Skin Rashes in Children

A rash is a reaction of the skin. It can be caused by many things, such as a reaction by contact to a skin irritant, a drug reaction, an infection, or an allergic reaction. Many different agents can cause similar-appearing rashes because the skin has a limited number of possible responses. Very often the other associated symptoms or history, in addition to the rash, help establish the cause of the rash. A history of tick bites, exposure to other ill children or adults, recent antibiotic use, environmental exposures, or prior immunizations are all important elements of the patient's history to help determine the cause of a skin rash in a child.

Most rashes caused by viruses do not harm a child and go away over time without any treatment. However, some childhood rashes have serious or even life-threatening causes. Parents should be familiar with these rashes. Many rashes can look the same, making it difficult to know the exact diagnosis. See a doctor immediately for any concerns.

Many childhood diseases have viral or bacterial causes and include a rash of some type. As additional vaccines become available, these diseases become less of a threat to a child's long-term health. A rash of any kind should be taken seriously, however, and may require a trip to the doctor's office for evaluation. Examples of viral or bacterial rashes include several common childhood illnesses.

Impetigo

Impetigo is a superficial skin infection caused by Streptococcus or Staphylococcus bacteria. It is often found around the nose and mouth but can occur anywhere. The rash is more common in the warmer months. It can also occur as a secondary infection in skin that has been damaged, such as with insect bites, poison ivy, eczema, or abrasions.

• Symptoms and signs
  • Impetigo begins as small superficial blisters that rupture, leaving red, open patches of skin.
  • Often a honey-colored crust forms over this rash.
  • The rash may be quite itchy.
  • Impetigo is highly contagious. A child can spread the infection to other parts of the body by scratching himself or to other people by person to person (non-respiratory) contact.
  • Impetigo is rarely a serious disease but is generally treated to cure the patient, reduce the risk of complications, and lessen the likelihood of transmission to others.
• Treatment
  • This infection of the skin is easily treated with prescription topical or oral antibiotics. Over-the-counter topical antibiotic ointments are less effective than prescription versions.
  • A child usually is no longer contagious after one to two days of therapy. The rash begins to heal in three to five days.
  • If the rash does not show signs of healing by the third day of treatment, the child needs to be seen by a doctor.
  • If itching is intense, the child's doctor can recommend anti-itch medications.

Scarlet Fever (Scarlatina)

Scarlet fever is simply a strep throat or other strep infection with a characteristic rash. The infection is caused by the bacteria group A Streptococcus pyogenes. Strep throat is most commonly seen in school-aged children in the winter and early spring, but it can occur in individuals of any age and in any season. It is very contagious, and the risk of transmission can be decreased with good hand washing. Strep infection may also occur around the anus or in the vaginal region.

The rash is not serious or contagious, but significant complications can occur from the underlying strep infection. The most worrisome of these is rheumatic fever, a serious disease that can damage the heart valves and cause long-term heart disease.

• Symptoms and signs
  • The child's symptoms begin acutely with sore throat (which can be mild), moderate fever (101 F-103 F), headache, upset stomach, and swollen glands (lymph nodes) in the neck region.
  • After one to two days of these symptoms, the child develops a rash on the body that is red and has a sandpaper-like roughness. The classic medical description paints an accurate picture: "sunburn on skin with goose bumps." The rash usually spares the palms and soles.
  • The cheeks may look very flushed with a thin ring of normal skin color around the mouth.
  • Symptoms of perianal or vaginal strep infection are those of moderate redness (without discharge) of the area associated with itching and often pain with passing stool or urine.
• Treatment
  • Streptococcal sore throat as well as perianal or vaginal strep infections should be treated with antibiotics.
  • Have a child seen by a doctor immediately if one suspects that he or she has strep throat or scarlet fever.
  • A child will require a full course of antibiotics, which should be finished even if the child is better before completion.
  • A child may return to school or day care in 24 hours if the fever has resolved and he or she is feeling better.

Chickenpox (Varicella)

A virus called varicella-zoster (VZV) causes this very contagious disease. The disease is generally not associated with major complications for most children. The symptoms generally last two weeks and can make the child moderately uncomfortable. Chickenpox can be a serious illness in people with weak immune systems such as newborns, people on chemotherapy for cancer, people taking steroids, pregnant women, or those with HIV/AIDS. A safe and effective vaccine is now available for children aged 1 year or older to prevent chickenpox. The symptoms of chickenpox generally appear 10-21 days after exposure. Transmission of VZV is via respiratory droplets or direct contact with the skin lesions during the blister stage.

