Reference Cards
Pediatric Rashes
Rashes:

Drug Allergic Reaction - erythematous maculopapular rash generally confluent, hives less frequent; onset from 1 -2 days to 1 week after starting medication; pruritic, afebrile; spreads distally;
Rx - D/C offending meds, Antihistamines (Benadryl), ? Prednisone; resolves slowly over 1- 2 weeks;
Complications interstititial nephritis, TEN (? burn unit admission)



Urticaria - General hives, wheals, via acute dermal edema and erythema (lgE mediated, histamine release), pruritic, erythematous borders with pale centers, usually lasts < 24 hrs;
Etiology medications, insect bites or stings, food (seafood, nuts...), soaps, chemicals, emotional stress, infections, sunlight, heat, cold; Rx - Benadryl, SQ Epinephrine, ?Prednisone, D/C offending agent or medication; DDx - Erythema Multiforme (fixed, lasts > 24 hrs, Epinephrine no help; etiology- HSV, Mycoplasma, Penicillin, Cephalosporins, Sulfa...)


Chicken-Pox (Varicella)
Background - common and usually benign disease, >90% of children infected by age 10, highly infectious via vesicles or respiratory tract (coughing, sneezing); Incubation: 1 -3 weeks Prodrome (fever, headache, flu like symptoms, malaise) Rash
Physical Exam (PE) - red macules 1 -2 mm vesicles with a light red erythematous base which may follow flu like symptoms, after 1 -2 days vesicles become pustular and them form crusts/scabs; lesions start on trunk and progress to arms, legs, scalp, and oral mucosa (lips and inside mouth);
Labs - low WBC, ? Skin Biopsy, Tzanck smears, viral culture
Rx Tylenol for fever (not aspirin - may cause Reye's Syndrome), Calamine or Caladryl lotion, Benadryl for itching, Acyclovir for severe disease or complications, oatmeal bath
Note - Don't scratch blisters which may become infected, ? prophylactic vaccination


Measles (Red Measles, Rubeola)

Background - highly contagious, infects skin and respiratory tract, mortality -1:3000 secondary to complications; Incubation: 1 -2 weeks Prodrome for 3 - 4 days (cough, coryza, conjunctivitis, fever, weakness, congestion, photophobia, runny nose) Morbilliform Rash. Adults and babies may have more severe symptoms and complications.
PE - enlarging red - pink fine spots starting over forehead, behind ears, and upper neck; spreading towards face, trunk, and then arms and legs (2nd day of rash); facial rash merges; tiny grey white papules on red base involve lips, gums, and intraoral-buccal mucosa (Koplik spots); rash associated with fever; rash disappears with fine skin peeling
Complications - Conjunctivitis (red watery eyes), ear infections, hearing loss, diarrhea, pneumonia, encephalitis, seizures
Rx - Supportive care, Tylenol (not aspirin), rest;     Labs serum titers (lgG, IgM)


Morbilliform Rash. Adults and babies may have more severe symptoms and complications.
PE enlarging red - pink fine spots starting over forehead, behind ears, and upper neck; spreading towards face, trunk, and then arms and legs (2nd day of rash); facial rash merges; tiny grey white papules on red base involve lips, gums, and intraoral-buccal mucosa (Koplik spots); rash associated with fever; rash disappears with fine skin peeling
Complications - Conjunctivitis (red watery eyes), ear infections, hearing loss, diarrhea, pneumonia, encephalitis, seizures
Rx - Supportive care, Tylenol (not aspirin), rest;        Labs - serum titers (lgG, IgM)


Rubella (German Measles)
Background - less common; Incubation: 2- 3 weeks Mild Prodrome 1 -4 days (URI symptoms), mild fever Rash - lasts 1 -5 days; Caution -can lead to abortions or fetal congenital abnormalIties (up to 50%) if pregnant when infected.
PE - maculopapular rash (small round raised and flat spots <= 5 mm) starting at hairline and face and spreads to trunk, arms and legs in 1 day, tender palpable lymph nodes (suboccipital, posterior auricular), associated with arthritis (joint swelling); rash does not become confluent
Rx - Supportive care, Tylenol (not aspirin), Benadryl, rest


