what's rash is that!

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

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


• 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


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/

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?


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


Petechial/Purpuric Rash


Vesiculobullous Rash


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

what's rash is that!

Health & Medicine