• Symptoms and signs
  • The earliest symptoms of chickenpox are fever, sore throat, and feeling tired. This is followed, usually within a day, by the appearance of the classic, intensely itchy rash that typically begins on the head and torso and then spreads outward to the arms and legs. The total duration of the rash is seven to 10 days.
  • The rash begins as an area of redness with a small, superficial blister in the center. After one to two days, the blister ruptures and the lesion will form a crusty scab that will fall off in two to three days. This entire evolution takes four to five days.
  • Children with chickenpox will have new outbreaks of the initial lesions as older crusted lesions are resolving. They characteristically will have both new and older lesions present at the same time.

Measles ("Regular" or "Hard" Measles)

A paramyxovirus causes measles. A safe and effective vaccine is available to prevent this disease, but outbreaks in people who have not been fully vaccinated still occur.

• Symptoms and signs
  • Initial symptoms generally appear 10-12 days after exposure to this highly contagious virus. Respiratory droplet inhalation is the mode of transmission. The rash is not contagious.
  • The disease usually begins with nasal congestion and cough, eye redness without discharge, and moderate fever (102 F-103 F).
  • The child will generally look sick, with decreased appetite and activity level.
  • On the third or fourth day of the illness, a higher fever (104 F-105 F) develops and the child will develop a purplish red rash on the face, along the hairline, and behind the ears. The rash then spreads down the body to the thighs and feet. After approximately a week, the rash fades in the same pattern as it developed.

Rubella (German Measles or "Three-Day Measles")

Rubella is a much milder disease than "regular" measles and is also caused by a virus (rubivirus).

• Symptoms and signs
  • Rubella is purely a disease of humans and is spread by virus in nasal and oral secretions. The rash is not contagious.
  • Following an incubation period of 14-21 days after viral exposure, the infected child will develop a pink or light red rash on the face that then spreads to the body. The rash does seem to itch to a mild degree. Other symptoms, which improve in three days, include low-grade temperature (100 F), headache, mild joint pains, conjunctivitis without discharge, and swollen lymph nodes in the neck and especially behind the ears.
  • Generally children do not appear to be very ill especially when compared to those suffering from "regular" measles.
  • Rubella can be very serious to an unborn child if the mother develops rubella early in her pregnancy. All women of childbearing age should have their immune status verified. Complications include congenital rubella syndrome. Congenital rubella syndrome occurs when intrauterine infection occurs during the first trimester. Complications involving the brain, heart, vision, hearing, and liver of the infant may be life threatening.

Fifth Disease

Fifth disease, also known as erythema infectiosum or "slapped cheeks" disease, is caused by a virus (parvovirus B19). This infection tends to occur more commonly in the winter and spring but can occur year-round. Infection tends to occur after an incubation period of four to 14 days.

• Symptoms and signs
  • Parvovirus B19 infection is strictly human to human in nature. While there are animal parvovirus infections, these do not affect humans. Most people with a parvovirus B19 infection will have no symptoms. Only one in four will develop fifth disease. The vast majority of infections occur during childhood, and infection conveys lifelong immunity.
  • Fifth disease often starts as a cold -- nasal congestion with slight cough, headache, mild sore throat, and low-grade fever. The rash only appears immediately after the symptoms of the viral illness are over and the child is no longer contagious.
  • The earliest specific sign of the disease is often bright red cheeks, inspiring the name "slapped cheeks disease."
  • After one to two days, as the slapped-cheek appearance fades, a lacy, red rash spreads throughout the body and is most commonly found on the arms. The rash appears to fade when the skin is cool, but with a warm bath or with activity, the rash becomes more pronounced.
  • Occasionally the child may have sore joints with the rash. Adults who contract parvovirus B-19 infection are more likely to report soreness of the joints of the hands, knees, and elbows.
  • Once the rash appears, the child is no longer contagious. However, people with fifth disease who have weakened immune systems may be contagious for a longer amount of time.

Roseola Infantum

Roseola is also called exanthem subitum and is a common childhood illness caused most commonly by human herpes virus 6 (HHV-6). Human herpes virus 7 (HHV-7) is less commonly the cause of this disease. A great majority of individuals who contract this disease are children between 6 months and 2 years of age. There is no seasonal variation.

• Symptoms and signs
  • The classic symptom sequence of roseola is that of an abrupt onset of a high, spiking fever for two to five days without other significant respiratory or intestinal symptoms. The fever breaks and is quickly followed by the onset of a rash.
  • The rash consists of small, pink, flat, or slightly raised lesions that appear on the trunk and spread to the extremities.
  • The rash is not bothersome and resolves quickly, usually only lasting one to two days. The rash is not contagious or bothersome.

Coxsackieviruses and Other Enteroviruses

The enteroviruses, including the coxsackieviruses, are a very common cause of fever and rash in children. Two common diseases caused by coxsackieviruses are hand foot and mouth disease and herpangina. Coxsackievirus infections are more common in the summer and autumn. All childhood age ranges are susceptible.