Atypical measles: Background - status post receiving killed measles vaccine in 1960's.
PE - vesicular red spoIling patchy rash over arms, legs, hands, and feet; swelling of arms and legs; fevers, muscle aches, headaches, abdominal discomfort, cough, pneumonia.
Rx - Supportive care, Tylenol (not aspirin), treat complications


Roseola (Roseola Infantum, Sixth Dis.) common, contagious, viral (Herpes Virus 6), < 2-3 yrs
PE/Symptoms often high fever (lasts 2 -5 days), cough maculopapular rash (appears 2 days later - pink rosy red, 1 - 5 mm spots which may merge together but disappears in < 2 - 3 days), rash initially appears over neck, chest, trunk, and abdomen and spreads to arms, legs, and face; fever quickly decreases with rash appearance; Rx - Tylenol, supportive care


Erythema Infectiosum - (Fifth Disease, Parvovirus B19) - usually benign, generally in young school aged children; no prodrome; red rash on cheeks "slapped cheeks"; maculopapular rash spreading to trunk and extremities; fever; duration 3-5 days; Complications aplastic crises with hemoglobinopathies or HIV; Adults may get arthritis.


Infectious Mononucleosis (Epstein Barr Virus - EBV, Mono) -common infection, Incubation. 2- 8 weeks, transmission via saliva contact, complete course of IM 4-6 weeks
PE - fever, pharyngitis (sore throat - exudate over tonsils), weakness, fatigue (weeks), enlarged neck lymph nodes, enlarged spleen; rare - peripheral neuropathy, kidney inflammation, anemia, liver infection; rare rash < 5%; with Ampicillin Rx rash may occur up to 100%
Labs - TLC 5 - 10,000/mm3 (10-20% atypical lymphs), + Heterophile Ab;
Rx - Supportive care


Other Viral Exanthems - Echoviruses, Coxsackievirus A and B, Adenovirus, Enteroviruses

Impetigo - (Bullous - S. aureus, Impetigo Contagiosa)
Background - Contagious, Staph aureus or Streptococcus (GABHS) skin infection
PE - vesicular, purulent, crusting, honey colored, erythemetous or bullous lesions usually over face, arms, or legs of variable size
Rx - Bactroban, Cephalosporins -Cephalexin, Dicloxacillin, Erythromycin (50 mg/kg/day)


Scarlet Fever (group A beta hemolytic streptococci - S. pyogenes)
Background Contagious streptococcal throat infection (pharyngitis, tonsillitis) with fever, headache, nausea, ?vomit, ?abdominal pain -followed in 1-2 days by bright red rash (sandpaper quality) spreading from face to neck, chest, back, skin folds, and entire body over 3 - 4 days; followed by desquamation; strawberry tongue; circumoral pallor;
Rx - Penicillin, Erythromycin;
Complications - rheumatic fever, glomerulonephritis, pneumonia, meningitis


Toxic Shock Syndrome - (via Staph. aureus exotoxin, occasionally Strep.) - high fever, headache, vomiting, abdominal pain, diarrhea, myalgias, pharyngitis, hypotension, confusion, diffuse macular erythematous rash (like Scarlet fever) which later desquamates; effects 3 or more organ systems (GI, renal, hepatic, CNS, heme, muscle);
Rx - D/C tampons, drain or remove nidus of infection, hemodynamic support, ICU, anti-Staph (or ?Strep.) Antibiotics


Staphylococcal Scalded Skin Syndrome - < 5 years old, exfoliative toxin intraepidermal cleavage à bulla; local Staph infection nidus; diffuse erythema; + Nikolsky's sign - pressing on skin sliding of epidermis off skin; more likely to affect skin creases, groin, axilla, neck; later desquamates; known as Ritter's disease in the newborn;
Rx - Nafcillin, Oxacillin; admit


