Assessment of rash in children

rash during defervescence from high fever, especially in infants; may predispose to seizures, encephalopathy, and aseptic meningitis; mild upper respiratory symptoms sometimes present

high fever; abrupt appearance of a generalised rose-pink rash on the trunk and proximal extremities during defervescence; cervical or occipital lymphadenopathy sometimes present; red papules and erosions of soft palate and uvula (Nagayama spots)

history of exposure to infected person; mild prodrome, particularly in children aged 4 to 10 years during winter and spring, arthralgia of hands, wrists, ankles, and feet not uncommon

initial slapped cheeks erythema with sparing of nasal ridge and peri-oral area, followed in 1 to 4 days by lacy rash on extremities

cutaneous eruption with pharyngitis, fever, and lymphadenopathy

fever, rash at day 4 to 6 of illness, initially on trunk and upper extremities, extends to forearms and face; lymphadenopathy (cervical, submandibular, or generalised), hepatosplenomegaly common; genital ulcerations can be noted

usually presents in the summer or autumn; vesicular rash on the palms of hands, soles of feet, and buttocks; low-grade fever, loss of appetite, sore throat, cough, abdominal pain, diarrhoea, general malaise​

elliptical vesicles; pharyngitis common, sometimes petechiae, oral erosions, and conjunctival haemorrhage

exposure to infected person; presentation can range from mild upper respiratory tract illness to severe viral pneumonia and acute respiratory distress syndrome; cough; fever; dyspnoea; loss of taste or smell; children can present with gastrointestinal symptoms more commonly than adults; mild ocular symptoms (e.g., conjunctival discharge, eye rubbing, conjunctival congestion) in children; children may develop multisystem inflammatory syndrome (MIS-C)

diverse presentations in the skin: urticaria, widespread maculopapular rash, papulovesicular rash, chilblain-like acral lesions, livedo reticularis, vasculitic rash; cutaneous findings usually present in the prodromal stage but chilblain-like lesions present late in disease​​

history of hay fever, atopic asthma, milk allergy, or family history of atopic diseases; or wool and lipid solvents; intense pruritus

scaling red patches or papules on face or extensor surfaces; xerosis; excoriations are typically evident; hypo/hyperpigmentation

typically <2 months of age, non-pruritic

thick scale in scalp ('cradle cap'); if widespread, may involve nappy area, perinasal area, eyebrows, glabella, and scalp; variable erythema

history of previous irritant or atopic dermatitis; burning and stinging

erythematous scaly papules or patches are noted; location is agent dependent, typically confined to pattern of offending agent (e.g., urine may cause nappy dermatitis in children aged <3 years); if patient scratches them, the lesions may become excoriated

history of recent exposure to allergens (e.g., nickel; poison ivy, poison oak, or poison sumac if resident of, or recent travel to, the US); previous history of allergy to these agents, or previous dermatitis in response to an agent; recurrent dermatitis in areas of exposure to potential allergens such as skincare products

erythematous scaly papules or patches are noted; location is agent dependent, typically confined to pattern of offending agent; if patient scratches lesions, they may become excoriated

fever, malaise, headache, arthralgia; history of recent upper respiratory tract infection

presence of herald patch (2- to 5-cm oval-shaped lesion with superficial scale, sometimes with a collarette of scale); within a few days crops of smaller lesions will be noted; lesions on trunk and proximal extremities, arranged along skin lines to form a 'fir tree' pattern on the back or a 'school of minnows' pattern on the flank

history of exposure to infected person, particularly within the household; history of existing skin condition (e.g., atopic dermatitis, scabies); usually starts in an existing lesion or in a traumatised area[133]Mork RL, Hogan PG, Muenks CE, et al. Longitudinal, strain-specific Staphylococcus aureus introduction and transmission events in households of children with community-associated meticillin-resistant S aureus skin and soft tissue infection: a prospective cohort study. Lancet Infect Dis. 2020 Feb;20(2):188-98. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995751 http://www.ncbi.nlm.nih.gov/pubmed/31784369?tool=bestpractice.com

typical lesion begins as an erythematous papule, then becomes a unilocular vesicle; when subcorneal vesicle becomes pustular, it ruptures and eventually becomes a yellow-golden crust that is a hallmark of the disease process; bullous lesions or collarettes of scale may be visible

history of immunosuppression or exposure to contaminated water (e.g., in a hot tub); history of previous episodes or skin infection in household members; may begin with trauma to skin, lesions typically resolve spontaneously

typically presents with multiple small papules and pustules on an erythematous base, on any hair-bearing site, with deeper infection resulting in follicle-centred dermal abscesses; scalp lesions may be present