• Symptoms and signs
  • In hand, foot and mouth disease, children develop a moderate fever for one or two days and then a characteristic rash. The rash includes tender blisters in the mouth and tongue as well as on the palms and soles of the hands and the feet. Less commonly, it may also involve the lower legs, the buttocks, or the genital area. Young children have a general feeling of being ill (malaise) and are often cranky with a depressed appetite. The incubation period following exposure is five days.
  • Herpangina causes a fever, headache, sore throat, and painful blisters or ulcers in the back of the mouth. It typically occurs during the summer months and is most commonly seen in children between 3-10 years of age. A diminished appetite is common as a consequence of mouth pain. The incubation period is seven days.

Chickenpox

• Treatment
  • The virus is spread primarily from nasal and oral secretions of the child, but the rash itself is also contagious. The child remains contagious and cannot go to school or day care until the last lesion to appear has fully crusted over.
  • There is no "cure" for chickenpox once it has begun, but there is a vaccine that is very effective in preventing the disease. If a child contracts chickenpox, a physician can prescribe treatments to help control the itching and make the child more comfortable.
  • The chickenpox vaccine, called the "varicella vaccine" was added to the U.S. routine childhood immunizations in 1995. It is given in two doses. The first dose is given at 12-15 months of age. The second dose is recommended between 4-6 years of age. The vaccine is both safe and effective. The vaccine can cause mild tenderness and redness at the site for a few days. While the vaccine will protect most children, some children (3%) who are later exposed to chickenpox can develop a mild chickenpox case usually without fever and with very few lesions. A combination vaccine against measles, mumps, rubella, and chickenpox was introduced in 2005. It was shown to work as well as the separate MMR and chickenpox vaccines. Because of a higher frequency of febrile seizures with the MMRV versus separately administered MMR and varicella vaccines, children below 2 years of age receive a split vaccine protocol. The febrile seizure side effect has not been shown in children over 4 years of age.
  • People who get chickenpox vaccines can spread the vaccine-strain VZV to others, but this is very rare.
  • Three out of 100 children get a chickenpox-like rash after the first vaccine dose, but only about one of 100 children get a rash after the second dose.
  • Contraindications to receiving the vaccine include having a suppressed immune system, pregnancy, a current moderately severe illness, recent blood or blood product transfusion, or recent recipient of antiviral medications (for example, acyclovir [Zovirax] or oseltamivir [Tamiflu]).
  • Never give aspirin to a child with chickenpox. A deadly disease called Reye's syndrome has been associated with children taking aspirin, especially if they have chickenpox. Be sure to check any other over-the-counter medications for the ingredients aspirin or salicylates because these are often found mixed with over-the-counter cold medications.
  • Chickenpox can occasionally affect the cornea, the clear front portion of the eye. If a child develops chickenpox in the eyes or if the child develops a red, irritated eye, see a doctor immediately.

Measles ("Regular" or "Hard" Measles)

• Treatment
  • Once the disease begins, no medication is available to treat measles.
  • Children who have measles appear quite ill and are miserable, but the illness usually gets better without lasting ill effects.

One can prevent a child from getting measles by making sure they receive the recommended vaccines. The measles vaccine is part of the MMR (measles, mumps, and rubella) vaccine given at age 12-15 months and repeated at age 4-6 years. Multiple international studies have shown the vaccine to be safe and definitely not associated with autism or any other behavioral abnormality. Safety concerns also focused on the formerly used vaccine preservative, thimerosal, which contains mercury. The studies on thimerosal have shown it to be safe, and its use is still endorsed by the World Health Organization (WHO). Moreover, the MMR vaccine and the DTaP vaccines in the United States have been thimerosal-free since 1995. Since 2001, with the exception of the multidose vials of influenza (flu) vaccines, thimerosal has not been used as a preservative in routinely recommended childhood vaccines in the U.S.

Approximately 20% of those who develop measles may experience a complication. These may include ear infection, pneumonia and bronchitis, encephalitis, pregnancy problems, and a low platelet count (platelets are necessary for effective blood clotting).

Rubella (German Measles or "Three-Day Measles")

• Treatment
  • There is no specific treatment other than supportive care. Generally rubella is a short term, mild disease.
  • Rubella is easily prevented with an effective vaccine (the MMR) generally administered at 12-15 months with a booster dose at 4-6 years of age.

Fifth Disease

• Treatment
  • While there is no specific therapy other than comfort measures, several points are significant.
  • Fifth disease is not serious in otherwise healthy children but can pose a serious problem for children with sickle cell anemia, leukemia, or HIV/AIDS.
  • The disease can also cause problems for pregnant women who have not already had parvovirus B-19 infection prior to the pregnancy. Women should consult their obstetrician to discuss laboratory studies that will help determine risk factors.
  • Because the healthy child is contagious only before the rash appears, children who develop the rash are free to return to day care or school.

