, and vasopressors may be required in shock. Diphenhydramine is appropriate for suspected allergic reactions. Specific antimicrobial therapy should be directed toward the underlying cause. Acetaminophen may be used for fever control.
Admission decisions depend on the underlying diagnosis and systemic involvement. Children with systemic illness, unstable vital signs, staphylococcal scalded skin syndrome, severe varicella, or other high-risk conditions require hospitalization. Stable children with self-limited exanthems may be discharged with close follow-up. Return precautions should include rapidly spreading rash, new petechiae or bleeding, changes in rash morphology, new fever, neck stiffness, or systemic deterioration.
Careful attention to the initial appearance and spread of the rash, along with associated systemic symptoms, is critical. Meningococcemia must always be considered in a child with fever and purpura, as early recognition and treatment are lifesaving.
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