may give history of exposure to another person or animal who has a lesion; presents on trunk, extremities, or face; pruritus

single or multiple (and asymmetrical), annular, scaly lesions with central clearing, slightly elevated reddened edge and sharp margination (abrupt transition from abnormal to normal skin) on trunk, extremities, or face

may give history of exposure to another person or animal who has a lesion, Trichophyton (most commonly) and Microsporum fungal species

patchy hair loss with varying degrees of scaling and redness in addition to occipital lymphadenopathy

intense pruritus, especially at night; history of exposure to another person with scabies

lesions can appear anywhere; sites of predilection are interdigital spaces, umbilicus, groin, and axillae; typically present as eczematous papules and patches, some lesions may become nodular; keratotic thickening can be seen on hands; urticarial lesions can be noted; burrows (intact tunnel with a tiny dark dot, the mite, at the end) are pathognomonic, typically seen in interdigital web spaces

localised lesions on exposed areas of skin, often after outdoor exposure; recent insect bites; often other family members also affected; rapid onset, urticaria within minutes to hours of exposure to insect bite or sting; bedbug bites occur on the upper body, neck, arms, and shoulder, sometimes seen in linear arrangements of threes

lesions usually occur on unclothed areas of skin; nodules on lower extremities in summer suggest bites; swelling may develop; generalised swelling and airway compromise may follow

rash appearing on day 2 of life and resolving by day 14

erythematous papules and sterile pustules, surrounded by an erythematous halo, on trunk, face, and extremities, palms and soles spared

more common in dark-coloured skin; usually present at birth or in first few days of life

superficial sterile pustules, affecting forehead, chin, neck, and shins, may also be seen on palms and soles, later hyperpigmented macules, some with a white collarette

inconsistent/incongruent history from parent/carer (e.g., fractures in a non-mobile child); frequent hospital visits and injuries; delay in presentation to healthcare practitioner; recurrent trauma episodes without adequate explanation; <2 years of age

cutaneous findings (bruises, finger marks, burns, scratches, scalds), signs of neglect and/or poor growth; child inconsolable in presence of parents; suspicious pattern of injury (metaphyseal 'bucket handle' fractures, posterior rib fractures, spiral fractures, unexpected old fractures); guarding or reduced range of movement; palpable callus in healing fractures (shin bruises, knee grazes); antalgic gait; limp

history of emotional distress, social or mental health problems, child may accept responsibility for self-harm, or may not accept responsibility for harming themselves (dermatitis artefacta)

evidence of actions of the patient on the skin, hair, nails, or mucosae: cutting, picking, or burning often in accessible areas such as the face and limbs

patches may have developed with sweating or excess moisture

Typically involves fold areas with an erythematous patch centrally and surrounding smaller satellite lesions, occasionally has whitish discharge centrally

may have prodrome of burning, followed by itching and lesions; in children with eczema, may present as eczema herpeticum (<20%)

grouped vesicles with surrounding erythema

development of skin-coloured papules, usually asymptomatic, possible history of exposure to an individual with similar lesions

skin-coloured small papules; occasionally with an eczematous surround (molluscum dermatitis)

occurs mostly in children aged <10 years, although this infection occurs much less frequently in areas where vaccination is routine; history of exposure to infected person; initial viraemia between days 4 and 6; days 11 to 20 secondary viraemia and appearance of characteristic vesicular eruption on erythematous base, often referred to as 'dewdrops on rose petals', low-grade fever, malaise, headache

vesicular rash; successive crops of lesions appear over several days on trunk, face, and oral mucosa; typically, lesions are in different stages of evolution from vesicles to crusts; haemorrhagic and bullous lesions rarely occur; may see concentration in areas of previous eruptions or irritation​​

history of exposure to infected person; prodrome of cough, coryza, conjunctivitis, and Koplik spots (grey-white papules on buccal mucosa/soft palate); unimmunised or immunodeficient patient; lasts about 5 days

erythematous macules and papules begin on the forehead, hairline, and behind the ears, then extend cephalocaudally; Koplik spots

history of immunocompromise; cutaneous eruption with pharyngitis, fever, malaise, and headache

fever, rash with petechiae commonly present; lymphadenopathy (cervical, submandibular, or generalised), hepatosplenomegaly common; signs of sepsis in severe disease (immunocompromised patients)

residence in or travel from a dengue-endemic region within the past 2 weeks; fever; skin flushing, evolving into maculopapular rash; backache, arthralgia, myalgia, bone pain, headache, retro-orbital pain; in severe dengue petechiae, dyspnoea, abdominal distension, epistaxis, bleeding gums, haematemesis, melaena, bleeding from venepuncture site

skin flushing; maculopapular rash; fine petechiae scattered on the extremities, axillae, face, and soft palate, usually in the febrile period; fever; epistaxis, gingival bleeding, haematemesis, melaena, or bleeding from a venipuncture site; features associated with shock, including tachycardia, prolonged capillary refill time, cold clammy skin; hepatomegaly, ascites, pleural effusion​

acute syndrome 3 to 6 weeks after exposure; fatigue, malaise, headache, and myalgia

fine morbilliform eruption on trunk and upper arms, occasionally palms and soles; lasts for 4 to 5 days, resolves spontaneously

