Remote Primary Health Care Manuals

Rashes

 

Red Flags — Urgent Medical Consult
  • Purpuric or petechial rash with fever
  • Itchy rash with breathing problems
  • Young baby unwell with rash

Ask

  • Rash
    • How long have they had it
    • Where it started, where is it now
    • Is it itchy
    • Is it painful
  • Associated features — fever, cough, runny nose, sore eyes, shortness of breath, eating and drinking
  • Medicine used recently — including bush medicine or alternative medicine
  • Any immunisations given recently
  • Any contacts who also have a rash

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Head-to-toe exam — attention to skin, nails, hair, inside mouth and throat
    • Remove clothing if appropriate
    • Make sure there is good light
    • Take photo of rash in sunlight (with consent) — can help with diagnosis
  • Immunisation status

Describe rash

  • Colour, eg red, purple, pale
  • Evidence of scratching — has this affected appearance 
  • Type of lesions
    • Purpuric or petechial — red-purple blotches/spots that don’t blanch. Note if raised
    • Maculopapular — red spots with raised lesions you can feel
    • Pustular — raised lesions more than 0.5cm across. Contain clear fluid or pus
    • Vesicular — small raised lesions less than 0.5cm across. Contain fluid
    • Itchy
  • Size of lesions and distribution over body
  • Blanching — rash fades with pressure
    • Press down on skin with glass (eg slide) or acrylic sheet (eg clear plastic ruler) and note if rash fades
    • Bleeding into skin doesn’t blanch — pinpoint lesions are petechiae and larger lesions are purpura

Table 7.27 Diagnosis and what to do 

Purpuric or petechial rash
AND other features		 Possible diagnosis What to do
  • Fever
  • +/– confusion
  • +/– neck stiffness
  • +/– low BP
  • Meningococcal infection
  • Septicaemia
Other causes — Henoch-Shönlein purpura, enteroviral infection, thrombocytopenia

Table 7.28   

Maculopapular rash
AND other features		 Possible diagnosis What to do
  • Cough
  • Conjunctivitis
  • Rash spreads down from head to body
  • Fever
 Measles
  • Medical consult
  • Notify PHU
  • Take blood for measles and rubella antibodies
  • Throat and/or nose swab for measles
  • Check if any non-immune pregnant women may have been exposed
  • Infectious until 4 days after rash appears
  • Mildly unwell
  • Swollen lymph nodes, especially behind ears and back of head
  • Fever
 Rubella
  • Medical consult
  • Notify PHU
  • Take blood for measles and rubella antibodies
  • Check if any non-immune pregnant women may have been exposed
  • Infectious until 4 days after rash appears
Other causes — Scarlet fever, Kawasaki disease, drug reactions

Table 7.29   

Vesicular rash
AND other features		 Possible diagnosis What to do
  • Rash starts on head or trunk, then spreads to limbs
  • Lesions start as raised red spots then form vesicles, then crust — all 3 stages are present
  • Fever
 Chickenpox
  • Check if people with weakened immune system have been exposed — chickenpox very serious for them
  • Check if any non-immune pregnant women may have been exposed — chickenpox in pregnancy can be harmful
  • Infectious until all lesions have crusted
  • Small vesicles in mouth and on hands and feet
  • Fever
 Hand, foot and mouth disease
  • Vesicles and ulcers on lips, gums, tongue, palate
  • Fever
 Oral cold sore (herpes simplex)
  • Single or few painless lesions
  • Small, round, pearl-coloured lump/s
 Molluscum contagiosum virus

Table 7.30   

Pustular rash
AND other features		 Possible diagnosis What to do
… School sores (impetigo)
… Scabies

Table 7.31   

Itchy rash
AND other features		 Possible diagnosis What to do
  • Papules or plaques
  • Small to large welts (raised, solid lesions)
  • May have pale centre
  • Usually itchy
  • Can appear and move about body very quickly
 Urticaria (hives)
  • Always check for anaphylaxis
  • Medical consult
  • Need to check for cause — medicines, immunisations, bites, food allergy
  • Excoriation (missing skin), red, weeping, crusting
  • On face and scalp in infants
  • In bends of joints in older children
 Eczema
Check for scabies
  • Avoid soap and hot water
  • Moisturisers to skin
  • Medical consult about corticosteroid creams
  • Scaly, raised, spreading edge
  • Often area of warm, moist skin, eg groin, armpit
 Tinea

Nappy rash

  • Rash in baby's nappy area — usually due to skin irritation from prolonged contact with urine and/or faeces
  • Keeping skin in nappy area dry and free from irritation are most important parts of treatment

Do

  • Use absorbent disposable nappies
  • Change nappies often
  • Let baby go without a nappy for a few hours each day — unless diarrhoea
  • Use barrier cream (eg zinc and castor oil cream) with each nappy change to keep skin dry
  • Wipe baby’s bottom with damp cloth only. Do not use wipes with scent or alcohol — can irritate skin
  • If rash not improving or moderately severe — use hydrocortisone 1% and miconazole 2% cream, twice a day (bd) under barrier cream
  • Do not use topical corticosteroids stronger than hydrocortisone 1% on nappy area — stronger steroids may cause long-term skin damage

Medical consult if

  • Rash not improving
  • Rash glazed with shiny red skin or rash painful or baby has fever —may be streptococcal or staphylococcal cellulitis
    • Swab lesion for MC&S
    • Give trimethoprim-sulfamethoxazole oral — 4+20mg/kg/dose up to 160+800mg — doses — twice a day for 7 days
    • If allergy OR if vomiting or won't take oral medicine — medical consult
    • If not improving — consider sending to hospital
  • Vesicles and red painful rash
    • May be herpes simplex
    • Swab for viral culture
    • If severe — consider antiviral treatment, sending to hospital