1. Children’s Rashes and 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

51. Information Papular and vesicular rash noted behind ears and on back of neck. This may lead to secondary excoriation and crusting.

52. Head Lice (Pediculosus Capitis)

53. Pitfalls Beware ‘labelling’ any rash. If in doubt describe it. Assess the child properly and treat according to symptoms. Some very sick children have no rash. Some spectacular rashes are of little significance.

54. Summary Understanding the terminology will help you to document your findings. Repeated examination of rashes will aid your recognition. Consult the textbooks and experts before commencing treatment.