Pediatric Rashes

It Looks…Red…and Bumpy

Pediatric Rashes

Molly Hagler, MD
PHM Fellow PGY5

​Objectives

By the end of this session you should be able to:

• ​Recall common terms to describe rashes

• Recognize signs and symptoms associated with common pediatric dermatologic diagnoses

• Describe the rashes associated with certain pediatric diagnoses

Poll

How do you feel about Rashes?

• They are my favorite

• I'm ok

• They all look the same

Plaques: elevated lesions
that are >1 cm in diameter

Papules are palpable, discrete
lesions measuring <1 cm in
diameter

Macules: nonpalpable lesions <1 cm that
vary in pigmentation from the surrounding
skin

Patch: nonpalpable lesions >1 cm

Pustules: small, circumscribed skin
papules containing purulent
material

Vesicles are small (<1 cm in diameter),
circumscribed skin papules containing
clear serous or hemorrhagic fluid

Wheals are irregularly shaped, elevated,
edematous skin areas that may be
erythematous or paler than surrounding
skin

Purpura are red-purple lesions that do not
blanch under pressure, resulting from the
extravasation of blood from cutaneous
vessels into the skin

Petechiae are
1-2 mm non
blanchable
macules, due to
tiny hemorrhages

Excoriation – Excoriation describes
superficial, often linear skin erosion
caused by scratching

Lichenification – Lichenification is dry,
leathery thickening of the skin with
exaggerated skin markings secondary to
chronic inflammation caused by
scratching or other irritation

Scale – Scale describes superficial
epidermal cells that are dead and cast off
from the skin

Crust – Crust is dried exudate of serum,
blood, sebum, or purulent material on the
surface of the skin, a "scab"

Fissure – Fissure is a deep skin split
extending into the dermis

Case #1

5yo old male, No PMH, comes into the office for worsening rash. Mom says that for the past several weeks, he has had worsening redness, itching. He’s had a similar rash for the past several months, but recently it has started getting worse. She has tried putting aquaphor on it, but there is no improvement. Has not used any new detergents, soaps, or lotions. No new foods. No other symptoms.

Open Ended

Describe the Rash

Multiple Choice

What is the diagnosis?

• Psoriasis

• Atopic Dermatitis

• Cellulitis

• Tinea Corporis

Atopic dermatitis (eczema)

• Acute – erythema, vesicles, bullae, weeping, crusting

• Subacute – scaly plaques, papules, round erosions, crusts

• ●Chronic eczema – lichenification, scaling, hyper- and hypopigmentation

●

Open Ended

How would you treat this patient?

Treatment:

• Mild: frequent and consistent emollients, avoidance of exacerbating factors

• Moderate-Severe: Topical Corticosteroids (starting with lower dose if moderate)

●

Case #2

6yo F, PMH of eczema, comes into the office with new rash over the past week. Family noticed a spider bite on her face, and then started to get red. Now has scabbed lesions around her mouth and chin. No fevers. She has been itching at it. Sister now has similar rash.

Open Ended

Describe the rash

Nonbullous IMPETIGO

• Superficial skin infection caused by Staphylococcus aureus or Group A streptococcus

• "Honey-crusted," or golden-yellow-crusted plaques, sometimes with small inflammatory halos

Bullous impetigo initially presents as flaccid bullae, which then rupture, leaving round
erosions that become crusted.

Open Ended

How would you treat this patient?

Treatment

• Limited: Topical treatment with mupirocin 3 times daily, for 5 days

• Extensive: oral antistaph penicillin or cephalosporin

  • First line: Keflex 25-50mg/kg/day divided in 3-4 doses per day for 7 days

  • Penicillin Allergic: Erythromycin 40mg/kg/day in 3-4 doses

  • MRSA suspected: Clindamycin 30mg/kg/day in 3 divided doses

Case #3

3yo M presents to the office. Mom noticed "bug bites" that started several weeks ago, and are not going away. More spots have popped up over the past week or 2. Usually does not bother him, but sometimes he itches at them.

Open Ended

Describe the Rash

Molluscum Contagiosum
One or more smooth, dome-shaped, firm, white, pink, or skin-colored, 2- to 6-mm
papules with central umbilication, often clustered together, cause by a poxvirus

Case #4

3yo M, recently adopted with no previous records, comes in with a new rash. Had
fever 2 days ago with a Tmax of 101. Then yesterday, developed a red rash. That
started on his abdomen and has spread. Started as little “blisters” and then started
scabbing over, but new spots are still popping up. Has been extremely itchy.
Otherwise acting himself, tolerating PO well.

