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. 

Is That Measles???

This week’s guest columnist is Dr. Jesse Livingston, a family practice resident at the University Health Center here in Lafayette.

Rashes are a common reason parents bring their children to the doctor. Sometimes the parents get so alarmed by a rash that they come to the Emergency Department.  Maybe the child has been mildly ill for a few days- some cough, some fever, but has been doing okay.  Then one morning the kid wakes up covered head to toe with red spots!  Not only does the rash look horrible, but Grandma chimes in with the worst cases: “Looks like measles!”  ”Could be meningitis!”  Get him seen!  Now!

To Grandma’s credit, in her earlier years rashes were sometimes the herald of life-threatening infections.  However, these days those bad illnesses- meningitis, measles, rubella, pneumococcus- are prevented by your child’s vaccinations.  The vast majority of infectious rashes today are benign.

Viral rashes (what doctors call “exanthems”) are extremely common and usually go away within a few days.  Generally theses rashes appear red and blotchy and are present from head to toe.  Unlike allergic rashes, they are not swollen or “raised.”  Many viruses can cause a similar-appearing rash as the skin has only a limited amount of responses. This can make it difficult to tell what virus is responsible.

Viruses can affect many different parts of the body besides the skin.  For example, the common cold viruses make a person cough and sneeze, but may also cause a rash.  The list of viruses that cause rashes is long.  Some of the more common are Roseola (virus HHV-6) and Fifth Disease (Parvovirus).  These viruses often start with a fever and then in a few days the rash comes.  A more unusual rash is Hand, Foot, and Mouth Disease, caused by the Coxsackie virus.  This virus causes a strange, spotty rash to appear on the palms of the hands, soles of the feet, and inside the mouth.  It can cause fevers and diarrhea as well.  Unlike most viral rashes, the sores and spots of Coxsackie are painful.

Like our child from above that scared mom and Grandma with his head-to-toe spots, viral rashes can look pretty freaky.  They can look like red lace on the skin, or like leopard spots all over- even the top of the head!  Though they look pretty bad, they usually don’t feel bad. They mostly don’t itch or hurt and there is no specific treatment required.  There is nothing to put on the rash that will make it feel better or go away sooner. The child often does not feel well, but that is because of the virus, not the rash.

Like above, viral rashes come with other symptoms: fever, fatigue, headache, no appetite, aches, and irritability.  Supportive care at home is the best treatment.  Make sure the child stays hydrated.  Not eating is fine.  If the child is drinking enough to make pee once or twice per day, you’re doing okay.  Acetaminophen (Tylenol) or Ibuprofen can lower the fever and reduce the aches and pains.  Antihistamines may help with occasional itching. These rashes usually only last for a few days.

The main reason to see a doctor with a rash is if the child acts truly sick.  These warning signs are: poor drinking leading to urination less than once per day, worsening fatigue such that the kid becomes progressively harder to wake up, or shortness of breath.  If you are worried that your child is getting sicker, call your doctor.  They can steer you to the office or the Emergency Department.

It is important to note that viruses that cause rashes can be contagious.  Close contact with others should be avoided until the rash is gone, and take special care to avoid exposure to pregnant women or people with immune problems.

Childhood rashes are usually benign, go away by themselves, and often go with other symptoms.  Vaccinations prevent many of the harmful diseases that cause rashes, so keep your child’s immunizations up to date.  If you have any concerns about the rash or the warning signs above, call your doctor.  She can help decide if your child needs to be seen, and tell you Its Not The Measles.