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

1. Children’s Rashesand things that go ‘itch’ in the night! Janet Youd Calderdale and Huddersfield NHS Trust

2. Objectives • To understand the terminology used in describing rashes and skin lesions. • To illustrate some common rashes seen in children.

3. 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.

4. SYSTEMATIC APPROACH TO RASH IDENTIFICATION • History/Examination • Distribution (Body Location) • Morphology of primary and secondary lesions. • Configuration / Arrangement • Pattern of Distribution • Consult Textbook

5. 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

6. 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

7. Distribution • Scattered/Generalised: spread throughout the body • Localised: involve only a selected part

8. Morphology

9. 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

10. PATCH As a macule but greater than 1cm. • e.g. Vitiligo or Café au Lait spot

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

12. NODULE • As a papule but greater than 1cm.

13. PLAQUE Raised, palpable skin lesion greater than 1cm in diameter. Usually confined to the superficial dermis. • Typically seen in psoriasis.

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

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

16. BULLAE As 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.

17. PUSTULES Papules filled with pus. • Commonly seen in patients with acne.

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

19. Secondary Lesions • Excoriations • Scratch marks

20. Secondary Lesions • Lichenification • Typical thickening of the skin. Often seen in patients with chronic pruritus.

21. Secondary Lesions • Crusts • Raised lesions produced by dried serum and blood cell remnants.

22. 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.

23. Secondary Lesions • Ulcers • Depressed lesions produced whenever not only the epidermis but also part of (or all of) the dermis is gone.

24. 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.

25. Terms to describe configuration • Annular: Ring shaped

26. Terms to describe configuration • Linear: Lesions arranged in a line

27. Terms to describe configuration • Reticular: Net-like clusters

28. Pattern of distribution • Clustered: Grouped • Confluent: Multiple lesions that blend together • Dermatomal: Distributed along neurocutaneous dermatomes

29. 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.

30. Chicken Pox

31. 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.

32. Measles

33. 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.

34. Rubella

35. Information • Systemically well child with discrete papules (1-5 mm) with a central dimple, clustered and localised to chest and abdomen.

36. Molloscum Contagiousum

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

38. Herpes Simplex

39. Information • Localised flaccid blisters rupture and form ‘golden’ crusts. Spreading occurs readily. Most commonly seen around the nose and mouth.

40. Impetigo

41. Information • Rapid onset (hours) flu-like symptoms. May have scattered non-itchy maculopapular rash followed by development of petechiae and purpura.

42. Meningococcal Septicaemia

43. Information • Child presents with non-itchy purpuric rash localised to legs and buttocks. May also have haematuria +/- abdominal pain. He is otherwise well.

44. Henoch-Schonlein Purpura

45. Information • Sudden onset widespread wheals following ingestion of strawberrries.

46. Urticaria

47. Information • Localised very itchy oedematous and erythematous lesion may develop to vesicles followed by secondary crusting and scaling.

48. Contact dermatitis

49. 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.

50. Scabies