Roseola Infantum

• Treatment
  • No curative therapy is currently available to treat roseola.
  • Despite the worrisome fever, the disease is not harmful and gets better without specific therapy. Acetaminophen (Tylenol) may be used if desired.
  • The fever associated with roseola can occasionally cause a seizure. Simple febrile seizures are not associated with long-term neurological side effects.

Coxsackieviruses and Other Enteroviruses

• Treatment
  • No specific treatment is available except acetaminophen or ibuprofen (Advil) for fever and discomfort. A diet of soft and cold items (for example, yogurt and ice cream) is generally well tolerated.
  • The diseases are not harmful but can be prevented with good hand washing and not eating off of someone else's plate or sharing straws.

Rashes associated with life-threatening diseases are uncommon, and a child will usually appear quite ill. If one suspects that a child may have such a condition, go to a hospital's emergency department immediately.

Fever and Petechiae

Petechiae are small red or purplish flat spots on the skin that don't fade when pressed. Petechiae are due to broken capillaries in the skin. Petechiae without fever can occur in the head and neck after forceful coughing or vomiting. Most children with petechiae and fever have a mild viral illness. However, fever and petechiae are also seen with bacterial sepsis, especially with meningococcal disease. This disease is highly fatal and extremely contagious. Any child with a fever and petechiae should be seen by a doctor immediately.

• Symptoms and signs
  • Petechiae are flat red dots on the skin that do not fade when pressure is applied. The dots represent bleeding from the capillaries, leaving a small, temporary blood blister in the skin.
  • Children with petechiae may appear healthy but may rapidly become very ill.

Meningococcemia

Also called, meningococcal sepsis, meningococcemia is a life-threatening bacterial invasion of the blood by bacteria called Neisseria meningitidis. This disease is seen primarily in the winter and spring in children younger than 2 years of age, but epidemics can occur in any season. Meningococcemia is spread from the nose and mouth of other people. Good hygiene and hand washing can help decrease the risk of transmission. Children exposed to people with this disease need to be evaluated by their doctor and possibly be put on antibiotics to protect them from getting the disease. (Other bacteria such as Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus can cause similar syndromes.)

• Symptoms and signs
  • Fever and a petechial rash are present. Petechiae are broken capillaries in the skin that cause flat red dots that do not blanche with pressure applied to the skin. The petechial rash can rapidly evolve to appear as large bruises over the entire body.
  • Headache, congestion, nausea, vomiting, and muscle aches may occur. Some children may appear to be delirious and may rapidly develop seizures or become unresponsive and comatose.
  • The rash may start out as small bumps or raised blisters but develop into petechiae.

Rocky Mountain Spotted Fever

Rocky Mountain spotted fever (RMSF) is a disease spread by tick bites. The disease occurs because the tick harbors the bacteria that cause the disease in its salivary glands. When the tick attaches to the skin, it feeds on the victim's blood and enables the transmission of the bacteria into the patient's blood. Often the child and parent may not remember any tick bite. RMSF is more common in the southeastern U.S. than in the Rocky Mountains. It tends to occur in the warmer months of April through September when ticks are more active and outdoor exposures are more likely to occur. Rocky Mountain spotted fever can be fatal even in young healthy adults, but with early diagnosis and treatment with appropriate antibiotics, the mortality rate is low.

• Symptoms and signs
  • The first symptoms are not specific for RMSF and may occur in many illnesses: sudden onset of high fever (102 F-103 F), chills, moderate headache, nausea and vomiting, abdominal pain, and fatigue. These symptoms generally occur two to 14 days after the tick bite.
  • On the second to fifth day of the illness, a characteristic rash develops on 85%-90% of patients.
  • The rash begins as red spots on the wrists and ankles and spreads centrally toward the trunk. The rash begins as flat, red marks that blanch with pressure. Later on, the rash will become raised and may have a non-blanching red center. Nine to twelve percent of patients will not develop a rash at all.
  • The rash may involve the palms of the hands and soles of the feet but usually does not involve the face. As the rash progresses, it becomes petechial (does not blanch with pressure), with red to purplish dots or even small bruises.
  • In addition to this rash, generalized muscle aches and pains, diarrhea, and restlessness occasionally developing into delirium may develop.

Lyme Disease

An organism spread by deer tick bites also causes Lyme disease. It is the most common tick-spread illness in North America and Europe. Lyme disease has been reported in the Northeast, Mid-Atlantic, North Central, and Pacific coastal regions of the United States. About half of all cases are clustered in New York and Connecticut. (The disease was first described in a patient from Lyme, Conn.)

