Rashes in children

Childhood rashes are common — most are harmless and no cause for concern, and disappear without the need for treatment. If a child is in good health and has no other symptoms, simple observation of the rash over the following few days may be sufficient and the rash should disappear without need for significant treatment. If the rash is accompanied by high fever, breathing difficulties, vomiting or reduced general health, it may be indicative of something more serious.

Patients aged under 15 years comprise around 20% of the average GP list and account for one in four GP consultations. School children visit the GP between two and three times a year, but this figure is doubled in the under-fives who visit the GP an average of six times a year^[1]
.

Skin rashes in children require careful history taking, assessment and examination of the skin. This article describes a range of rashes in paediatric patients, according to a step-by-step approach to the classification and identification of the rash.

Rash with fever

Slapped cheek syndrome

Slapped cheek syndrome (also called fifth disease or erythema infectiosum) is caused by parvovirus B19. Infection is most common in children, although it can occur in people of any age^[2]
. Infection is also seasonal, with increases observed in spring and early summer, and additional increases in incidence occurring every 3–4 years^[3]
.

Patients usually develop symptoms 4–14 days post-infection, but sometimes these may not appear for up to 21 days. The defining feature is a bright red rash on one or both cheeks, often with an accompanying paleness around the mouth^[4]
. Other symptoms can also include low-grade fever, runny nose, sore throat, headache, upset stomach and generally feeling unwell^[2]
.

A light pink erythematous, macular rash may also appear on the chest, stomach, arms and thighs^[4]
. This often has a raised, lace-like appearance and may be itchy, clearing spontaneously within a few days.

Children should be encouraged to rest and drink plenty of fluids, and babies should continue their normal feeds^[2]
. If the child is experiencing fever, headache or joint pain they can be treated with paracetamol and ibuprofen. Additionally, antihistamines can be used to help with any itching. Once the rash has formed, the child is no longer contagious therefore it is not necessary for him or her to stay away from school or nursery, or avoid contact with pregnant women. However, parents and carers should inform anyone who has been in contact with the child during the prodromal period so they can be managed effectively^[5]
.

Chickenpox

Chickenpox is caused by the varicella zoster virus (VZV). The infection commonly occurs in childhood, but may occur at any time^[6]
. Chickenpox is usually a self-limiting disease in healthy children.

The symptoms of chickenpox begin one to three weeks after infection. The main symptom is a rash that develops in three stages:

1. Spots — small, red erythematous macules develop on the face or chest before spreading to other parts of the body;
2. Blisters — over the next few hours or the following day, very itchy fluid-filled blisters develop on top of the spots and have a typical erythematous halo;
3. Scabs and crusts — after a further few days, the blisters dry out and scab over to form a crust; the crusts then gradually fall off by themselves over the next week or two.

Chickenpox is contagious until all the blisters have scabbed over, which usually occurs around five or six days after the rash first appeared^[7]
.

Mild cases of chickenpox only require symptomatic treatment. Relief of itching and prevention of scratching, which predisposes to secondary bacterial infection, may be difficult especially in younger children^[8]
. Antihistamines can help with itching, as well as wet compresses, sodium bicarbonate baths and colloidal oatmeal baths^[9]
. For neonates (children aged less than 28 days), specialist advice for management should be sought immediately^[7]
.

Hand, foot and mouth

Hand, foot and mouth disease (HFMD) is due to enteroviral infection, most commonly Coxsackie A16, although other group A and B Coxsackie viruses may be causative. Less commonly, but more seriously, it can be caused by enterovirus 71^[10]
.

The first observed symptom is usually a low-grade fever, followed by scattered papules that develop into vesicles affecting the hands, feet and mouth, where they progress to shallow ulcers^[10]
,^[11]
. However, lesions may also be present on other parts of the body (e.g. buttocks and groin)^[12]
.

The condition is typically mild and self-limiting, resolving within ten days. Children should be encouraged to drink plenty of fluids. Paracetamol or ibuprofen can be used for fever and pain^[12]
, using the doses given in the BNF for Children. A topical analgesic or anaesthetic, such as benzydamine hydrochloride or lidocaine, may be recommended.

Patients should be referred to A&E if they have any of the following symptoms:

• Any signs of dehydration (e.g. passing little or no urine);
• They develop seizures, confusion or weakness;
• A temperature of 38â°C or above (for children aged under three months) or a temperature of 39â°C or above (for children aged between three and six months);
• If there is any discharge of pus;
• If symptoms are getting worse or have not improved after seven to ten days^[12]
  .

