Rashes

Hilliard Pediatrics, Inc. - Dr. Tim Teller, MD


Introduction


Rashes are very common in childhood. This handout is designed to help you with knowing what to do for rashes. A note: rashes are difficult to identify without seeing. A famous skin specialist for kids says he can tell you what the rash is over the phone if you can describe the shirt he is wearing at the time! Having said this, there are times when the look of a rash or the other symptoms going on can help us decide what is causing the rash. Whatever is the cause, many rashes fade within a short time


Types of Rashes


  • If the rash is small to medium sized dry, rough patches that look worse at time and better at others and seem to be in certain areas and not others. The rash may itch but does not always. => It is likely eczema or atopic dermatitis. Eczema is a chronic skin condition that can run in families with a history of allergies. It cannot be cured but can fade over time. Eczema is a combination of dryness and irritation or inflammation of the skin so a combination of moisturizers and, when needed, hydrocortisone creams help with the rash (and itching if it is present). We encourage you to use the weakest steroid (hydrocortisone or similar) cream that helps. There are prescription creams that can be prescribed if the over-the-counter creams do not help. If regularly using a moisturizer works, regularly use that whenever the dryness and rash are present. If needed, use the steroid cream once or twice a day for a few days to a week to keep the rash under control while still using the moisturizer. Please see our Eczema protocol for more information.
  • If the rash is dozens to hundreds of pink to red small splotches in many areas after 2-5 days of a high spiking fever (102-105 degrees) with minimal other symptoms.=> it is likely roseola, which is a viral illness. Roseola is a common illness in the first few years of life. It is contagious during the days of the fever. The rash does not need any treatment (no creams or Benadryl®, etc.) and fades away over a few days without leaving a scar. The rash does not itch. Roseola is generally a onetime illness.
  • If the rash is small, fine pink to red areas on the chest and stomach areas and appears with a fever and a sore throat => it is likely to be scarlet fever. A Strep infection in the throat can cause a rash. The rash will not itch. It appears at the same time as the other symptoms and fades after treatment with an antibiotic. As with any possible Strep infection, we cannot treat over the phone but need to see the children for a Strep test in the office. The rash can also appear in clustered areas in the creases of the arms and legs. Please see our Sore Throat protocol for more information.
  • If the rash appears first as a pink to red area at the cheeks and side of the face that appear like the face has been slapped or wind chapped. Then a fine pink lacey rash appears on the chest and shoulders, occasionally spreading down the arms and legs. Your child may have a low grade fever and cold symptoms, sometimes with achiness => it is likely Fifth’s disease. Erythema infectiosum or Fifth’s Disease is a viral illness caused by Parvovirus B19. It is a common illness of childhood that you only have once. The rash can come and go for up to 6-8 weeks, but does not always last this long. The rash will worsen if someone is warm (a hot shower or running around outside will often worsen the rash). The rash does not need any special treatment, unless someone is scratching at the rash. If there is itchiness, we recommend giving Benadryl® by mouth for the itchiness. Once the rash is present, your child is no longer contagious (this is different than so many other illnesses). The illness can be spread from one person to another. If a pregnant woman is exposed to Fifth’s Disease and becomes ill with the virus, the infant may become quite ill due to heart failure. Any pregnant woman exposed to Fifth’s Disease should contact their obstetrician’s office right away. There is a blood test that can be done to determine if a woman has previously had the infection and is immune. If she is immune, she and the infant will not become ill. Fifth’s disease may not need a visit to the office, but your child’s school may require that we confirm that the rash is Fifth’s disease.
  • If the rash is rough, dry, itchy spots that have a raised round or oval edge and gradually get bigger and spreads => it is likely that the rash is a yeast or fungal infection. A common name for a yeast infection is “ringworm”. These can be tricky to tell sometimes the difference between a yeast rash and a rash from dryness, irritation, or eczema. Often with these other possibilities, a moisturizing cream or hydrocortisone cream will help. But with a yeast rash, the spots will not go away with these treatments. What will work is an anti-fungal cream. The most common cream we recommend is the over-the-counter clotrimazole cream (Lotrimin AF®). It is applied twice a day to the affected area for 5-10 days (until the rash is gone). Please call if the rash is not improved by 5-7 days of cream. Many yeast infection rashes do not need a visit to the office. Yeast infections are contagious until the cream has been used for 3 days.