• Symptoms and signs
  • Lyme disease may be difficult to diagnose since patients may not have all of the potential signs and symptoms.
  • Lyme disease starts with a flu-like illness consisting of moderate fever (102 F), chills, body aches, and headache. A characteristic rash occurs in 70%-80% of patients several days to a few weeks following a tick bite. The rash often starts as a small red tender nodule. The nodule decreases in size but an enlarging red ring spreads outward. This characteristic rash is called erythema migrans and can vary in size from fingertip to up to 12 inches in diameter.
  • The illness consists of a fever, which can range from 100 F-104 F, headache, muscle and joint aches, a mild sore throat, a cough, stomach upset, neck pain and stiffness, and Bell's palsy (a paralysis of the facial nerve that causes an asymmetric facial expression when smiling or frowning).
  • As it grows, the rash can remain red throughout, although it often can develop a clear area and may take on the appearance of a target with concentric circles of red next to clear areas.
• The early symptoms are not as threatening as the later complications if the infection is not treated. Potential complications of untreated Lyme disease include heart rhythm disturbances, a chronic arthritis most commonly affecting the knees, and brain swelling that causes learning difficulties, confusion, or coma.

Kawasaki Disease

Kawasaki disease (also called mucocutaneous lymph node syndrome or MCLNS) has no proven cause, although it is suspected to be caused by a bacteria or virus. Kawasaki disease usually affects children between 4 and 9 years of age. It can have serious effects on a child's heart if not diagnosed and treated correctly. With treatment, only 2% of children die from this disease. Call a doctor or go to a hospital's emergency department immediately if one suspects a child may have Kawasaki disease.

• Symptoms: The child typically appears quite ill.
• There are no definitive tests to establish a diagnosis of MCLNS; however, four of the following six criteria are considered necessary to establish a case of typical Kawasaki disease.
  • The disease is defined by the following diagnostic criteria:
    • Fever for five days straight -- generally 102 F or higher
    • Redness of the eyes but no discharge is present
    • Swollen lymph nodes in the neck
    • Red throat, tongue, or lips: The lips are often cracked and fissured.
    • Redness or swelling of the fingers and toes that may be associated with peeling of the skin of the fingertips
    • Rash with flat red lesions, raised red lesions, blisters, or any combination of these: The rash is most impressive in the region of the hands and feet.
  • Less frequent symptoms arise from inflammation of the lining of the sac surrounding the heart (pericarditis), the large and small joints (arthritis), the tissue covering the brain (meningitis), and the gall bladder (cholecystitis) or urinary bladder (cystitis).

Toxic Shock Syndrome

Toxic shock syndrome (TSS) is a life-threatening disease in which many body systems are acutely affected. Early in the course of TSS, the disease may resemble RMSF, measles, and several other diseases. This disease is caused by a toxin produced by Staphylococcus aureus (staph) or Streptococcus. When the causative organism is Streptococcus, the disease is called streptococcal toxic shock syndrome (STSS). This disease can be fatal even with the maximum intensive treatment. If one suspects that a child may have TSS or STSS, go to a hospital's emergency department immediately.

• Symptoms and signs
  • Toxic shock syndrome is known for a sudden onset of high fever, chills, sore throat, body aches, and may include vomiting or diarrhea.
  • These signs and symptoms can rapidly progress to low blood pressure (shock), with multiple types of organ failure that may lead to disorientation. Death occurs in about 5% of all cases.
  • A characteristic rash is often present from the onset of symptoms. This rash looks like a mild sunburn but will be found in areas normally covered by clothes when outdoors. Peeling of the skin of the palms and soles may also occur.
  • Children with this disease appear very ill, and the disease can progress rapidly to a life-threatening situation.
• Cause
  • Staph and strep bacteria commonly are present in the skin as well as the nasal and vaginal cavities of healthy individuals. Women who take extended time between changes of tampons or intravaginal contraceptive devices or people with prolonged nasal packing following surgery are at risk for developing TSS or STSS. These situations promote retention of the bacteria and provide an opportunity for release of their toxin into the circulation.

Fever and Petechiae

• Treatment
  • Petechiae resolve completely in seven to 10 days without any treatment. However, a doctor should evaluate a child to determine that a serious disease process is not present.
  • A child may need blood tests and X-rays to find the cause of the petechiae and fever.
  • Occasionally, a child also requires a lumbar puncture (spinal tap) to be sure meningitis is not the cause.