Scarlet fever

Scarlet fever is an infectious disease caused by toxin-producing strains of the bacteria Streptococcus pyogenes, also known as group A streptococcus (GAS). Any child presenting with symptoms of scarlet fever needs to be referred to their GP immediately.

Onset is usually rapid, with fever, sore throat, vomiting, headache, abdominal pain, myalgia and malaise^[13]
. This is followed 12–48 hours later by a blanching rash, which usually starts on the neck then extends to the trunk and extremities. The tongue may also be covered in a heavy white coating, through which red papillae may be visible. The white covering disappears after a while, leaving the tongue with a beefy red appearance (known as ‘strawberry tongue’)^[13]
.

The rash is a fine erythematous punctate eruption, which blanches with pressure. This is followed by dry rough skin, with the feel of sandpaper. Seven to ten days later, desquamation of all affected areas will occur, which may last on the palms for up to a month.

Scarlet fever is highly contagious and, if not treated with antimicrobials, can be infectious for two to three weeks after the onset of symptoms (with antimicrobials it remains infectious for 24 hours after starting treatment). Scarlet fever is treated with antibiotics and symptomatic relief (e.g. paracetamol to reduce the fever), and fluids should be maintained to prevent dehydration^[13]
.

Rash with itching

Prickly heat rash/heat rash

Heat rash is an uncomfortable but usually harmless condition. Prickly heat (also known as miliaria rubra) appears without a preceding disorder and should clear up after a few days without treatment.

The symptoms of heat rash are small red spots — numerous papules around the size of a small pin head and elevated so as to produce a considerable roughness of the skin, itchy and prickly feeling with mild swelling and redness. They can appear anywhere on the body^[14]
.

Treatment includes avoiding excessive heat and humidity, ensuring adequate fluid intake, wearing loose cotton clothing and using calamine lotion. On GP advice, a mild steroid cream such as hydrocortisone cream may be prescribed^[14]
.

Eczema

Atopic eczema (also known as atopic dermatitis) is a chronic inflammatory skin condition that causes the skin to become itchy, red, dry and cracked^[15]
. Although atopic eczema can affect any part of the body it mainly affects the hands, insides of the elbows, backs of the knees and the face and scalp. In some children, the condition will improve, or even clear completely, as they age.

Patients should be advised to avoid drying agents (e.g. soap, prolonged bathing and chlorinated pool water). Bath oil and fragrance-free emollients can help, and oral antihistamines can be considered for severe itching (oral antihistamines should not be used routinely in the management of atopic eczema in children^[16]
). Patients can also be prescribed topical steroids to reduce swelling, redness and itching during flare-ups.

Pharmacists and healthcare professionals should consider the severity of atopic eczema, the child’s quality of life (e.g. everyday activities and sleep) and psychosocial wellbeing when deciding management options^[16]
. Patients should be referred to their GP if their skin is cracked or blistered, if there is a history of atopic eczema in the family, if the child has allergies and/or asthma, or if the patient has painful eczema or fever.

Hives

Hives (also known as urticaria) is a superficial swelling of the skin. Hives can occur due to certain allergies to foods, drugs, insect bites, skin contact to chemicals, or cold or heat exposure^[17]
.

Hives are small raised areas (1–2cm) of the skin that develop suddenly. They are red or white in colour and are surrounded by an area of redness. The rash may disappear, but may reappear in hours or days. Hives may coalesce with others, making the rash look extensive^[18]
. The rash is often itchy, and can be localised or generalised^[18]
.

As hives tends to be self-limiting, treatment is often not required. However, patients should avoid trigger factors, and use calamine lotion and oral antihistamines for treatment. Topical corticosteroids can also be used for severe cases^[17]
. Referral to the GP may be required if symptoms persist for more than six weeks and are associated with pain and fever.

Ringworm

Ringworm (also known as tinea) is a common fungal infection of the skin, caused by dermatophytes, that can appear almost anywhere on the body. It is not serious and can usually be treated easily, however, it is contagious (e.g. through direct contact with an infected person or animal)^[19]
.

Ringworm appears as single or multiple circular red or silvery ring-like rashes on the skin^[19]
. Blisters and pus-filled sores may form around the rings. The skin can be inflammed and itchy.

For mild, non-extensive ringworm, topical antifungal creams, such as clotrimazole cream 1%, can be used for treatment^[20],[21]
; however, more serious infections may need to be referred to a GP, where either stronger topical preparations or oral antifungals may be required. Babies aged less than one month should always be referred to their GP. If the patient has symptoms on the scalp, ringworm that has not improved after two weeks of over-the-counter antifungal cream, or if the patient has an underlying condition, is immunosuppressed or is on steroids, he or she should also be referred to the GP.