Open Ended

Describe the Rash

Varicella
1-3 day prodrome of fever and malaise followed by a rapidly progressive
vesiculopustular eruption. The eruption is characterized by crops of
erythematous macules that develop central papules, which progress into
2-3 mm diameter vesicles, pustules, and crusts within 12-48 hours. Crops
of lesions continue to develop over 3-4 days before becoming completely
crusted over by 6-7 days. The pathognomonic picture is that of a centrally
focused eruption with lesions in all stages of evolution simultaneously

Case #5

2yo M comes into the clinic for a new rash. Over the last week had runny nose, and cough, had fever and diarrhea 2 days ago. Now developed a new full body rash.

Open Ended

Describe the Rash

Multiple Choice

What is the diagnosis?

• Papular Acrodermatitis of Childhood

• Scabies

• Contact Dermatitis

• Papular Urticaria

Gianotti-Crosti syndrome

(papular acrodermatitis of childhood)

Symmetrically distributed monomorphous, pink or brown, flat-topped papules or
papulovesicles 1-10 mm in diameter on the face, extensor limbs, and buttocks

Classic scabies in children presents with pruritic papules affecting the flexural areas, including the axillary folds,
wrists, and dorsal ankles; the interdigital web spaces of the hands and feet; the anogenital area; and the truncal
area, especially around the nipples and periumbilical area. The papules are accompanied by itch, which is
classically worse at night

Case #6

A newborn comes to clinic for her first visit. She’s a FT F on DOL4, born to a G1 now P1 with good prenatal care. All third trimester labs were negative. Baby has been doing well since birth. Waking up to feed, takes about 2oz with every feed. No fevers. Mom noticed a rash this morning when she woke up.

Open Ended

Describe the rash

Multiple Choice

What is the diagnosis?

• Neonatal HSV

• Neonatal Pustular Melanosis

• Miliaria

• Erythema Toxicum neonatorum

Erythema Toxicum Neonatorum

1-2 mm pale-to-yellow papule or pustule within a large (over 1 cm) inflammatory wheal.
Early on, however, the rash may only consist of blotchy, irregular erythematous macules

Neonatal HSV

Miliaria

Case #7

A 6mo F presents to clinic for rash and refusal to eat. She developed fever
yesterday this morning and this morning, her father noticed a rash this morning.
She has also only taken a few sips from her bottle at each feed and has seemed
super fussy. She is in daycare, and a couple of the other kids were sent home this
week with “viruses”

Open Ended

Describe the rash

Hand Foot Mouth

Erythematous macules on an erythematous base on palms, soles,
lateral and dorsal fingers and toes, and occasionally on the buttocks.
Small erythematous macules appear on the back of the oropharynx and
spread forward to the buccal mucosa and gingiva

Case #8

4yo M comes into clinic with a new rash. He has had runny nose, cough,
congestion over the past several days. Several of his friends are sick too. His rash started yesterday evening and the spots have come and gone, but new spots keep popping up. He seems uncomfortable and itchy.

Open Ended

Describe the Rash

Multiple Choice

What is the diagnosis?

• Erythema Multiforme

• Anaphylaxis

• Contact Dermatitis

• Urticaria Multiforme

Urticaria multiforme

Transient annular, polycyclic erythematous and edematous
wheals, potentially with a dusky or ecchymotic center in a
well-appearing child, with a recent illness

Erythema Multiforme

The early lesion consists of a well-defined, fixed erythematous macule or papule that
rapidly develops a dusky grayish central discoloration. The central color change may
be preceded by a vesicle that involutes, leaving behind a sharply marginated, central
dusky hue (the target lesion).

Alternatively, a well-defined wheal with a dusky or vesicular center develops within the
erythematous macule that flattens, leaving behind concentric circles consisting of a
well-circumscribed erythematous border, pale middle zone, and a dusky center (also
called the target lesion).

Case #9

22m F no PMH presents to clinic with worsening rash. He started having fevers 2 days ago and then started having redness of his armpits and inguinal area. At first her family thought it was from the fever, but then his skin started peeling off an family was very concerned so they brought her in today.

