Rashes

 

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 

Table 7.28   

Table 7.29   

Table 7.30   

Table 7.31   

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