Rashes- The Home Triage

This week’s guest columnist is Dr. Justin Pratt, a Family Practice resident at the University Hospital and Clinics here in Lafayette. 

The nurse’s note read “rash.”  When I walked into the exam room, the mother’s eyes were wide with fear.  ”Doc, over the past 2 days he’s been having a reaction to the antibiotic he got earlier this week.  I gave Benadryl this morning and the rash is still there!  Is he going to be okay?”  Meanwhile, the patient, an 8 year-old boy, was lying in bed laughing at cartoons on TV. The rash certainly wasn’t bothering him much, unlike his mother!

Rashes can be distressing for parents of infants and children. They can appear out of nowhere, cover a large part of the body, and look awful.  The good news is that most rashes are not life-threatening and don’t need immediate attention. Some are caused by direct irritation of the skin, some indirectly like with allergies, and some by infections from viruses, bacteria, or fungus.

In the case of the boy I saw that Saturday night, his rash wasn’t a sign of anything bad, though it certainly looked weird.  It consisted of flat, paisley-shaped red blotches all over his body.  It didn’t hurt, didn’t itch, and he didn’t feel too bad. This rash, called erythema multiforme, turned out to be due not to the antibiotic,but from an infection called mycoplasma, a.k.a. “walking pneumonia.”  We changed his antibiotic to cover that infection, and off he went.

Every year there are about 12 million visits for rashes and other skin concerns.  68% of these are with the patient’s own doctor, leaving 32% to walk-in clinics and Emergency Departments.  How do you know if your kid can wait to see their pediatrician, or needs immediate attention?

First, don’t panic at the site of a rash, no matter how much of your child it covers.  Rashes are like fevers- the height of the fever and the amount of rash don’t correlate with severity. It’s more about how your child is acting with the rash.  If she’s calm, drinking easily, breathing comfortably, and awake and with it, then it’s not an emergency. Give benadryl for the itch, call your doctor for reassurance, and chill out.

This advice about how to respond to your kid’s rash, brings up an experience I had in my last year of medical school.  It wasn’t about a pediatric patient- it was ME!  I woke one morning after an itchy night.  I turned to my wife to ask if she had used a new laundry detergent on our sheets, and was met with a look of shock: “Justin, ARE YOU OK!?!” Besides being a little itchy, I felt fine.  ”Look in the mirror!  I think you need to go to the hospital now!”

I was covered with a rash from head to waist, my face beet red.  A little startling to see, but then I remembered my training.  When did it start?  During the night I guess.  Was I breathing okay?  Yes.  Were my throat, tongue, or lips swollen?  No.  Was it getting worse? Didn’t seem so.  Did I feel ill or have fever?  No. There, no emergency honey.

Was the rash raised and itchy?  Yes- thus probably allergic.  Was there peeling, crusting, pain, or weeping?  No- therefore probably not an infection.  Were there tiny red freckles that didn’t blanch when pressed on?  No- again not a serious infection.  What was different in the past few days?  Soaps, detergents, food?  Wait, I’d been stung by a hornet yesterday! The rash I had was urticaria, commonly called hives, a delayed reaction to the sting. When I saw my allergist later that day, she prescribed steroids, an antihistamine, and in two days I was better.

When deciding whether your child’s rash can wait for the pediatrician, or needs to be seen immediately, remember the important questions:  Does he appear ill (looking past that awful rash!).  Is there lip, tongue, or throat swelling?  Is she not breathing comfortably? Are there tiny red freckles that don’t blanch when pressed?  If yes, proceed to the nearest Emergency Department.

If no to these questions, relax!  Give benadryl, tylenol, or ibuprofen for itching, fever, or other discomfort.  Call your pediatrician if you need further guidance.  Like fevers, rashes are generally not emergencies.  Take a deep breath, take two benadryl, and call me in the morning. 

Was Rudolph The Red Nosed Reindeer Allergic?

When my son got his first ear infection at 8 weeks old, I might have known.  Soon after he began having continual congestion.  He spent much of his childhood with itchy eyes and nose.  Many pictures from that time show him smiling away with a red nose like Rudolph.  He lived on Zyrtec and Flovent in the winter months in order to keep the itching and coughing down and to help him sleep and not be miserable during the day.  Teenage years came and thank god he outgrew that stuff.  Now his biggest medical complaint is a sore pitching arm.

Head allergies are common in kids, though they are sometimes hard to diagnose.  Cold viruses and sinus infections give kids a lot of the same symptoms- runny nose, cough, itching eyes and noses.  Allergies tend to give kids symptoms a lot longer, but young ones in daycares or schools can have long lasting symptoms too because they catch cold virus after cold virus, one right after the other, so it looks like one continous illness.  Chronic asthma can sometimes act like allergies, with continous coughing and chest congestion that doesn’t always wheeze. 

So how do you tell the difference between continuous colds, allergies, or mild chronic asthma?  Besides the itchy head, does your child get his symptoms with change in seasons?  Is there a history of allergies in mom or dad or other relatives?  Do obvious allergic triggers like animals or dust seem to make the child sneeze and itch?  If it seems like the kid has allergies, one way to make the diagnosis is to try an anti-allergy medicine.  Drugs like Claritin (Loratidine) or Zyrtec (Cetirizine) are pretty effective and very safe, so safe that they can be bought over-the-counter.  If the child gets better in a day or two and stays better on the drug, allergies may be the cause.  Some allergies are hard to diagnose, or hard to treat effectively, in which case the child might need to see the allergist.

Your pediatrician or family practitioner can usually diagnose allergies without an allergist’s help.  If the child has lots of eye and nose itching and is always congested, if there is a family history of allergy, that may be enough.  The doctor will often ask for the parent’s help with figuring out what is causing the allergic reaction- dust, dogs, seasonal pollens in the air, mold?  What seems to make their child sneeze and twitch?  Sometimes parents are asked to keep a journal of when their child has symptoms and where they are at the time.  Your doctor can also order blood tests which can give clues to allergy being the problem and what is causing the allergy. 

If your doctor has trouble figuring out if allergies are truly the cause of the child’s misery, or if standard treatments aren’t working, that is when the child is referred to an allergist.  The allergist can perform more accurate tests to see if the child is allergic, and to what.  Once the diagnosis is confirmed, the allergist then often goes back to the basics for treatment- avoiding the thing the kid is allergic to.

Avoidance is the mainstay of allergy treatment.  If dust is the cause, and it often is, then the allergist can talk to the family about dust control in the bedroom and the rest of the house.  If it is cockroaches, another common allergy trigger, they can address that.  If medicines are needed, the allergist can help the family figure out what medicine or combination of medicines would be best.  Finally, if a child has an allergy that is really hard to avoid and treat, the allergist can design a “immunotherapy” program to help the child’s body be less sensitive to the allergen.  These are the”allergy shots.”  Immunotherapy is safe and effective for the right patient, and can make a big difference in the quality of the kid’s life.

So if you think your child has allergies, talk to your doctor.  Pay attention to what seems to make your child cough and sneeze and rub his nose and eyes.  Itchy faces can be miserable, take it from my son.