Meningococcemia - (via N. meningitidis) -has red maculopapular rash or with petechiae or purpura;
Symptoms - fever, chills, weakness, tachypnea, meningitis (fevers, alteration of mental status, stiff neck, shock, variable nonspecific symptoms);
Rx - IV Abx, ?prophylaxis


Ecthyma - Group A Strep skin infection, through epidermis, usually on lower extremities, ? ulcer present, surrounding erythema;
Rx - Oral Antibiotics


Erysipelas - Streptococcal cellulits with sharply distinct border;
Rx - Antibiotics


Lyme Disease (spirochete Borrelia burgdorleri via tick Ixodes dammini)
Background - #1 tick-born infection, more common < age 20.
Clinical stages - 1. Skin/systemic -tick bite - expanding red spot (red macular rash) with demarcated rim (Erythema chronicum migrans) - may be pustular, vesicular, crusting, or central clearing; lesion must be > 5 cm; other red rings (or curvilinear) elsewhere over skin; fevers, chills, muscle aches, neck and joint stiffness, malaise, enlarged lymph nodes, headaches; rash expands slowly days - weeks; 2. Neurologic/Cardiac (15-20%) - heart block (AV), headaches, meningitis, radiculitis, cranial nerve palsies (Bell's Palsy), optic neurtis, eye inflammations; 3. Arthritis -months - years after bite, knee #1 joint, potentially affects all joints
Labs - Serologic tests (Elisa or Western Blot) -may take 6 weeks after infection for positive results, and may be seropositive without the disease in endemic areas
Rx - Erythromycin, Amoxicillin, Ceftin, Biaxin, Ceftriaxone, Doxycycline ...


Rocky Mountain Spotted Fever

Background - infection (Rickettsia) spread by infected ticks; Incubation. 2 - 5 days, associated with outdoor activities especially in wooded areas
Clinical - fever, chills, fatigue, nausea, vomiting, muscle pains, back pains, headaches, may be able to identify history of tick bite; Red skin rash -starts about 4th day of fever (secondary to vasculitis, erythematous macular rash to darker-papular-petechial rash) starting at feet and hands (flexor sides) and spreads up arms and legs to include chest and abdomen
Rx - Tetracycline, Chloramphenicol, supportive care, usually requires hospitalization


Kawaski's Disease - Mucocutaneous Lymph Node Syndrome, males usually 1.5 - 2 yrs old, or < 10 yrs old; ?etiology; nonspecific vasculitis. Three Phases: 1. Acute Phase (1-2 wks): fever up to 40 C, variable rashes (scarlatiniform, morbilliform, measles like, urticaria, maculopapular), conjunctivitis (nonpurulent), erythematous lips and mucous membranes, strawberry tongue, palmar and plantar erythema and induration; unilateral cervical lymphadenitis, tachycardia, gallop, CHF, myocarditis, pericardial effusions, elevated ESR; 2. Subacute Phase (2-3 wks): less fever, desquamation, arthralgias, arthritis, nausea, vomiting, diarrhea, abdominal pain, urethritis, hydrops of GB, thrombocytosis, coronary artery dilation; 3. Convalescent Phase (3-6 wks +): coronary artery dilation and aneurysms;
Rx - High dose ASA, IV Immunoglobulin;
Dx - fever > 5 days + 4/5 symptom groups (conjunctivitis, cervical LNs, mucosal erythema, truncal exanthem, hands and feet erythema - edema - later desquamation


Scabies - Transmitted by a mite (small insect) directly from person to person; mites burrow under the skin and deposit eggs and feces which causes moderate to severe itching; Incubation: 3 weeks - 2 months
PE - scaling bumpy, red rash (papules) usually over axilla, wrists, web spaces over fingers and toes, elbows, knees, groin, genitalia, soles of feet, small burrows (with black dot at end)
Rx - Lindane - Kwell (avoid with pregnancy and < 6 months old), 6% Sulfur Ointment, Crotamiton Cream (Eurax), 5% Permethrin (Elimite) - per MD. Benadryl and corticosteroid cream prn. Treat family members and sexual partners.