Meningococcemia

• Treatment
  • A child with the symptoms of meningococcemia should be brought to a hospital's emergency department immediately.
  • Blood tests, including blood cultures, will be needed, as may X-rays and a spinal tap (lumbar puncture) to fully evaluate the child.
  • Meningococcemia is treated in the hospital with IV antibiotics. Intensive-care therapy may also be required.
  • Meningococcal sepsis is often fatal even with appropriate antibiotic therapy. Early treatment and close observation are needed.
  • Vaccines exist to protect children against severe disease caused by N. meningitis, H. influenzae, and Streptococcus pneumoniae. These vaccines are part of those routinely recommended by a child's pediatrician.

Rocky Mountain Spotted Fever

• Treatment
  • Contact a physician immediately if one suspects a child has RMSF or with any concerns of a tick-related illness.
  • RMSF treatment must be started before confirmatory blood test results are available since they may not turn positive for up to 10 days after the start of the illness. Treatment must be started before this time to avoid serious complications.
  • Most children are put in the hospital and given antibiotics.
  • Complications of RMSF are generally rare but can include meningitis, brain damage, generalized organ failure, shock, and death.
• Prevention
  • The most effective means to prevent Rocky Mountain spotted fever and many other tick-transmitted diseases (such as Lyme disease or ehrlichiosis) is to keep from getting bitten by ticks.
    • When outdoors, dress in light colors that make it easier to see ticks if they attach themselves.
    • Wear long-sleeve shirts and long pants, tucking the pant legs into the socks.
    • Check for ticks on the body periodically, paying special attention to the scalp, underarms, and genital areas.
    • Use an insect repellent that is effective against ticks. Both DEET and picaridin are long lasting and provide protection. Picaridin has low skin absorption and does not stain fabrics.
    • Never use a concentration of DEET (N, N-diethyltoluamide) higher than 30%, and never apply DEET directly to the skin. Do not use DEET on children less than 4 months of age. Do not apply to broken skin. Avoid getting DEET into the eyes, nose, or mouth. DEET can damage synthetic fibers, so be careful applying this to clothing.
    • Apply the insect repellent to the shirt collar, sleeves, and pants. There are permethrin products that can be applied only to clothing which are long lasting and effective in helping to prevent tick bites.
    • RMSF may be contracted more than once. Continue to follow the precautions listed above.
  • Once a tick has attached itself, it should be promptly removed. The longer the tick remains attached, the higher the likelihood of transmission of the causative bacteria.
    • Gently grab the tick with tweezers close to the skin (to include the head) and apply a gentle tug. Do not crush the tick, as this usually results in leaving the microscopic mouthparts still attached. (The mouthparts may contain the salivary glands that are the reservoir for the causative bacteria.)
    • Hold this gentle tension until the tick releases. This may take several minutes. Save the tick in a plastic sandwich bag since a doctor may need to use it to determine which type of bacteria is causing the child's illness.
    • Cleanse the bite area with alcohol, and call a doctor immediately. Wash the hands immediately after tick removal.
    • Avoid the old home remedies of applying lighter fluid, petroleum jelly, gasoline, or a lit match to kill a tick. Once the tick is dead, the mouthparts may stay in the wound and greatly increase the risk of disease.
  • Ticks can also be brought into the home by pets, so be sure to have a veterinarian check pets regularly and ask about products to reduce the risk of tick attachment.

Lyme Disease

• Treatment
  • Lyme disease should be treated promptly.
  • A doctor will treat early Lyme disease with oral antibiotics. When treated early, nearly all people with Lyme disease experience rapid improvement and minimal complications. If therapy is delayed, the response to antibiotics will be slower with a higher prevalence of complications.
  • A vaccine has been approved for people older than 15 years of age to prevent Lyme disease (LYMErix), but it is given only to people with significant occupational exposures to Lyme disease.
• Prevention
  • See the Prevention section in the preceding section on Rocky Mountain spotted fever for suggestions for prevention of tick-borne illnesses.

Kawasaki Disease

• Treatment
  • No test is available to diagnose this disease. The diagnosis is made by evaluating for the presence of established diagnostic criteria. Children with this disease may have an elevated platelet count and erythrocyte sedimentation rate (a test that measures the extent of inflammation). Approximately 20% of patients with Kawasaki disease will develop saclike dilatations of the coronary arteries called aneurysms. All children suspected of having Kawasaki disease should have an echocardiogram and electrocardiogram (EKG).
  • Children with Kawasaki disease are admitted to the hospital and given IV gamma globulin and high-dose aspirin. Upon discharge from the hospital, they remain on low-dose aspirin and have timely follow-up with a pediatric cardiologist.

Toxic Shock Syndrome

• Treatment
  • The source of the infection must be found and adequately treated with antibiotics. The mainstay of therapy involves supporting the circulation and thus major organs (for example, kidneys).
  • Children with this disease are often admitted to the hospital for close observation and therapy in an intensive-care setting.

