QuestionSBA
QuestionChoice
This describes eczema herpeticum, which classically presents with a monomorphic rash, fever and affects patients with a history of atopy. It needs to be treated in hospital with IV antivirals. The history of possible impetigo contact should not distract from the presentation, as the patient’s rash is not consistent with impetigo.
10017201
a
Referral to local ED
QuestionChoice
This is a suitable treatment for widespread non-bullous impetigo/bullous impetigo, not eczema herpeticum.
10017205
e
Oral flucloxacillin
QuestionChoice
This is an alternative treatment for non-bullous impetigo, not eczema herpeticum.
10017203
c
Topical fusidic acid
QuestionChoice
Oral antivirals are insufficient for eczema herpeticum.
10017204
d
Oral aciclovir
QuestionChoice
This is first line treatment for non-bullous impetigo, not eczema herpeticum.
10017202
b
Topical hydrogen peroxide
QuestionComment
Just wondering if the pt's classmate had impetigo, and if so is that a red herring for eczema herpeticum, which is a HSV infection?
44211
User
subscriber
Chronic Nightshift
QuestionComment
The impetigo was a distractor
51931
User
subscriber
Hereditary Kawasaki
QuestionComment
damn it I fell for the distraction :(
62301
User
subscriber
Medgyal
Concept
Chapter
# Summary
 

Fever and rash is a frequent emergency presentation in paediatrics, often due to a non-specific viral infection. Key considerations include septicaemia; slapped cheek syndrome; Hand, foot and mouth disease; Scarlet fever; Measles; Urticaria; Chickenpox; Roseola, and Rubella. Depending on the specific presentation and diagnosis, management strategies range from supportive care to initiation of antibiotics or antiviral medication.
 

# Definition
 

A fever is a temporary elevation in the body's thermoregulatory set-point, typically by more than 1–1.5 °C. In children, a fever is usually defined as a rectal temperature over 38.0 °C (100.4 °F). A rash refers to any change in skin colour, texture, or overall appearance.
 

# Epidemiology
 

Fever and rash commonly present in paediatric populations, predominantly due to non-specific viral infections, often unidentified. The specific epidemiology varies according to the underlying cause.
 

# Aetiology
 

Fever and rash in children can be caused by a multitude of conditions including:
 

 -  Septicaemia
 -  Slapped cheek syndrome (Fifth Disease or Parvovirus B19)
 -  Hand, Foot and Mouth disease
 -  Scarlet fever
 -  Measles
 -  Urticaria (hives)
 -  Chickenpox
 -  Roseola
 -  Rubella
 

# Signs and symptoms
 

 - **Erythema toxicum (erythema toxicum neonatorum):** This is a benign rash in newborns which consists of erythematous macules (flat red patches) papules (small bumps) and pustules. The eruption waxes and wanes over several days and rarely for more than a day.
 - **Threadworm**: also known as pinworm, presents with an itchy bum, especially at night, and may also be visible in faeces.
 - **Septicaemia**: Rapid development of a non-blanching purpuric skin rash, lethargy, headache, fever, rigors, vomiting.
 -  **Slapped cheek syndrome**: Rash on both cheeks, fever, upper respiratory tract infection symptoms.
 

 [lightgallery]
 

 -  **Hand, foot, and mouth disease**: Blisters on hands and feet, grey ulcerations in the buccal cavity, fever, lethargy.
 

 [lightgallery1]
 

 [lightgallery2]
 

 -  **Scarlet fever**: Coarse red rash on the cheeks, sore throat, headache, fever, 'sandpaper' texture rash, bright red tongue.
 

 [lightgallery3]
 

 [lightgallery4]
 

 -  **Measles**: Erythematous, blanching maculopapular rash, fever, cough, runny nose, conjunctivitis, Koplik spots.
 

 [lightgallery5]
 

 [lightgallery6]
 

 -  **Urticaria**: Raised, itchy red rashes, usually not accompanied by fever.
 

 [lightgallery7]
 

 -  **Chickenpox**: Maculopapular vesicular rash that crusts over and forms blisters.
 

 [lightgallery8]
 

 -  **Roseola**: Lace-like red rash across the whole body, high fever.
 

 [lightgallery9]
 

 -  **Rubella**: Rash that starts on the head and spreads to the trunk, postauricular lymphadenopathy.
 

 [lightgallery10]
 

# Differential Diagnosis
 

The differential diagnosis of a child with fever and rash is extensive and includes:
 

 -  **Septicaemia**: The key signs include rapid development of a non-blanching purpuric skin rash, lethargy, headache, fever, rigors, and vomiting.
 -  **Trauma**: Presents with localised rash or bruising, often with a clear history of injury.
 -  **Liver disease**: Accompanied by jaundice, pruritus, and other systemic symptoms.
 -  **Drug Reaction (e.g., antiepileptics)**: Rash may be accompanied by other signs of drug reaction, like itchiness or wheezing.
 -  **Vasculitis**: Can present with fever, weight loss, and multi-system symptoms.
 -  **Thrombocytopaenia**: Accompanied by mucosal bleeding and petechiae.
 -  **Coagulopathy**: Similar to thrombocytopenia, patients may have petechiae and mucosal bleeding.
 -  **Malignancy**: Presents with fatigue, unexplained weight loss, and systemic symptoms.
 -  **Disseminated intravascular coagulation (DIC)**: Accompanied by systemic symptoms of sepsis or malignancy.
 

