* This is the Professional Version. *
Rash in Infants and Young Children
Rash is a common complaint, particularly during infancy. Most rashes are not serious.
Rashes can be caused by infection (viral, fungal, or bacterial), contact with irritants, atopy, drug hypersensitivity, other allergic reactions, inflammatory conditions, or vasculitides (see Some Causes of Rash in Infants and Children).
Overall, the most common causes of rash in infants and young children include
Numerous viral infections cause rash. Some (eg, chickenpox, erythema infectiosum, measles) have a fairly typical appearance and clinical manifestation; others are nonspecific. Cutaneous drug reactions are usually self-limited maculopapular exanthems, but sometimes more serious reactions occur.
Uncommon but serious causes of rash include
Some Causes of Rash in Infants and Children
History of present illness focuses on the time course of illness, particularly the relationship between the rash and other symptoms.
Review of systems focuses on symptoms of causative disorders, including GI symptoms (suggesting immunoglobulin A–associated vasculitis [formerly called Henoch-Schönlein purpura] or hemolytic-uremic syndrome), joint symptoms (suggesting immunoglobulin A–associated vasculitis or Lyme disease), headache or neurologic symptoms (suggesting meningitis or Lyme disease).
Past medical history should note any drugs recently used, particularly antibiotics and anticonvulsants. Family history of atopy is noted.
Examination begins with a review of vital signs, particularly to check for fever. Initial observation assesses the infant or child for signs of lethargy, irritability or distress. A full physical examination is done, with particular attention to the characteristics of the skin lesions (see Description of Skin Lesions), including the presence of blistering, vesicles petechiae, purpura or urticaria, and mucosal involvement. Children are evaluated for meningeal signs (neck stiffness, Kernig and Brudzinski signs) although these signs are often absent in children < 2 yr.
Well-appearing children without systemic symptoms or signs are unlikely to have a dangerous disorder. The appearance of the rash typically narrows the differential diagnosis. The associated symptoms and signs help identify patients with a serious disorder and often suggest the diagnosis (see Some Causes of Rash in Infants and Children).
Bullae and/or sloughing suggest staphylococcal scalded skin syndrome or Stevens-Johnson syndrome and are considered dermatologic emergencies. Conjunctival inflammation may occur in Kawasaki disease, measles, staphylococcal scalded skin syndrome, and Stevens-Johnson syndrome. Any child presenting with fever and petechiae or purpura must be evaluated carefully for the possibility of meningococcemia. Bloody diarrhea with pallor and petechiae should raise concern about the possibility of hemolytic uremic syndrome. Fever for > 5 days with evidence of mucosal inflammation and rash should prompt consideration of and further evaluation for Kawasaki disease.
Treatment is directed at the cause (eg, antifungal cream for candidal infection).
For diaper rash, the goal is to keep the diaper area clean and dry, primarily by changing diapers more frequently and gently washing the area with mild soap and water. Sometimes a barrier ointment containing zinc oxide or vitamins A and D may help.
Pruritus in infants and children can be lessened by oral antihistamines:
Diphenhydramine: For children > 6 mo, 1.25 mg/kg q 6 h (maximum 50 mg q 6 h)
Hydroxyzine: For children > 6 mo, 0.5 mg/kg q 6 h (maximum for children < 6 yr, 12.5 mg q 6 h; for those ≥ 6 yr, 25 mg q 6 h)
Cetirizine: For children 6 to 23 mo, 2.5 mg once/day; for those 2 to 5 yr, 2.5 to 5 mg once/day; for those > 6 yr, 5 to 10 mg once/day
Loratadine: For children 2 to 5 yr, 5 mg once/day; for those > 6 yr, 10 mg once/day
* This is the Professional Version. *