Because children often share many things and are less likely to take hygienic precautions than adults, parasites and fungal infections can spread quickly through a day-care center or a child's class at school. Pay attention to any prolonged itching or hair loss a child might experience.

Scabies

Scabies is a very itchy rash that is often worsened with bathing or at night. It is caused by a mite (Sarcoptes scabiei) that burrows beneath the top layer of skin, where is lives and lays its eggs. It is spread by close bodily contact such as sleeping together or sharing of clothing. It can also be sexually transmitted. Mites can survive for several days in clothes, bedding, and dust. It may take four to six weeks following initial exposure to develop symptoms.

• Symptoms and signs
  • The itchy rash of scabies tends to be found between the fingers, in the armpits, and on the inner wrists and arms. It tends to spare the head, palms, and soles except in infants and with severe infestations. This rash is most bothersome at night. Initially the rash appears as discrete, tiny blisters. After heavy scratching, these areas commonly develop a secondary skin infection. Often only 10-20 mites have burrowed beneath the skin. The large extent of generalized itching represents an allergic type of response to the mite.
  • Sometimes one can see the wavy pattern under the skin where the mite has burrowed. These are most commonly seen in areas where the skin is most delicate and thin (for example, webbing between the fingers).
• Treatment
  • To prevent scabies, good hygiene, frequent hand washing, and not sharing clothing is important. Scabies is purely a person-to-person disease -- animals do not develop scabies.
  • If a child has an intensely itchy rash that lasts for more than two to three days, he or she should be checked by a doctor.
  • Prescription medications are available to kill the mites and to decrease the allergic skin reactions of swelling and itch. Treatment should occur at the same time for all family members to avoid reinfection. It may take two to four weeks after the treatment for the itching to subside. If symptoms persist for greater than four weeks, retreatment may be necessary.
  • Once anyone in the family is diagnosed with scabies, everyone in the home should be treated for mite infestation.
  • All clothing and bedding must be washed in hot water and the mattresses vacuumed.

Ringworm

Ringworm is a local infection of the skin with a fungus, usually Microsporum canis, Microsporum audouinii, or Trichophyton tonsurans. Doctors refer to these infections as tinea with several forms such as tinea corporis (ringworm on the body) and tinea capitis (ringworm of the scalp). Although the two are caused by the same organisms, they must be treated differently. Ringworm can be caught from friends (exchanging combs, brushes, or hats) or from household pets. If one thinks a child may have ringworm, see a doctor.

• Symptoms and signs
  • With tinea corporis, the lesion starts as a red, slightly scaly oval that gets bigger over time. As the lesion increases in diameter, the border remains raised, slightly red, and scaly, while the central region resembles unaffected skin. The rash commonly develops one to two weeks after exposure.
  • The rash may be slightly itchy.
  • Tinea capitis usually starts with a round to oval area on the scalp characterized by an associated loss of hair.
  • Sometimes the area of the scalp will swell and may ooze. This is called a kerion and is a reaction of the body to the tinea fungus.
  • Tinea capitis may also present as normal to severe dandruff without hairless patches on the scalp. It may take six to eight weeks of effective oral therapy to resolve a kerion.
• Treatment
  • Tinea corporis can easily be treated with topical medications available from a doctor.
  • Unfortunately, it can be easily spread among family members and friends.
  • Good hygiene combined with appropriate therapy can break this cycle.
  • Tinea capitis requires an oral medication from a doctor.

Athlete's Foot

Athlete's foot is also caused by a fungal infection of the skin. The medical term for this condition is "tinea pedis."

• Symptoms and signs
  • Athlete's foot is characterized by a very itchy rash between the toes. While it may occur in young children, it is more commonly a disease of older children, teens, and adults. Toddlers and younger children may develop a non-fungal rash between the toes due to excessive dampness of the feet.
• Treatment
  • Although athlete's foot can be treated with over-the-counter medications, other causes of rash can appear similar. It is best to have a child checked by a doctor to confirm the diagnosis if one suspects athlete's foot.
  • Keeping feet dry and wearing sandals in public showers will help to control the spread of tinea pedis.

When one brings a baby home from the hospital, every little bump or red patch causes alarm. It is normal for a baby to have some skin rashes. After all, he or she has suddenly been forced to adapt to an environment that is not what he or she was used to (amniotic fluid). Diaper rash, cradle cap, and a host of other conditions are common in newborns. If one suspects that a child has more than a simple skin irritation, it is best to see a doctor.

Milia

• Symptoms and signs
  • Small (1 mm) white bumps which may appear of the nose, cheeks, and chin of approximately one-half of all newborns.
• Treatment
  • Milia resolve spontaneously over the first few weeks of life. No therapy is necessary, and the bumps do not cause scars.
  • Milia are not contagious.