16- to 18-day incubation period, prodrome of fever, headache, joint pain, and upper respiratory symptoms; more common in unimmunised or immunodeficient patients

maculopapular eruption beginning on the face and spreading cephalocaudally; petechial macules on soft palate (Forschheimer spots), tender cervical lymphadenopathy, joint tenderness

positive family history of psoriasis; pruritus; history of arthritis

discrete erythematous plaques with thick silvery scales located on elbows, knees, and scalp; in 'inverse psoriasis' less scale is evident, and psoriatic lesions are noted in axillae, other folds, and genital area

acquired solitary or widespread cutaneous eruption, lesion periodically urticates and blisters, then returns to original form

5- to 15-mm papules, yellow-brown to yellow-red; oedema, urtication, vesicle and bullae formation, urticaria surrounding erythematous flares when rubbed (Darier sign)

history of exposure in a tick-endemic area; summer/autumn incidence, outdoor activity predisposing to tick exposure about 1 week before development of influenza-like syndrome, gastrointestinal symptoms, rash rarely present in first 3 days of illness; headache, confusion, malaise, nausea, vomiting, myalgia, abdominal pain, diarrhoea; seizures uncommon

fever; rash begins as a macular eruption on wrists, ankles, palms, and soles, and spreads centrally, generally sparing the face, which becomes petechial as the vasculitis progresses; intense inflammation or ecchymoses may be present at site of a tick bite; conjunctivitis, altered mental status, lymphadenopathy, peripheral oedema, hepatomegaly

history of exposure in tick-endemic area; rash develops 1 to 2 weeks after tick bite; headache, myalgias, fatigue, arthralgia

erythema migrans is characteristic; meningismus, neuropathy

history of recent use of drug, typically antibiotics such as penicillins, sulfonamides, cephalosporins; chemotherapeutic agents; use of new nutritional or herbal supplements; past history of medication allergy; eruption typically occurs within 4 to 14 days of exposure to a new medication; pruritus

maculopapular eruption on the trunk and extremities; sometimes febrile; in allergic reactions, cutaneous findings predominate; patient may appear unwell or show mild malaise

acute-onset urticaria, flushing, angio-oedema, wheezing, dyspnoea, pruritus, nausea or vomiting, abdominal cramps, rhinitis; exposure to sensitiser, e.g., venom, latex, food, medication; history of atopy or asthma; previous anaphylactic reaction

tachycardia, wheeze, dyspnoea, urticaria, flushing, angio-oedema, swelling of lips, eyelids, and tongue, agitation, confusion, abdominal pain, stridor (if laryngeal oedema develops), hypotension, dizziness, collapse

may present with non-specific, non-localised symptoms (especially in younger children); fever, low body temperature or temperature instability; altered mental state or behaviour (e.g., drowsiness, delirium, lethargy, irritability, non-responsiveness, or apnoeas); may be history of risk factors (e.g., immunosuppression and comorbidities); healthcare associated factors (e.g., indwelling vascular catheters, recent invasive procedures); in neonates, history of premature rupture of membranes, chorioamnionitis, or intrapartum maternal fever may be present; may present with circulatory shock; poor feeding, or emesis

tachycardia, tachypnoea, fever (>38°C [>100.4ºF]) or hypothermia (<36°C [<96.8ºF]); infants and young children may be hypotonic with normal or poor peripheral perfusion and hypotension; prolonged capillary refill, mottled or ashen skin, cyanosis, low oxygen saturation, reduced urine output; may be absence of bowel sounds; hypo- or hyperglycaemia may be present

exposure to chemotherapy

maculopapular rash, characterised by monomorphic erythematous papules

recent medication history (e.g., anticonvulsants, sulfonamides, non-steroidal anti-inflammatory drugs, allopurinol, antihelminthics, antimalarials, chlormezanone, corticosteroids, AIDS medications such as nevirapine, selective cyclo-oxygenase-2 [COX-2] inhibitors, and lamotrigine); recent upper respiratory infection, infection with mycoplasma, herpes, Epstein-Barr virus (EBV), or cytomegalovirus (CMV)

