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What Rash is that?Is it Infectious?
By Kane Guthrie
Learning Points
• General assessment of rashes
• Describing rashes
• When to Isolate
• Pearls & Pitfalls
• Case studies
Rashes
• Most are not evidence of serious illness
• Frequently alarm patients/parents
• Rashes are one of the top 20 presentations to ED
• Often anxiety provoking to health care providers
Rashes!
“Recognition is 99% of the problem; treatment/advice is usually simple”
Describing a Rash
• It’s a little tricky
• Keep it simple
• Pattern recognition!
http://www.ausmed.com.au/blog/entry/how-to-describe-a-rash
http://www.ausmed.com.au/blog/entry/how-to-describe-a-rash
http://www.ausmed.com.au/blog/entry/how-to-describe-a-rash
History Taking
• When did it start?
• How quickly did it progress?
Pearl:• The more lethal – the more rapid progression!
History Taking
• Has the rash changed over time?
• Where did it start & progress to?
• Is the lesion pruritic?– Allergic response!
History Taking
• Recent travel?– In the last month!
• PMHx:– Immunocompromised, asplenia, cancer, DM, ETOH
• Occupation– Child care, student, military, aid workers
• Medications
Physical Exam
• Get them undressed!
Check:• Oral cavity• Adenopathy • Hepatosplenomegaly• Genitals• Nails & fingers
Skin Exam
• Characterise type of lesion
• Shape of individual lesion
• Arrangement of multiple lesions– Linear, annular, disseminated
• Pattern of rash– Sun exposed areas, flexor/extensor surfaces
Case 1
• 10 year old girl
• Coryza, conjunctivitis, cough, fever
• Maculopapular rash, starts behind ears
• Descends onto upper torso
http://scghed.com/
Koplik’s Spots
• Manifest 2-3 days before measles rash• Cluster lesions buccal mucosa
http://en.wikipedia.org/wiki/Koplik%27s_spots
Measles
• Acute viral disease
• Incubation period 10-14 days
• Highly contagious – airborne route– Airborne precautions needed!
• Non-immune @ high risk!
Early Symptoms
• Fever• Tiredness• Cough• Sore throat• Runny nose• Sore eyes• Photophobia
http://www.nevdgp.org.au/info/murtagh/Childrens/measles.htm
The Rash
• Symptoms usually worsen over 3-5 days
• Blotchy rash begins on the head
• Spreads to rest of body over 1-2days
• Rash last 4-7 days
Measles Complications
• Middle ear infection 7% of cases
• Bacterial pneumonia 6% of cases
• 1:1000 cases encephalitis occurs – Results in death, permanent disability
http://www.abc.net.au/news/2014-07-31/health-department-warns-of-surge-in-measles-cases-in-wa/5639558
Measles Management
• Vaccination is the best treatment
• Supportive care
• Treat complications with AB’s
Case 2
• 4 year male
• C/O headache, fever, then rash develops
• Explosion of lesions: 1st to face/scalp, then trunk & limbs
• No rash soles or palms!
The Rash
• Many papules• Become vesicles
http://bit.ly/1zL2y5E
Chicken Pox
• Acute generalised viral infection
• Incubation period 11-17 days
• Highly contagious
• Transmission direct contact/airborne – Use airborne precautions
Shingles
• Blistering rash – dermatome distribution
• Increased age• Immunosupression• Stress
http://1.usa.gov/1yBhN0c
Varicella Zoster Complications
Chicken pox:• Pneumonia, congenital varicella, neonatal
varicella
Shingles:• Post-herpetic neuralgia, zoster keratitis, motor
nerve paralysis
Varicella Management
• Prevention –imunisation
• Supportive care• Pneumonia – give AB’s
Shingles:• Commence acyclovir ASAP– Limits post-herpetic neuralgia
Case 3
• 17 female
• S/B GP c/o fever, headaches & muscle pain– Dx: viral illness – sent home to rest
• 12 hours later develops peticial > purpuric rash
• Arrives in ED shocked!
The Rash
Non-Blanching Rashes!