Seborrheic Dermatitis (Cradle Cap)

• Symptoms and signs
  • Cradle cap is a greasy, scaly, red, bumpy rash that can occur on the scalp, behind the ears, in the armpits, and the diaper area. It commonly presents at about 6 weeks of age and can resolve spontaneously within a few months. It is not contagious and will not scar. It is not itchy and is generally believed not to bother an infant. While several theories have been proposed, the exact cause has not been completely identified. It is not due to poor hygiene.
• Treatment
  • Therapy commonly involves daily shampooing of the scalp and other involved body areas. Gentle rubbing to remove the greasy scales using a facecloth, hairbrush, or the fingernails is usually helpful. If the area is more heavily involved, applying baby oil to the affected area may be helpful. Occasionally a pediatrician may recommend the use of a medicated shampoo (for example, Head and Shoulders, Sebulex, T-Gell). Once the rash is resolved, washing the scalp or other regions every few days will help to keep the area rash free.

Infantile Acne

"Baby acne" commonly develops at about 2 weeks of age, increases in intensity for two weeks, and resolves without scarring over the next two weeks (total duration of condition is thus six weeks). While the exact cause of infantile acne is unknown, most doctors believe it represents a sensitivity of the baby's oil glands to the maternal hormone level of pregnancy. The rash most commonly involves the cheeks and nose.

Erythema Toxicum

This rash has a scary name but should really be called "the normal newborn rash" because it occurs in about half of all newborns.

• Symptoms and signs
  • The rash is characterized by multiple flat red areas approximately 1 cm in diameter. Often in the center will be a small raised 2-3 mm white or yellow bump.
  • The rash starts with small blisters on a red base.
  • Sometimes only the blotchy red base shows, and sometimes the blisters have a white or yellow material inside.
  • The rash starts the second or third day of life and usually resolves without treatment in one to two weeks.
• Treatment
  • Since the rash is not serious and is not contagious, it does not require treatment.
  • The rash can look somewhat similar to other types of rash, so see a doctor with any questions or concerns.

Miliaria (Prickly Heat)

This rash includes small, clear blisters usually on the nose. It is caused by the production of sweat in a warm environment and plugged sweat glands. This rash is more common when the child is dressed too warmly. It gets better on its own.

Candidal Rash (Yeast Infection)

This diaper rash is a fungal or yeast infection of the skin by Candida albicans. This is the same organism that causes thrush, the white plaques in the mouths of infants. The combination of the moist diaper environment and the presence of C. albicans in the normal gastrointestinal tract of children facilitates the development of a Candida diaper rash.

• Symptoms and signs
  • An intensely red, raised rash with discrete borders is found. The borders may have a ring of fine scales. The rash may involve the genitalia of boys and girls. In addition, occasionally Candida infection may occur around the anus.
  • Surrounding the main area of rash there may be smaller lesions, called satellite lesions, which are characteristic of candidal diaper rashes.
  • The rash tends to involve the skin creases and folds because of the warm, moist environment. This characteristic may help in distinguishing Candida rash from irritant diaper rash that commonly will spare these areas (see below).
• Treatment
  • This rash is easily treated by medications available from a doctor but may recur.

Seborrheic Dermatitis

A greasy, scaly, red diaper rash, seborrheic dermatitis tends to occur in the creases and folds just as in Candida rashes. Unlike Candida rashes, the rash is usually not intensely red or scaly but instead is usually moist and greasy in appearance. This rash is not harmful and can be easily treated by a doctor.

Irritant Diaper Rash

The effects of urine and feces on the sensitive skin of the newborn cause this rash. The creases and folds are spared in this rash, unlike seborrhea or Candida diaper rash.

• Treatment
  • To prevent diaper rash, change soiled or wet diapers as soon as possible.
  • Make sure that baby clothing is well rinsed, and do not use fabric softeners because this may irritate delicate skin.
  • Many doctors suggest allowing the bottom to go bare for several hours a day, especially to help heal a diaper rash.
  • Topical ointments with zinc oxide also provide a barrier and may help with healing of a diaper rash.
  • Extra bathing will also promote resolution of this common rash.

The prognosis is dependent upon the cause of the rash. The outcome can vary from (1) excellent (for example, milia), (2) good (for example, chickenpox), (3) concerning (for example, Kawasaki disease), and (4) life-threatening (for example, toxic shock syndrome).

Routine skin rashes are generally easily managed by the child's pediatrician. Should the rash be associated with severe disease (for example, petechiae and meningococcemia), intensive-care specialists will assist in the child's care. A consultation with a dermatologist will be important to help diagnose an unusual rash or manage a rare skin condition.