Rosen & Barkin's 5-Minute Emergency Medicine Consult (599 page)

• Fever (consider infectious exanthemas)
  
• Pruritus
  
• Joint pain
  
• Abdominal pain
  
• Heart murmur
  

Obtain a detailed history:

• Age group: Conditions, distribution, and appearance may vary with age
  
• Development, progression, pattern, and duration of the rash
  
• Lesions synchronous or asynchronous
  
• Associated symptoms
  
• Prodromes—cough, rhinorrhea, pharyngitis, fever, meningismal symptoms, pruritus
  
• Family history, exposures, immunizations
  
• Recent travel; insect or arthropod bites
  
• Medications especially new medications
  
• Generic dermatoses
  
• Atopic dermatitis; psoriasis
  

• Cardiac:
  
  • Murmurs/rubs
    
• Pulmonary:
  
  • Crackles/wheezing
    
• Abdominal:
  
  • Tenderness
    
  • Hepatosplenomegaly
    
• Skin: See Essential Workup.
  

Classify the rash based on the primary lesions:

• Papulosquamous
  
• Vesicobullous
  
• Purpuric
  

• Indicated if the rash is purpuric:
  
  • CBC with platelet count
    
  • Bleeding screen (prothrombin test, partial thromboplastin time, bleeding time, disseminated intravascular coagulation [DIC] screen)
    
• Indicated if fever present:
  
  • CBC
    
  • Electrolytes, BUN, creatinine to evaluate dehydration and scarlatiniform rash (exclude glomerulonephritis)
    
  • Viral culture and titers for suspected exanthems
    
  • Lactate and blood cultures for suspected sepsis/bacteremia
    
• Lumbar puncture if
  meningococcus
  or other meningitides or encephalitis suspected
  

Chest radiograph for suspected pulmonary involvement

• Potassium hydroxide (KOH) preparations:
  
  • Indicated with scaling lesions to differentiate dermatophytosis from nummular eczema and pityriasis rosea
    
  • Superficial scale sample from active border of lesion removed from the skin with a scalpel or the edge of a glass slide
    
  • Place on a slide and add 1 drop of 10% KOH.
    
  • Place a coverslip and heat slowly without boiling. Allow to set for a few minutes and scan for hyphae.
    
• Wood lamp:
  
  • Useful in dermatophytosis and erythrasma
    
• Scabies preparations:
  
  • Most of the mite population resides on the hands and feet.
    
  • Place a drop of mineral oil on the lesion. Scrape with a no. 15 blade to produce speck of blood.
    
  • Examine under low power for the mite, ova, larva, or fecal matter.
    

• Solid, skin colored, or yellow:
  
  • Keratotic
    
  • Wart
    
  • Corn or callus
    
  • Nonkeratotic
    
  • Molluscum contagiosum
    
  • Sebaceous cyst
    
  • Basal and squamous cell carcinoma
    
  • Nevi
    
• Solid, brown:
  
  • Café au lait patch
    
  • Nevi
    
  • Freckle
    
  • Melanoma
    
  • Photoallergic/phototoxic drug eruption
    
  • Tinea nigra palmaris hypopigmentation
    
• Solid, red, nonscaling:
  
  • Nonpurpuric
    
  • Exanthems
    
  • Rubeola, rubella, or roseola
    
  • Scarlet fever
    
  • Toxin-producing staphylococcal or streptococcal disease
    
  • Erythema infectiosum (“fifth disease”)
    
  • Rubella-like rash (echoviruses, Coxsackie A viruses)
    
  • Varicella (early manifestations)
    
  • Variola (smallpox: Early manifestations)
    
  • Epstein–Barr virus
    
  • Enterovirus or adenovirus
    
  • Mycoplasma
    
  • Kawasaki disease
    
  • Erythema multiforme
    
  • Localized, pruriginous
    
  • Insect bites, scabies
    
  • Allergic or irritant contact dermatitis
    
  • Purpuric
    
  • Bacteremia sepsis
    
  • Meningococcemia, pneumococcemia, gonococcemia,
    Haemophilus influenzae
    
  • Endocarditis
    
  • Plague
    
  • DIC
    
  • Rocky Mountain spotted fever (RMSF)
    