spectrum of severe, generalised exfoliative dermatitis; widespread cutaneous involvement, involvement of ≥2 mucosal surfaces (oral, conjunctival, anogenital); skin lesions initially targetoid, often become confluent; bullous lesions may develop; positive Nikolsky's sign (blister induced with lateral pressure) in involved areas; lesions are painful; patient appears acutely unwell, uncommonly, secondary infection may develop

history of recent use of anticonvulsants, sulfonamides, allopurinol, or minocycline; fever, dermatitis, lymphadenopathy, internal organ involvement; abdominal pain; facial swelling​

morbilliform eruption usually found initially; face, upper trunk, and upper extremities are affected first with later involvement of lower extremities; fever, lymphadenopathy, clinical features of severe visceral involvement (e.g., right upper quadrant tenderness/hepatomegaly with hepatitis, crackles/wheezes/tachypnoea with pneumonitis)

history of recent use of sulfonamides, penicillin, antimalarials, anticonvulsants; history of recent infection with mycoplasma, herpes, Epstein-Barr virus (EBV), or cytomegalovirus (CMV); rapid onset of painful lesions

typical target lesions (annular erythematous rings with outer erythematous zone and central blistering sandwiching a zone of normal skin tone) with symmetrical distribution on extremities; atypical targetoid papules (no central blistering); mucosal (oral/genital) erosions

abrupt onset of fever and malaise; history of immunocompromise (e.g., asplenia) or exposure to infected person; may progress rapidly

petechial or purpuric rash on extremities or generalised (typically non-blanching), signs of sepsis (cold hands and feet, leg pain, pallor, mottled skin, drowsiness, respiratory distress), fever, nuchal rigidity; may initially have non-specific erythematous macular or maculopapular lesions, typically located on the extremities

scarlatiniform rash, fever, sore throat, headache, nausea and vomiting, abdominal pain, skin or soft tissue infection including impetigo, surgical wound infection, absence of cough or other viral symptoms; scarlatiniform rash may present prior to or independent of symptoms of pharyngitis, especially in children aged <5 years

scarlatiniform rash: diffuse, finely papular (sandpaper-like), erythematous rash that blanches with pressure, accentuated in flexor creases producing red streaks known as Pastia’s lines, flushed 'scarlet' bilateral cheeks with circumoral pallor, in patients with darker skin, may appear as though sunburnt; inflamed tongue with a white coating and prominent papillae ('strawberry tongue'); tonsillopharyngeal inflammation, patchy tonsillopharyngeal exudates, palatal petechiae, tender and enlarged anterior cervical lymph nodes; skin desquamation is a late finding (3-4 days after scarlatiniform rash); pyoderma

age <6 years or history of renal insufficiency; history of recent infection of skin, respiratory tract, mouth, or gastrointestinal tract; history of skin infection in household members; diffuse erythematous rash, prodrome of moderate fever, malaise, and tender skin; more likely than toxic shock syndrome in children

generalised erythematous rash with blisters and erosions accentuated in the intertriginous areas; skin exfoliation, fragile bullae on surface of skin, positive Nikolsky's sign (blister induced with lateral pressure); fever

history of recent surgery, pharyngitis, headache, high-grade fever, confusion, malaise, diarrhoea, vomiting, respiratory distress; history of recent super-absorbent tampon use in adolescent females; after surgery or associated with abscesses and closed space infections

diffuse, erythematous rash on trunk, palms, and soles of feet, may be desquamative; high fever, hypotension, evidence of multi-organ involvement

maternal history of secondary or tertiary syphilis in a young infant; neonate develops lesions within first 2 weeks of life subsequent to transplacental transmission; history of sexual activity in older child/adolescent; secondary-stage lesions generally appear 4 to 10 weeks after initial appearance of primary lesions; patients present with a variety of symptoms, such as malaise, sore throat, headache, weight loss, low-grade fever, pruritus, and muscle aches, in addition to dermatological manifestations

congenital syphilis, primarily acrally located vesicles and bullae, may be haemorrhagic, secondary syphilis, painless coin-like macular lesions on flank, shoulders, arms, chest, back, hands (palms), and soles of feet; lesions typically reddish-brown and 3 to 10 mm; variations of secondary syphilis skin eruptions may include pustules; other associated lesions include patchy (moth-eaten) alopecia, genital lesions (condylomata lata), superficial mucosal erosions (mucous patches)

history of sexual activity, dysuria, vaginal or penile discharge, arthritis

skin papules that progress into haemorrhagic pustules, bullae, petechiae, or necrotic lesions on extremities; polyarthritis; conjunctivitis

prolonged low-grade fever, malaise, arthralgias, myalgias, night sweats, heart palpitations, weight loss, rigors, diaphoresis, congenital heart disease