# Investigations
 
Often is a clinical diagnosis based on appearance of the rash and the associated symptoms. 
 
Investigations may include:
 

 -  Blood tests (FBC, Coagulation profile)
 -  Blood cultures
 -  Viral serology
 -  Skin biopsy
 
 

# Management
 

Management varies depending on the condition causing fever and rash:
 

 -  **Septicaemia**: Immediate broad-spectrum IV antibiotics, notify a senior paediatrician.
 -  **Slapped cheek syndrome**: Generally self-limiting, symptomatic treatment.
 -  **Hand, foot, and mouth disease**: Generally self-limiting, symptomatic treatment.
 -  **Scarlet fever**: Treated with antibiotics, usually phenoxymethylpenicillin.
 -  **Measles**: Supportive management and immunisation is crucial.
 -  **Urticaria**: Antihistamines and/or steroids, identify and avoid triggers.
 -  **Chickenpox**: Supportive treatment, antiviral treatment for high-risk groups.
 -  **Roseola**: Self-limiting, supportive management.
 -  **Rubella**: Self-limiting, supportive management, immunisation for prevention.
 -  **Threadworm**: Education on good hand hygiene, and oral mebendazole for the child **and** family.
 

# References
 

[NHS page on Rashes in babies and children](https://www.nhs.uk/conditions/rashes-babies-and-children/)
440
Picture
A typical appearance of hives.
977
Hives.jpeg
images/b2hgrg5z1665036171692.jpg
images/b2hgrg5z1665036171692_256.jpg
images/b2hgrg5z1665036171692_512.jpg
4RgGJYq+kJIXU4WGZ5iZlwOsNnB3
Picture
Hand, foot and mouth disease seen on the hand.
992
Hand, foot and mouth disease 2.jpeg
images/463i9n3h1665036171693.jpg
images/463i9n3h1665036171693_256.jpg
images/463i9n3h1665036171693_512.jpg
JWkOFoh/inikd3fEd4eHd4h4B7FyQQo=
Picture
Hand, foot and mouth disease seen around the mouth.
717
Hand, foot and mouth disease.png
images/n5kv1iom1665036171695.jpg
images/n5kv1iom1665036171695_256.jpg
images/n5kv1iom1665036171695_512.jpg
3kgKLoo3aWePiIaIiph3d2iJR4+F9Gg=
Picture
An example appearance of roseola.
983
Roseola.jpeg
images/118m5jsn1665036171692.jpg
images/118m5jsn1665036171692_256.jpg
images/118m5jsn1665036171692_512.jpg
oBgKDIIDc0eGaVXLiWJFKhDmIA==
Picture
An example appearance of measles.
807
Measles.jpeg
images/eph4thd91665036171707.jpg
images/eph4thd91665036171707_256.jpg
images/eph4thd91665036171707_512.jpg
aHkKDYIMU0Zkdndyh2d3dgtkBHZX
Picture
An example of the appearance of koplik spots.
785
Measles - koplik spots.jpeg
images/67x6slrh1665036171707.jpg
images/67x6slrh1665036171707_256.jpg
images/67x6slrh1665036171707_512.jpg
GigKDYIGyZqCeVWZl4l5hvp4+Egz
Picture
The typical appearance of a rash associated with scarlet fever.
996
Scarlet Fever.jpeg
images/137h9h2q1665036171693.jpg
images/137h9h2q1665036171693_256.jpg
images/137h9h2q1665036171693_512.jpg
3kgKDQIwZ3eIqYhXeIh3eFVroPYX
Picture
A typical appearance of a chickenpox rash seen in a child.
790
Chickenpox.jpeg
images/40nxxswf1665036171707.jpg
images/40nxxswf1665036171707_256.jpg
images/40nxxswf1665036171707_512.jpg
WAgSFQYLmnZnN4ZoiHV5Z2uPoPgp
Picture
The classical 'strawberry tongue' seen in scarlet fever.
993
Scarlet fever 2.jpeg
images/2b5ysi8b1665036171693.jpg
images/2b5ysi8b1665036171693_256.jpg
images/2b5ysi8b1665036171693_512.jpg
n1gODoqwmIl0d4mId3iId3h3A6tWsGg=
Picture
Back of an infant with Rubella
2219
rubella rash.jpeg
images/l75q4ciu1693834705874.jpg
images/l75q4ciu1693834705874_256.jpg
images/l75q4ciu1693834705874_512.jpg
JlkODgQId5Z2eIh3eIV3h2h4AKMDGDw=
Topic
29
Paediatrics
Picture
The typical appearance of slapped cheek syndrome.
980
Slapped cheek syndrome.jpeg
images/sgq4xoso1665036171693.jpg
images/sgq4xoso1665036171693_256.jpg
images/sgq4xoso1665036171693_512.jpg
3EgKFgREWPp6iMiYiHl2mHm3C3l1UEg=
440
Rashes in children
Topic
29
Paediatrics
15984
Eczema herpeticum presents with fever and monomorphic lesions in atopic individuals, requiring urgent hospital management with intravenous antivirals.
A 6-year-old boy with a history of eczema and asthma has a fever and multiple monomorphic lesions on his face, arms and trunk. His dad mentions his classmate at school last week had a golden crusted rash on their face.

What is the next most appropriate management step?
a