Rash without fever or itching

Milia

Milia are one of the most common transient skin disorders in neonates; the condition is present in around 30–50% of neonates. These consist of 1–2mm white or yellowish papules on the face^[22]
; the nose is usually predominantly affected. Less commonly, the trunk and extremities are also involved. Milia are epidermal keratin cysts developing in connection with the pilosebaceous follicle^[23]
.

Neonatal milia does not require treatment as it spontaneously disappears within a few weeks.

Erythema toxicum

Around half of all newborns develop a blotchy red skin reaction called erythema toxicum, usually at two or three days old^[24]
. It is thought to be a benign condition that causes no discomfort to the infant.

The lesions are firm, 1–3mm, yellow or white papules and/or pustules on a red swollen base. The lesions tend to be seen on the anterior and posterior trunk but may also be found on arms, legs and face^[25]
.

Erythema tends to last up to five to seven days and the lesions heal without any medical intervention.

Molluscum contagiosum

Molluscum contagiosum is a common, generally benign, contagious viral infection of the skin, which is caused by molluscum contagiosum virus (MCV)^[26]
. The condition is more prevalent in children, with the lesions involving the face, trunk, and extremities.

Molluscum contagiosum produces a papular eruption of multiple umbilicated lesions. The individual lesions are discrete, smooth and dome shaped^[27]
. They are generally skin coloured with an opalescent character. The central depression or umbilication contains a white, waxy curd-like core. The size of the papule is variable, depending on the stage of development, usually averaging 2–6mm.

Molluscum contagiosum is usually a self-limiting disease (usually within 6 to 18 months^[27]
), for which treatment is not mandatory. However, it is important not to squeeze the spots because the white substance contained within them is highly infectious, so there is an increased risk of the infection spreading to other parts of the body^[27]
. If treatment is deemed appropriate, multiple topical or surgical treatments are available.

Nappy rash

Persistent occlusion of the nappy area, resulting in overhydration and maceration of the epidermis causes nappy rash. The defective epidermal barrier allows irritants from the urine and faeces to penetrate and initiate an irritant contact dermatitis. The inflamed skin is quickly colonised with Candida albicans
^[28]
.

Convex surfaces closest to the nappy (buttocks, genitals, pubic area, and upper thighs) tend to be red, with sparing (no redness) in the deeper flexures. The rash has a glazed appearance if acute, or fine scaling if more longstanding^[28]
.

Overhydration improves with nappy-free periods and frequent nappy changes. Barrier creams (e.g. zinc and castor oil) should be applied at every nappy change to protect the skin. However, if nappy rash is causing discomfort, a topical hydrocortisone cream (0.5% or 1%) should be considered for children aged one month or older for a maximum of seven days ^[28]
. If candida infection is confirmed or suspected, a topical imidazole (e.g. clotrimazole or miconazole) should be prescribed and a barrier preparation should not be used until after the candidal infection has settled^[28]
.

Other rashes

Bacterial meningitis

Bacterial meningitis is an infection of the surface of the meninges^[29]
. It can affect anyone, but is most common in babies, children, teenagers and young adults^[29]
. Meningococcal disease and bacterial meningitis continue to have high mortality rates; around 1 in every 10 people affected dies^[30]
.

Healthcare professionals should be aware that classical signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis^[28]
,^[31]
. Early non-specific symptoms of meningitis include fever, vomiting/nausea, lethargy, irritability, ill appearance, refusing food/drink, headache, aches and respiratory symptoms. Less common early symptoms include shivering, diarrhoea, abdominal pain and distention, coryza and ear, nose and throat symptoms^[29]
. Children suspected of having any symptoms of meningitis should be taken directly to hospital. Public Health England needs to be notified about all cases of suspected meningitis.

General features of meningitis are non-blanching rash (anywhere on the body), altered mental state, shock, unconsciousness and toxic or moribund state. If a patient presents with these symptoms, the glass test should be used on the rash to confirm diagnosis (i.e. the side of a clear glass should be firmly pressed against the rash; if it does not fade under pressure, the patient may have septicaemia and needs urgent medical attention)^[29]
,^[32]
. However, a rash is not always present with meningitis and may be less visible in darker skin tones, therefore, it is important to also check the patient’s soles of feet, palms of hands and conjunctivae^[29]
.

For children aged three months or less, treatment is intravenous cefotaxime plus amoxicillin or ampicillin^[29]
. Children aged over three months should be treated with intravenous ceftriaxone (or cefotaxime if co-administering calcium infusions)^[29]
. Patients may also need to be treated for shock with intravenous fluids and may be started on additional antibiotics and steroids depending on their diagnosis.