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Many rashes in children are benign and self limited, but others demand immediate intervention. An exanthem is a rash involving skin with many causes—bacterial or viral infection, toxin, drug, or noninfectious inflammatory conditions. An enanthem is a rash involving mucous membranes. This chapter describes disease processes in children for which dermatologic symptoms are diagnostic and serves as a reference for the presenting complaint of “rash” in children and young adults. Detailed descriptions of the most important skin diseases are provided in chapters in Section 20, Skin Disorders, with Chapter 243, Approach to Skin Disorders in the Emergency Department, specifically outlining principles of evaluation of rashes in both children and adults.

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History

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Ask about fever and systemic symptoms, prior immunizations, potential human or animal contacts, recent bites or stings, travel, recent prescription or over-the-counter drug administration, and recent food and environmental exposure. Ask about the initial location of rash, the pattern and time frame of rash development, initial morphology, and whether any topical or systemic medications have been applied.

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Most exanthems present as an isolated episode in a single child, but outbreaks can also develop in groups of children. When evaluating only a single child with a rash, the diagnosis can usually be made by routine history and physical examination. When several children develop similar-appearing skin lesions, obtain detailed contact and exposure history, and consider the need to notify local public health authorities.

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Physical Examination

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Obtain vital signs. Disrobe the child completely and perform a complete physical examination. Check the scalp, ears, neck, mucous membranes, all skinfolds, digits, and web interspaces, palms, and soles. Look for ticks that may be adherent in hair-bearing areas or skinfolds. Identify the morphology and determine the location and distribution of the rash. In addition to the discussion below, chapters in Section 20, Skin Disorders, discuss diagnosis based upon anatomic location of the rash.

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Enteroviruses

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Enteroviruses are a very common cause of illness and rash in young children. Enteroviruses are small, single-stranded RNA viruses belonging to the picornavirus group and include polioviruses, coxsackievirus, and echovirus. The enterovirus family has been associated with a wide variety of illnesses, including polio. Enterovirus infections usually occur in epidemics, with a peak prevalence in the summer and early fall. Transmission usually occurs by the fecal–oral route and sometimes by respiratory or oral–oral transmission.1

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The clinical signs and symptoms of infection with coxsackieviruses and echoviruses vary and can include nonspecific febrile illnesses, upper and lower respiratory infections, GI infections and inflammations, aseptic meningitis, or myocarditis. Similarly, the associated skin manifestations include an array of exanthems. Diffuse macular eruptions, morbilliform erythema, vesicular lesions, petechial and purpuric eruptions, rubelliform rash, roseola-like rash, and scarlatiniform eruptions have all been reported.1 Strict clinical-virologic associations are difficult to demonstrate, unlikely to be practical in the ED, and equally unlikely to change the course ...

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