Meningococcal Septicaemia
• Acute Bacterial Infection• Mainly affects young children/adolescents• Transmission by direct contact Resp secretions– Droplet precautions– AB’s for staff if exposed to resp secretions
• Incubation period 2-4 days
Meningitis Complications
• Abscess• Cerebritis• Deafness• Cognitive impairment• Hydrocephalus• Death
Meningitis Management
• AB’s within 30mins of recognition– Broad spectrum (Ceftriaxone) – Immunocompromised add (Vancomycin)
• Haemodynamic support• Dexamethasone 0.15mg/kg Q6 hourly
Case 5
http://scghed.com/2013/11/cme-141113-paediatric-rashes/
http://scghed.com/2013/11/cme-141113-paediatric-rashes/
Hand Foot & Mouth Disease
• Coxsackie virus• Common in kids- can affect all age groups• Low grade fever, anorexia, sore mouth
• Oral lesions develop– Vesicles/erythematous base – painful
• Hand/foot lesions – red papules
• Symptomatic care- mouth wash/analgesia
Case 6
• 28 male• Hx epilepsy, on phenytoin • Presents: Shocked• Severe mouth ulcers• Maculopapular rash
Stevens Johnson SyndromeToxic Epidermal Necrosis
• SJS <10% BSA, TEN >30% BSA• Dermatological emergency
• Causes:– Drugs: anticonvulsants, NSAIDs, antiviral, allopurinal – Malignancy: lymphoma– Idiopathic– Infectious
Clinical Features
• Prodrome: fever, URTI, malaise• Macular rash develops:– Starts centrally – spreads peripherally– May be painful– Nikolsky’s sign (skin separation via blisters)
• Mucous membranes severely affected
Management
• Removing inciting cause• Airway support • Fluid replacements – follow burns protocol• Wound care• AB’s if infection• Consider but controversial:– IVIG, plasmapharesis, corticosteroids
Case 7
• 4 year boy• Hx of ^ red spots to legs over past 6/7• Now spread to legs, buttock • Not responding to cream • Systemically well
Henoch-Schonlein Purpura
• HSP- autoimmune, self limiting, – IgA-mediated small vessel vasculitis
• Affects children 2-8 years old
Diagnosis triad:1. Purpuric rash on lower limbs/buttock2. Joint pain/swelling3. Abdominal pain
Complications
Management
• Check renal function• Give analgesia• Consider Prednisolone 1mg/kg - 2/52• Abdo pain last <72 hours• Joint pain last <48 hours• Rash resolves 4-6 weeks
Case 8
• 18 male• Eating kebab after night out• Develops erythematous rash and SOB
Anaphylaxis
• IgE mediated hypersensitivity reaction
• Leads to profound:– Histamine & serotonin release
Urticaria Vs Anaphylaxis
• Urticaria: hives, weals, nettle rash• May occur alone or R/T allergic reaction• Histamine release
Anaphylaxis Pearls
• Forget about the rash!– Focus hypotension, bronchospasm
• Give adrenaline – its only thing that works!– Adult 0.5mg IMI, Child 0.3mg IMI
• Fluid bolus • Ranitidine• Steroid • D/C Epipen
Diagnosis?Diagnosis?
http://scghed.com/2013/11/cme-141113-paediatric-rashes/
Scabies
• Skin infestation scabie mite• 4-6 wk incubation period• Not a reflection of poor hygiene!• General eruption: linear burrows, papules,
pustules
• Treatment: Permethrin 5% all family members
http://www.wikem.org/wiki/File:ScabiesD08.JPG
The Algorithms
Erythematous Rash
http://bit.ly/1xf8rVH
Maculopapular Rash
http://bit.ly/1xf8rVH
Petechial/Purpuric Rash
http://bit.ly/1xf8rVH
Vesiculobullous Rash
http://bit.ly/1xf8rVH
There’s an App!
Take Home Points
• Pattern recognition is everything • Always take a good history• Isolate if unsure• Look for:– Fever, toxicity, distribution, specific signs
• Management is generally simple