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Introduction to Rashes

Introduction to rashes.
Hi, I’m Tina Newton. I’m an A&E Consultant in a big Children’s Emergency Department. Today I am going to talk to you about rashes. Now rashes in children are a really common problem and they cause a huge amount of anxiety for parents. Whether they are acute rashes that have just suddenly appeared or whether they’re a problem that the child has had for many weeks or many months. Rashes really do cause a problem. So in this session today, our aims are going to be to get you to be able to recognise rash patterns, think about what the causes of those rashes might be, and how you actually assess the patient to help you make decision if this is really a significant problem.
We’ll talk a little bit about the basic management of patients with rashes and we’ll get you to concentrate on recognising life threatening presentations because that’s the really important part of this. So when you come to see a patient with a rash you’re going to go through your initial assessment of a patient in the same way that you would anybody, you do your ABC approach because that’s the important thing so that you’re not missing anything vital. but we have said this before, and I’lll say it again, and again. The thing that you have got to do when you are going to see a patient is say, are they actually sick? Is this patent just sick and hot and miserable?
Or is this kid really, really unwell? And it’s back to the big sick/little sick approach that we’ve used time and again because it’s a really, really important concept. So the child with a rash who’s only just come out in it, they have had a bit of a temperature but you come to the house and they’re running past you at high speed… I’m not reckoning that child is a big sick and in my head that patient is one of those that I can put down a level on my level of anxiety.
So your initial assessment goes down the normal process and just in the back of your mind you’re saying all the time, is this a kid that I need to be worried about? Is this a kid who’s sick? And you have done your ABC and then the next bit you do is look at the rash. There are all sorts of terms for different sorts of rashes, and as doctors particularly we like to give them Latin names because it makes us feel really important but ultimately there are only a few rash patterns you need to be able to recognise. Most of us can recognise the vesicular rash of chicken pox.
And generally chicken pox is one of those that you can put down on the little sick route with a patient because most kids with chicken pox aren’t particularly unwell. But occasionally a child with chicken pox can be. If you ever see a child with infected chicken pox or horrendous situations like necrotising fasciitis that is in the big sick category, way up at the top. So don’t always be fooled just because you have seen something that you recognise and that you think that’s going to be ok that the patient is.
If the patient in front of you looks really unwell, even if you look and you say I recognise that rash, that’s chicken pox, don’t just suddenly feel that you have got all the answers. But calling them a macular rash, a papular rash, a petechial rash that’s not the important thing, the important thing is what do we think is causing this rash and what do we need to do about it? So out of all of those rashes, the one that really, really freaks parents is the petechial rash. And the petechial rash is the little rash, tiny little blood spots under the skin that don’t disappear when you stretch the skin.
And the first thing every parent will be thinking is, Is this the meningitis bug? Because that’s the thing that they’ve read about. They’ve read about the child who one minute was absolutely fine and two hours later was in hospital and was dead. That’s the thing that parents worry about. But you know, most of the time petechial rashes aren’t caused by meningitis. So again, if you look back at that patient and that patient has a petechial rash on their face but they’re smiling at you and they’re jumping up and down and pulling at your stethoscope and they’re hard to catch, well that really isn’t going to be a patient with meningococcal disease.
So think about the overall appearance of the patient, have an approach to how you actually look at rashes. How do I assess a rash? Where has it come from? Think about the history a bit, was it there 5 minutes ago? Has it come on suddenly? Did it come on immediately after they had eaten egg for the first time? Could this be a patient who has got an allergic reaction to something? Most rashes in children are relatively minor, many of them are caused by simple viral illnesses. The important thing is matching the rash with the clinical picture of the patient.
If the child is sick and they have got a rash then that rash may be a clue to you why they are sick. But ultimately you still need to get that child to the right place at the right time. So what we’re going to do in the simulation that follows is we’re going to take you through a case involving a patient with a rash and help you try to look at how you would approach that case yourself.

For all those non-medics out there, parts of this topic are quite technical. You may find it easier to first download the Parent Information Leaflet attached to the bottom of this page. This is written in plain English and avoids technical jargon.

Dr Tina Newton will guide you through this topic, rashes. Rashes are a common reason for children to present to a health care provider. Whether they are new onset or chronic, rashes cause significant anxiety to carers.

Learning Outcomes

  • Understand the common causes of rashes
  • Be able to spot the different features of different types of rash
  • Be able to spot potentially serious rashes
  • Understand what initial treatment is required

As in all of the sessions in this MOOC, the first question I would like you to ask yourself is, ‘Does the child look ill or do they look well?’. Of course well looking children can rapidly become very unwell but the child who runs past you and has to be caught by a parent to show you the rash, is unlikely to have a life threatening disease. On the other hand the child whose rash is part of a severe allergic reaction will look unwell from the outset.

In this session we are looking more at sudden onset rashes as these are more likely to prompt a call to the emergency services. Common chronic rashes such as eczema in children are more likely to present to health care services because the parents are at the end of their tether managing them, rather than because of a life threatening complication. But that said, children can become ill with any long term rash if, for example repeated scratching leads to infection or if they pick up another co incidental infection like chicken pox. But thinking about acute rashes, the common presentations we see will be rashes due to infection, rashes due to a reaction to something, or rashes that are a marker of something else going on in the body.

All rashes can be described in terms of the appearance of the lesions on the skin. The terms are used to describe the rash and not necessarily point to the diagnosis.

The commonest terms that we use are macular (flat lesions), papular (raised lesions), vesicular (fluid filled blisters), urticaria (hives), petechiae (dark red spots that do not temporarily disappear when the skin is stretched or pressed on) and purpura (bruises).

Of all of these, the rash that tends to strike fear into parents and health workers alike is the non-blanching, petechial rash as this may be a sign of meningococcal disease (the meningitis bug). But remember that there are a lot of other causes of this rash and in a child who is otherwise well and who doesn’t have a fever, these should all be considered. A child who has vomited repeatedly and has petechiae only on the upper body may well have them because of the increased pressure in the superior vena cava caused by vomiting. A child with widespread petechiae and/or bruising may have idiopathic thrombocytopenia purpura (ITP); in many cases a benign disease. But the child with petechiae and fever needs to be looked at in a different light. These children need to be assessed rapidly and taken to somewhere they can receive urgent intervention.

Take a look at the following simulation and use the questions posed to help you to learn a little more about rashes in children.

The 999 Call

Let’s have a look at this potentially emergency situation. A frantic mum calls 999. She is hysterical, her 5 year old daughter has been unwell today with a high temperature. She has come out in a rash over her whole body. She looks really unwell. Mum begs for someone to come quickly and help.

A paramedic team is dispatched.
What will they need to consider on they way?
What do you think their priorities will be?

Discuss below with the group.

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Emergency and Urgent Care for Children: a Survival Guide

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