History Taking and Management of a Child Presenting with Skin Rash

Abstract

Areas to focus on: infectious (viral: chicken pox, erythema infectiosum, roseola infantum, measles, rubella, hand-foot-mouth disease, molluscum contagiosum, herpes simplex, pityriasis rosea. Bacterial: impetigo, cellulitis, scarlet fever, staphylococcus scalded skin syndrome. Fungal: candida, tinea. Parasitic: scabies, cutaneous larva migrans), versus non-infectious rashes: inflammatory (atopic dermatitis, contact dermatitis, seborrheic dermatitis, diaper dermatitis, intertrigo), drug reaction, systemic disorders (Kawasaki disease, urticaria, psoriasis, Henoch-Schonlein purpura), neonatal rashes (Melia, erythema toxicum neonatorum, neonatal acne, benign cephalic pustulosis).

FormalPara Learning Objectives

• How to master history taking for a child presenting with rash?

• How to demonstrate a good understanding of common and potential differential diagnosis for children presenting with fever?

• How to perform focused exam for a child presenting with rash?

• How to provide management for children presenting with rash?

Focus areas on infectious causes (viral: chicken pox, erythema infectiosum, roseola infantum, measles, rubella, hand-foot-mouth disease, molluscum contagiosum, herpes simplex, pityriasis rosea. Bacterial causes: impetigo, cellulitis, scarlet fever, staphylococcus scalded skin syndrome. Fungal causes: candida, tinea. Parasitic causes: scabies, cutaneous larva migrans), versus non-infectious causes of rash: inflammatory (atopic dermatitis, contact dermatitis, seborrheic dermatitis, diaper dermatitis, intertrigo), drug reaction, systemic disorders (Kawasaki disease, urticaria, psoriasis, Henoch-Schonlein purpura), neonatal rashes (Melia, erythema toxicum neonatorum, neonatal acne, benign cephalic pustulosis).

• 1. Introduce yourself and establish good rapport.

• 2. Identify the complaint (rash or eruption): site, onset, initial appearance, duration, progression (how it has evolved), exacerbating and reliving factors (prior trials of treatment), red flags (fever, inconsolability, extreme irritability, mucosal inflammation, respiratory distress, blistering, or skin sloughing), other associated symptoms (itching, stinging, tenderness, discharge, pain, fatigue, respiratory symptoms), and possible provoking factors:

  • (a) Recent upper respiratory tract infection, gastroenteritis, insect bite, travel, or stress (new school, new baby at home, abuse).

  • (b) History of contact.

  • (c) Attendance to day care.

  • (d) Exposure to new pets, medications, personal care products, or clothes.

  • (e) Allergies.

  • (f) History of previous similar episode and management if any.

  • (g) Diarrhea or abdominal pain.

  • (h) Explore secondary issues: sleep disturbance or feeling embarrassed.

• 3. Determine underlying health status: vaccination status, ongoing health issues, and medication history.

• 4. Explore parent’s ideas, concerns and expectations (ICE), effect of the complaint on quality of life: “How does the problem affect you and your child? Has the problem affected his or her attendance at school or day care?”

• 5. Social and family history: similar complain in the family, any chronic skin conditions, or skin cancer in the family?

• 6. Examination:

  • (a) Vital signs and general appearance of the child: assess for fever and ill looking child.

  • (b) Examination of the rash (consider utilizing a Woods lamp or dermoscopy): assess morphology, color, lesion pattern (scattered, clustered, linear, or coalescing), number, distribution across affected areas, consistency, and texture. Classify accordingly (refer to Table 36.1 for details).

• 7. Investigations: if and only if history and physical exam was not sufficient to make a diagnosis.

• 8. Aim at identifying potential life threats as follows:

  • (a) Complete blood count, renal function tests, and stool tests (if suspecting hemolytic uremic syndrome).

  • (b) Gram stain and cultures of blood and cerebrospinal fluid (if suspecting meningococcemia).

  • (c) Skin biopsy.

• 9. Management: refer to Table 36.2 for details.

• 10. Give reading educational materials if any.

• 11. Discuss health maintenance and age-appropriate screening.

• 12. Arrange for the following as needed:

  • (a) Admission: if a life-threatening diagnosis is suspected or found.

  • (b) Referral: if diagnosis is not clear or rash is refractory to treatment.

  • (c) Follow up: in 1–2 weeks.

• 13. Communication skills: organized approach, mixed questioning styles (open and close ended questions), active listening, clear language, and reflection on patient’s ICE.

Table 36.1 Appearance of common rashes in children

Table 36.2 Management of common skin rashes in children