Janeway lesions (painless maculopapular lesions on palms and soles), heart murmur, Osler nodes (painful nodules on tips of fingers), Roth spots (haemorrhagic retinal lesions)

history of food allergy; rapid onset, urticarial eruption within minutes to hours of exposure

urticarial eruption, generalised swelling and airway compromise may follow, hypotension and tachycardia generally present

recurrent infections, fever, chills, fatigue, weakness, infection, anorexia, night sweats, shortness of breath, abdominal pain, bony tenderness, epistaxis, bruising, petechiae, bleeding gums, gingival hyperplasia

petechial rash; fever, lymphadenopathy, hepatosplenomegaly, pallor, bleeding gums

usually rapid onset of bleeding, sometimes post-viral or post-immunisation

petechiae, ecchymoses, buccal mucosal haemorrhages, absence of lymphadenopathy or organomegaly

usually children aged <5 years, winter to late spring, fever for ≥4 days

fever, cervical lymphadenopathy, conjunctival injection, oral hyperaemia, strawberry tongue, erythema and oedema of extremities with desquamating rash on palms and soles; maculopapular rash on trunk, occasionally marked perineal erythema and desquamation; variable multi-system findings

periodic, transient fevers associated with rapid rash onset; rash disappears as fever remits; joint pain and myalgia commonly present

fever, transient erythematous rash favouring trunk and sites of pressure; joint tenderness (e.g., knees, ankles)

history of upper respiratory tract infection; abdominal pain; joint pain, arthralgia

classic tetrad of petechial or purpuric lesions (typically on lower extremities), abdominal pain, arthritis/arthralgia, and IgA nephropathy

malar (butterfly) rash, fever, fatigue, recurrent infection, arthralgias, malaise, chest pain

malar rash, discoid rash, photosensitive rash; fever, arthritis, serositis (pleuritis or pericarditis), hypertension, oedema, hepatomegaly, splenomegaly, lymphadenopathy

rash; prolonged fever, history or evidence of group A streptococcal infection; sore throat, joint pains, chest pain, dyspnoea, involuntary movements

erythema marginatum (fleeting pink rash typically involving the trunk and proximal arms and legs), polyarthritis (typically migratory and involving large joints), subcutaneous nodules (typically firm and painless), murmur, pericardial rub, Sydenham chorea

cough, fatigue, arthralgias, wheezing, photophobia, red eye, blurred vision, weight loss, headache

erythema nodosum; multiple scattered papules (most commonly on face but may affect any site) or larger plaques (often multiple with a symmetrical distribution), lupus pernio (indurated plaques with discoloration of nose, cheeks, lips, and ears); weight loss, lymphadenopathy, uveitis

vesicular rash in an otherwise well neonate

1- to 2-mm vesicles on face, neck, and trunk

a characteristic rash that progresses in sequential stages (from macules, to papules, vesicles, and pustules); anorectal symptoms have been reported (e.g., severe/intense anorectal pain, tenesmus, rectal bleeding, or purulent or bloody stools, pruritus, dyschezia, burning and swelling), and may occur in the absence of a rash; fever may be a symptom of the prodromal period (usually preceding the appearance of the rash), but may present after the rash or not at all; other common symptoms may include myalgia, fatigue, asthenia, malaise, headache, sore throat, back ache, cough, nausea/vomiting; there may be a history of recent travel to/living in endemic country or country with outbreak, or contact with suspected, probable, or confirmed case

rash or skin lesion(s) are usually the first sign of infection; physical examination may reveal a rash or lesion(s), and possibly lymphadenopathy; rash generally starts on the face and body and spreads centrifugally to the palms and soles (it may be preceded by a rash affecting the oropharynx and tongue in the 24 hours prior that often passes unnoticed); lesions simultaneously progress through four stages - macular, papular, vesicular, and pustular - with each stage lasting 1-2 days, before scabbing over and resolving; lesions are typically 5-10 mm in diameter, may be discrete or confluent, and may be few in number or several thousand; vesicles are well-circumscribed and located deep in the dermis; the rash may appear as a single lesion in the genital area without a prodromal phase; perianal/rectal lesions and proctitis may be present​; lymphadenopathy typically occurs with onset of fever preceding the rash or, rarely, with rash onset, may be submandibular and cervical, axillary, or inguinal, and occur on both sides of the body or just one side; inguinal lymphadenopathy has been commonly reported