  • If your child has a fever, small ulcers in their mouth, and small red blisters at the hands and feet => your child has Hand, Foot, and Mouth Disease. This is a viral illness caused by Coxsackie A virus and is common during the warm weather months. It is highly contagious. The rash fades over a few days to a week. Treatment for this virus is for comfort. We suggest using fever-reducers for fever or discomfort and using a combination of liquid Benadryl® and liquid Mallox® for the soreness in the mouth. The blistering rash fades away without special treatment. Please see our protocol on Hand, Foot, and Mouth disease for more details.
  • If your child has a red raised rash with a yellow, honey-colored rash => your child likely has impetigo. This is a bacterial illness caused by the germs getting under our skin and causing the infection, often after something has irritated the skin first. The irritation could be around the nose if a child has a cold or on the chin of a drooling toddler. Impetigo is contagious until it has been treated for 24 hours. Impetigo can bleed if the scab is removed. Impetigo can respond to the over-the-counter Neosporin (neomycin, bacitracin, and polymyxin b) ointment three times a day for a week. If the rash is worsening or not improved after 3 days of Neosporin® ointment, call our office. A visit to the office will be needed to confirm that a prescription antibiotic (cream applied to the skin or taken by mouth).
  • If your child has an itchy red rash with clear blisters, a fever, and itching => your child likely has chicken pox. This is a viral illness that is becoming more rare because we are vaccinating children against chicken pox. It is not common now to have any case of chicken pox, but those cases that do happen are often very mild. The rash is often now 15-30 red spots with a clear blister, very little or no itching, and no fever. The child is contagious for as long as the blisters are there, even if there are just a few. The rash typically appears 10-14 days after being exposed to the virus (as chicken pox or shingles). Chicken pox is usually just a one-time illness and one case makes you immune to getting it again.
  • If your child has symptoms consistent with a virus, including cold and cough, fever, an upset stomach, vomiting, and diarrhea then develops small red or pink bumps that do not itch that are scattered around the body => your child may have a nonspecific viral rash. If there is no sore throat, your child is alert and perks-up when their temperature is down, and the rash does not have drainage or blisters, many of these rashes occur when a child’s immune system responds to the viral infection with a few days of a rash. The rashes generally need no treatment to go away. Your child is generally no longer contagious if the rash lingers for a day or two after the rest of the symptoms are gone. There non-specific viral rashes are common during all seasons of the year.
  • If your child has a small circular bump of raised, rough skin, especially on the hands or feet => your child likely has a wart. These are a viral infection. Some children and adults are particularly prone to warts, while others never seem to get a wart. It is possible to have one at a time or as many as dozens. Warts tend to go away over 1-3 years without any treatment. If the wart is getting bigger, spreading, or painful, it is fine to try an over-the-counter treatment. There are so many treatments because none of them work all the time. There are liquid medicines that are applied with a small brush, medicated patches that are applied at night and removed in the morning, and an over-the-counter freezing treatment. All of these try to kill the virus that causes the wart, allowing for the rough skin of the wart will go away. In addition, taping a piece of duct tape over the wart and keeping it covered like this for weeks can treat the wart. If an over-the-counter treatment is not working well, we can use a freezing treatment here in the office that may work better than the other treatments. Sometimes, the wart (or warts) will be troublesome enough that a referral to a dermatologist will be needed for further treatment. See our Wart protocol for more information.
  • If your child has one or more of fleshy, soft, small bumps somewhere on the skin => your child likely has molluscum contagiosum. This is a viral infection that is mildly contagious to others but is more contagious to you. The bumps often spread to the area around the original bump. Molluscum can last a few months or longer but generally goes away on its own without any specific treatment (the average is 6 months). The areas can be itchy or irritating and many children pick or scratch at them. Sometimes the bumps get scratched open and then go away, but other times this allows bacteria to enter the skin and the area becomes red and infected with drainage or pus under the skin. We need to see your child in the office if this happens. Although there are prescription treatments for molluscum, none of them are particularly easy, painless, and effective. Simply watching molluscum for some time (months even), expecting them to go away on their own is recommended. Sometimes, a referral to a dermatologist is needed.