Open Ended

Describe the Rash

Open Ended

What are your next steps?

Staphylococcal scalded skin

syndrome

begins with a sudden onset of fever, irritability,

cutaneous tenderness, and diffuse erythema that

is accentuated at the flexures and perioral area.

Within days, flaccid blisters or flaky desquamation

may be seen, predominantly on flexural surfaces

and in the perioral area

8yo F comes in after 2 days of fever. Started having sore throat 3 days ago, then
developed fever with a Tmax of 101 2 days ago. This morning developed a full
body rash and her tongue "looks funny".

Case #10

Open Ended

How would you treat?

Open Ended

Describe the Rash

Scarlet Fever

Tiny erythematous papules. Tends to develop
within 12-48 hours of fever. Due to Group A strep.
Treatment: Amox 50mg/kg/day in 1-2 doses for 10 days

Case #11

6yo unvaccinated F presents to ED for high fever and rash. Started having
congestion, cough, and very high fever 3 days ago. Tmax today was 104.3.
Today, developed rash on face, that spread to trunk. Mom also noted that her eyes
were red.

Open Ended

Describe the rash

Measles

Erythematous macules and papules beginning at
the forehead and behind the ears, eventually
spreading in a cephalocaudal fashion down the
neck, upper extremities, trunk, and lower
extremities. Confluent lesions can occur on the
face

Fill in the Blanks

Case #12

12yo M comes into clinic with a rash. It has been there for a couple of weeks and
has been spreading. It initially started as a small area on his back, but now it is all
over his back, chest and abdomen. It started out kind of itchy, but now isn’t
bothering him. But it is not going away and seems to be getting worse.

Open Ended

Describe the rash

Multiple Choice

What is the diagnosis?

• Tinea Corporis

• Tinea Versicolor

• Pityriasis Rosea

• Guttate Psoriasis

Pityriasis Rosea

Initially Starts as a “Herald Patch” and spreads along the skin
folds of the trunk in the classic “Christmas Tree” pattern

Guttate Psoriasis

Inflammatory Plaques with overlying scale. on trunk and extremities. Genetic component, often preceded by strep infection.

Case #13

4yo F comes into clinic with a rash. She initially had a fever for 3 days which resolved and then broke out in a full body rash. The rash isn’t bothering her, but Mom is concerned and wants to make sure this isnt an allergic reaction to something.

Word Cloud

Describe the rash

Roseola

Viral illness caused by HHV6 or HHV7. Starts as a high fever for 3-5 days and then when the fever resolves it is
followed immediately by the onset of asymptomatic, rose-pink, blanchable macules and papules 2-3 mm in diameter
that begin on the trunk and may spread to the neck, upper extremities, and lower extremities

Case #14

4 mo M comes in with a diaper rash. Dad has been using the diaper cream with
every diaper change, but it has been just getting worse. Now he is super fussy
every time they change his diaper.

Open Ended

Describe the rash

Multiple Choice

What is the diagnosis?

• Contact Diaper Dermatitis

• Psoriasis

• Langerhans Cell Histiocytosis

• Candida Diaper Dermatitis

Candida Diaper Dermatitis

Classically, candidal diaper dermatitis presents as a sharply demarcated, beefy-red diaper area; satellite pustules with
collarettes of scales may also occur. Most commonly, there is diffuse erythema with peripheral scale or pink, scaly
papules that coalesce into plaques. The skin folds and entire scrotum or labia may be confluently involved

Irritant Diaper Dermatitis

Case #15

14 yo M comes in with complaints of pimples on his face, and
would like help with treatment. He has not tried any medications.

Treatment

Open Ended

Describe the rash

Multiple Choice

What kind of acne lesion is this?

• Closed comedones

• 
  Open comedone

• Papulopustular acne

• Nodular acne

Acne Vulgaris

Papulopustular acne –Inflamed, relatively superficial papules and pustules, typically <5 mm in diameter

Closed comedones – Noninflammatory; <5 mm; dome-shaped; smooth; skin-colored, whitish, or grayish papules

​Open comedones – Noninflammatory, <5 mm papules with a central, dilated, follicular orifice containing gray, brown, or black, keratotic material

​Nodular acne –Deep-seated, inflamed, often tender, large papules (≥0.5 cm) or nodules (≥1 cm)

References

-Up to Date

-VisualDx