  • Henoch–Schönlein purpura
    
  • Idiopathic thrombocytopenic purpura
    
  • Leukemia
    
  • Underlying bleeding disorder
    
  • Ecthyma gangrenosum
    
  • Rarely, pityriasis rosea
    
• Solid, red, scaling:
  
  • Without epithelial disruption:
    
    • Tinea corporis, capitis, pedis, or cruris
      
    • Pityriasis rosea
      
    • Secondary syphilis
      
    • Lupus erythematosus
      
  • With epithelial disruption:
    
    • Papular urticaria
      
    • Eczema
      
    • Seborrheic, diaper, contact, or stasis dermatitis
      
    • Impetigo
      
    • Candidiasis
      
    • Tinea corporis, capitis, pedis, or cruris
      
    • Vesiculobullous rash
      
    • Herpes virus: Varicella,
      variola
      (smallpox)
      
    • Herpes simplex/zoster
      
    • Hand-foot-and-mouth syndrome
      
    • Scabies
      
    • Drug hypersensitivity, toxic epidermal necrolysis
      
    • Staphylococcal scalded skin syndrome
      
    • Impetigo, bullous impetigo
      
    • Catscratch disease
      
    • Dermatitis herpetiformis
      
    • Eczema
      
    • Erythema multiforme
      
    • Lichen planus
      

• Acne
  
• Folliculitis
  
• Candidiasis
  
• Gonococcemia
  
• Meningococcemia
  
• Fever present, consider:
  
  • Infection
    
  • Drug reaction
    
  • Systemic inflammatory disease (juvenile rheumatoid arthritis, systematic lupus erythematosus, etc.)
    

TREATMENT

Field management is indicated when there are signs of systemic instability:

• Airway management using precautions to avoid exposure to respiratory secretions; IV access
  
• Identify rashes with a potentially life-threatening illness or need for special isolation.
  

• Aggressive, empiric management of children with a purpuric rash associated with fever or unstable vital signs:
  
  • Airway support, IV access, fluid resuscitation, pressors if cardiovascular collapse
    
  • IV antibiotics should be administered for suspected etiologies
    

• Specific ED treatment should be directed to the underlying etiology.
  
• Diphenhydramine should be used when an allergic reaction is suspected.
  

• Acetaminophen: 10–15 mg/kg PO/PR q4–6h; do not exceed 5 doses/24 h
  
• Cefotaxime: 50 mg/kg IV q6h; max. dose, 12 g/24 h
  
• Ceftriaxone: 50 mg/kg IV q12h; max. dose, 4 g/24 h
  
• Diphenhydramine: 1.25 mg/kg PO/IM/IV q6h
  

FOLLOW-UP

• Hospital admission is determined by the underlying disorder.
  
• Other illnesses associated with systemic illness or potential deterioration, SSS, rubeola, and varicella, as well as others, may require inpatient care.
  

Discharge instructions should be based on the underlying disorder.

• Exanthems associated with self-limited entities in stable children.
  
• Follow-up with primary care physician or dermatologist should be arranged.
  

Patient should return for re-evaluation for any rapidly spreading rash, changes in rash morphology, petechiae or hemorrhage, new onset fever or neck stiffness.

• Note where rash 1st appeared and how it is spreading.
  
• Note associated signs and symptoms. They are often key for critical illness.
  
• Keep meningococcemia in mind in any rash with fever.
  

• Dermatology atlas:
  http://www.dermatlas.org/
  .
  
• Ely JW, Seabury Stone M. The generalized rash: Part I and part II.
  Am Fam Physician
  . 2010;81:726–739.
  
• Fölster-Holst R, Kreth, HW. Viral exanthems in childhood. Part 1–part 3.
  J Dtsch Dermatol Ges
  . 2009;7:309–316, 414–418, 506–510.
  
• O’Connor NR, McLaughlin MR, Ham, P. Newborn skin: Part I. Common rashes.
  Am Fam Physician.
  2008;77:47–52.
  
• Stocker JT. Clinical and pathologic differential diagnosis of selected potential bioterrorism agents of interest to pediatric health care providers.
  Clin Lab Med
  . 2006;26:329–344.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Specific Condition for Management Guidelines
  
• Resuscitation, Pediatric
  

CODES