Skin and Bones

Dealing with ailing bodies and human foibles all day long, it’s no wonder doctors have a sick sense of humor, me included.  When people show me their kids’ rashes in public, I play it straight and happily consult.  However, occasionally adults will haul up their shirts at parties to show me the latest blemish on their bellies or backs and ask, “Hey Doc, what the heck is this?” I nod confidently: “It’s definitely cancer,” I say. Then I give them a wry smile that says, hey, only kidding!

Given the warm winter we’ve had, the early spring, and the early school closings, I predict a rough summer for rashes.  Children meet the outside world with their skin.  When falling off bikes or monkey bars, not “sticking the landing” as they say in gymnastics, they get scrapes and cuts and bruises.  When they plow through vegetation exploring or searching for stray balls, their skin gets irritated by thorns or poison ivy. Mosquitoes enjoy a blood meal from our children, and later, when the bite itches, they tear at themselves with ragged, dirty fingernails.  Sun cooks hot, exposed skin too.

We’re all learning new habits from Coronavirus concerns, like washing our hands more often and extra carefully, wiping down potentially contaminated surfaces, and trying not to touch our faces.  It’s also a good time to improve skin-care habits for children.  That’s the best prevention for skin injuries and infections that we’ll see in the Emergency Department in the coming months.  Paradoxically, skin is hardest to hurt when it’s soft and pliable.  It bounces back, and heals better.  Hard dry skin cracks under pressure and itches worse when insulted.

Kids should use moisturizing soap. Buy brands like Dove and Caress, which are easy on skin, rather than harsh drying soaps like Ivory, Zest, Dial, or Irish Spring.  Washclothes and vigorous toweling also can irritate, so kids should use only their hands and the soap, and pat dry with towels. Advanced Parenting involves using white lotion to moisturize kids’ skin, putting on sunscreen, and applying bug spray.  When a kid gets a cut or scrape, “rub dirt on it” is just a joke!  Wash broken skin with soap and water, and dress it with neosporin and bandages.  Please keep those grubby ragged fingernails clean and short.

In 2008, New York City mom Lenore Skenazy was shopping with her 9 year-old son.  They had ridden the subway, and that day he begged Ms. Skenazy to let him ride home by himself.  Having taught him how to read subway maps and distinguish between uptown and downtown trains, she decided to let him go.  He got home safely and was ecstatic with his feat.  But when Ms. Skenazy wrote about his adventure in a newspaper column, she set off a storm of controversy.

Some called her the “world’s worst mom.” Child Protection paid her a visit.  Others praised her for giving her child freedoms not allowed by “helicopter parents,” so-called because they hover over their kids’ every move. Ms. Skenazy then briefly had a reality TV series where she coached such parents on letting their kids ride bikes or slice vegetables.  The show’s title: World’s Worst Mom.

Fortunately, we in Acadiana needn’t worry about children navigating crowded cities. But they will be having adventures on bikes and trampolines, or dirt bikes and ATVs.  Most emergencies we’re seeing now are injuries from these. If your child falls off a bike or monkeybars, check the head first.  Head injuries are the most common serious injury in pediatrics.  If the kid has been knocked out or is acting confused, get them into us right away.  Please put helmets on bike-riders before this happens!

If the head checks out okay, limbs are next.  Broken bones are obvious: the child cries and points to the dinged wing.  Sometimes it’s bent in an unnatural way.  The best care for an injured arm or leg is to immobilize it. Preventing the hurt part from moving is the best pain control.  Tape it to a rolled up newspaper or magazine, or a handy board. Give your child some pain medicine, like ibuprofen or tylenol.  DON’T give your child anything to eat or drink.  They’ll need an empty stomach if anesthesia is necessary.

If your child crashes a motorized bike or ATV, you’ll feel like the World’s Worst Mom- these vehicles’ power and speed are too dangerous for little bodies.  Bikes are good enough, and better exercise for their skin and bones.

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?    

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.