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Many rashes in children are benign and self limited, but others
demand immediate intervention. An exanthem is a rash involving skin
with many causes—bacterial or viral infection, toxin, drug,
or noninfectious inflammatory conditions. An enanthem is a rash
involving mucous membranes. This chapter describes disease processes
in children for which dermatologic symptoms are diagnostic and serves
as a reference for the presenting complaint of “rash” in
children and young adults. Detailed descriptions of the most important
skin diseases are provided in chapters in Section 20, Skin Disorders,
with Chapter 243, Approach to Skin Disorders in the Emergency Department,
specifically outlining principles of evaluation of rashes in both
children and adults.
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Ask about fever and systemic symptoms, prior immunizations, potential human
or animal contacts, recent bites or stings, travel, recent prescription
or over-the-counter drug administration, and recent food and environmental
exposure. Ask about the initial location of rash, the pattern and
time frame of rash development, initial morphology, and whether any
topical or systemic medications have been applied.
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Most exanthems present as an isolated episode in a single child,
but outbreaks can also develop in groups of children. When evaluating
only a single child with a rash, the diagnosis can usually be made
by routine history and physical examination. When several children
develop similar-appearing skin lesions, obtain detailed contact
and exposure history, and consider the need to notify local public
health authorities.
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Obtain vital signs. Disrobe the child completely and perform
a complete physical examination. Check the scalp, ears, neck, mucous
membranes, all skinfolds, digits, and web interspaces, palms, and
soles. Look for ticks that may be adherent in hair-bearing areas
or skinfolds. Identify the morphology and determine the location
and distribution of the rash. In addition to the discussion below,
chapters in Section 20, Skin Disorders, discuss diagnosis based
upon anatomic location of the rash.
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Enteroviruses are a very common cause of illness and rash in
young children. Enteroviruses are small, single-stranded RNA viruses
belonging to the picornavirus group and include polioviruses, coxsackievirus,
and echovirus. The enterovirus family has been associated with a
wide variety of illnesses, including polio. Enterovirus infections
usually occur in epidemics, with a peak prevalence in the summer
and early fall. Transmission usually occurs by the fecal–oral
route and sometimes by respiratory or oral–oral transmission.1
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The clinical signs and symptoms of infection with coxsackieviruses
and echoviruses vary and can include nonspecific febrile illnesses,
upper and lower respiratory infections, GI infections and inflammations,
aseptic meningitis, or myocarditis. Similarly, the associated skin
manifestations include an array of exanthems. Diffuse macular eruptions, morbilliform erythema, vesicular
lesions, petechial and purpuric eruptions, rubelliform rash, roseola-like
rash, and scarlatiniform eruptions have all been reported.1 Strict
clinical-virologic associations are difficult to demonstrate, unlikely
to be practical in the ED, and equally unlikely to change the course ...