Itchy And Scratchy

This week’s guest columnists are Drs. James Hyatt and Amir Farizani, Family Practice residents at the University Hospital and Clinics here in Lafayette.

Friday night in the Pediatric Emergency Department, a 16 year-old checks in with mom.  While mom looks concerned the boy, wearing headphones, is obviously annoyed to be here.  Not his first choice for a Friday night destination!  They tell me he was on the porch swing last night with his girlfriend when itchy bumps appeared on the back of his neck and arms.  He wasn’t concerned, but when his mom noticed them tonight she hustled him into the car to come in.

After examining him, I realized that though the boy only had mosquito bites, mom had worse worries.  Was this a severe allergic reaction?  Would he start wheezing, his throat close up, and could he die?  After reassuring her this wasn’t anaphylaxis (“I told you it was just mosquitoes!” huffs the boy), they head home.

Child and adolescent rashes make up 12 million office visits per year.  The vast majority are annoying but benign: insect bites, eczema flares, poison ivy, viruses, or hives.  So when do you worry?  First, it’s rare for something to be bad without other signs and symptoms.  If your child has a rash without fever, fatigue, shortness of breath, or vomiting, these rashes aren’t emergencies.  If your child does have a fever accompanying the rash, that’s a little more concerning, but even most of these are okay.

What many parents worry about is anaphylaxis.  This is a life-threatening allergic reaction caused by whole-body sensitivity to an allergen.  Allergens are small molecules in the environment- pollen, ant venom, poison ivy- that trigger our immune system.  Usually the reaction is localized to one organ, like the skin (making hives) or the nose (making it itchy and runny).  When an allergen irritates more vital organs- airways, lungs, or the cardiovascular system, that’s anapylaxis.

Fortunately (as far as diagnosis), anaphylaxis is easy to spot.  There’s immediate lip and eyelid swelling, watering eyes, shortness of breath, wheezing, drooling, and fatigue. Time to call 911.

Like our boy above, it seems most benign rashes come in at the most unlikely time- weekend nights.  This next girl, 8 years-old, came in Sunday night after a weekend at the beach.  When she was in the bath, mom saw a strangely shaped rash on her arm.  It looked so freaky that mom snatched her out of the tub, threw on some clothes and came in.

The rash sure was odd, with paisley shapes and curly-cue streaks, like someone had  splashed liquid sunburn on her.  One question solved the mystery: were there limes at the beach?  “Why yes,” replied mom, “we were having margaritas, and she had a non-alcoholic one.”  In fact, she squeezed her own limes.

DIagnosis: Phytophotodermatitis.  Cuter names for this are Margarita Burn, or Lime Disease (instead of tick-borne Lyme Disease, get it?).  When certain plant substances drop on your skin, like lime juice, and are then in sunlight, they cause irritation.  Skin turns red, burns, and can even blister.  After the initial inflammation, the rash becomes hyperpigmented, like a tan, and can last for weeks.  Besides lime, many other plants can cause this reaction, merely by brushing their leaves.  Wild parslies, mulberry bushes, and hogweeds are some of the culprits, and the sun-activated streaks they leave on skin are often mistaken for poison ivy.

Like we mentioned above, many parents lose nights of sleep thinking about worst-case scenarios.  It’s only natural to worry about kids, but late-night internet searches don’t help.  Most helpful for parents is knowledge about common rashes, and what are the “red flag” symptoms.

Most pediatric rashes are caused by benign infections like viruses, and minor allergic reactions like hives, eczema, and heat rash.  While these rashes can cover the whole body and look freaky, if your child is otherwise acting well, he is well.  For example, two  common viral rashes are Roseola and Hand-Foot-Mouth disease.  While covered with spots, most of these kids are smiling, drinking, and calm.  They might have fever initially, but they’re not showing bad signs.

Bad signs are shortness of breath, worsening fatigue, pain, headache, and vomiting.  Rashes accompanied by these need to be seen.  But if your child is otherwise well, don’t panic over funky rashes!  Instead ask, Where were the limes?    

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