  • If your child has small, rough, dry patches at the side of the face, back of the arms, and side of the legs => your child likely has keratosis pilaris. This is a rash that often runs in families. It is often worse early in life and in seasons where the air is more dry but can be there for a life time. Although it is most common in families that have allergies, asthma, and eczema, someone with keratosis pilaris does not always have one on these. The rash is rarely itchy and generally can be calmed down with daily use of a gentle moisturizing cream or lotion after bathing. The lotion we recommend the most for this is the over the counter Lac-Hydrin® Five Lotion. It is hard to make this rash go away completely.
  • If your child has large, red, raised welts or streaks that are very itchy and spreads => your child likely has the rash from poison ivy. These poisonous plant rashes are also called “rhus reaction”. Treatment for poison ivy is generally a combination of treating the itching with Benadryl® by mouth and/or topical treatment for itching, along with over-the-counter hydrocortisone cream twice a day to help with the rash and the itching. Please see more details in our Poison Plant Rashes protocol. If your child’s rash is not responding to these treatments, we will need to see your child in the office.
  • If your child has a pimple-like rash with small to large red bumps with a white head on the top => your child may have folliculitis. This is inflammation of the skin follicles where oil from our skin or a few germs from our skin get trapped under the surface of the skin in the hair follicles. This is most common when someone has been in a hot tub, in and out of a swimming pool during the summer months, or hot and sweaty in the warm weather months. Sunscreen can sometimes clog the pores this way. The heat opens up the pores of the skin (follicles) and then they can close later when you cool down (out of the hot tub, back in the pool, in air conditioning), plugging the follicle. Within a few days, the rash will appear. It is common under a swimsuit and at the neck-line or waist band. Folliculitis can itch. It will often resolve over a few days to a week with avoiding whatever caused it (for example, staying out of the hot tub) and playing over-the-counter ½ or 1% hydrocortisone cream twice a day for up to 7-10 days. Occasionally the rash worsens with clusters of larger pimple-like areas and the rash will need to be seen. Sometimes an oral antibiotic is needed to help the rash clear up.
  • If your child has a large pimple-like area form with redness and pus underneath => your child likely has a localized skin infection from the bacteria Staph aureus. These can be as small as a dime or as large as a few inches across. This infection is becoming much more common and the bacteria more resistant to antibiotics (the “bad” form of Staph is MRSA, which is a more resistant form called methicillin-resistant Staph aureus). We want to culture the material (pus) from the infection, so we prefer to drain the infection here in the office rather than having you “pop” and drain the infection at home. Most of these children need to take an antibiotic by mouth to clear the infection. Call us during business hours for an appointment if your child appears to have this infection or come in during walk-in visits at 8 a.m.

Rashes That Need Immediate Attention


There are some rashes that demand immediate attention. Like with many things, it is not just the rash but everything else going on that makes it an emergency.

  • If a child has a fever plus severe headache, neck pain or stiffness, and/or is lethargic => we need to hear from immediately. We would be concerned that your child may have meningitis. Some of these children have a rash that is either many small, fine red dots that do not lighten when pushed on (petechiae) or larger deep red to purple flat areas (purpura). It is quite possible to have petechiae from bad coughing bouts or episodes of vomiting. If your child does not have neck pain or stiffness, is not lethargic, and does not have a severe headache, a fever and petechiae with a upper respiratory infection (“cold”) or vomiting (as with a “stomach flu”) can be watched. We want you to let us know right away, however, if purpura or petechiae and fever plus the headache, neck pain or stiffness, or lethargy are going on.
  • If a child has many fine red dots that do not lighten when pushed on (petechiae) and/or large flat red to purple areas (purpura) and has more bruises than normal from bumping into things, bloody noses, and/or bleeding from the gums of the mouth, we are concerned that your child may have an illness called ITP (idiopathic thrombocytopenic purpura). This needs to be evaluated promptly. Please let us know right away if your child has these symptoms. 

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