Common childhood exanthemas2

1. Common ChildhoodCommon Childhood
ExanthemasExanthemas
Done by : Dr. Roaya Al-LawatiDone by : Dr. Roaya Al-Lawati

2. ExanthemaExanthema
 It is a widespread rash that is usually accompaniedIt is a widespread rash that is usually accompanied
byby systemic symptomssystemic symptoms such as fever, malaise,such as fever, malaise,
headache, loss of appetite, abdominal pain,headache, loss of appetite, abdominal pain,
irritability and muscular aches and painsirritability and muscular aches and pains
 It is usually caused by an infectious conditionIt is usually caused by an infectious condition
 Mechanism:Mechanism:
 Reaction to a toxin produced by the organism,Reaction to a toxin produced by the organism,
 Damage to the skin by the organism,Damage to the skin by the organism,
 An immune response.An immune response.
 due to a drug (esp. antibiotics).due to a drug (esp. antibiotics).

3. Causes include:Causes include:
 impetigoimpetigo
 Chicken poxChicken pox
 RubellaRubella
 MeaslesMeasles
 Scarlet feverScarlet fever
 Hand foot & mouth diseasesHand foot & mouth diseases

5. MeaslesMeasles
 HighlyHighly contagiouscontagious viral illness caused by the measlesviral illness caused by the measles
virus.virus.
 Since the introduction of an effective vaccine inSince the introduction of an effective vaccine in
1968, the incidence of measles in has declined1968, the incidence of measles in has declined
dramatically.dramatically.
 There is a recent small increase from fall inThere is a recent small increase from fall in
immunization uptakeimmunization uptake
 Incubation period: aboutIncubation period: about 6 to 19 days6 to 19 days (median 13)(median 13)
 Period of infectiousness: about 1 to 2 days prior toPeriod of infectiousness: about 1 to 2 days prior to

6. Clinical featuresClinical features
1.1. FeverFever
2.2. CoughCough
3.3. runny noserunny nose
4.4. ConjunctivitisConjunctivitis
5.5. marked malaisemarked malaise
6.6. Koplik's spotsKoplik's spots
7.7. maculopapular rashmaculopapular rash

7. Koplik’s spotsKoplik’s spots
 Part of prodrome:Part of prodrome: day 1-3day 1-3 beforebefore
rashrash
 Raised papules onRaised papules on buccalbuccal mucosamucosa
andand conjunctivaconjunctiva
 Usually adjacent to molarsUsually adjacent to molars
 Often white on red baseOften white on red base
 Disappear about time rash occursDisappear about time rash occurs

8. RashRash
 2-4 days after prodrome, 14 days after exposure2-4 days after prodrome, 14 days after exposure
 SpreadSpread downwarddownward fromfrom behind the earbehind the ear to the wholeto the whole
of the bodyof the body
 DiscreteDiscrete maculopapularmaculopapular rash initiallyrash initially
 BecomeBecome blotchy and confluentblotchy and confluent
 May desquamate in second weekMay desquamate in second week
 Persists 5-6 daysPersists 5-6 days
 Fades in order of appearanceFades in order of appearance

10. ComplicationsComplications
-- There are a number of serious complications which can occurThere are a number of serious complications which can occur
in previously healthy children :in previously healthy children :
1.1. Encephalitis:Encephalitis:
- occurs in only 1 in 5000, about 8 days after the onset of the- occurs in only 1 in 5000, about 8 days after the onset of the
illness.illness.
-Initial symptoms are headache, lethargy and irritability,-Initial symptoms are headache, lethargy and irritability,
proceeding to convulsions and ultimately comaproceeding to convulsions and ultimately coma
- Mortality is 15%.- Mortality is 15%.
-- Serious long-term sequelae include seizures, deafness,Serious long-term sequelae include seizures, deafness,
hemiplegia and severe learning difficulties affecting up tohemiplegia and severe learning difficulties affecting up to
40% of survivors.40% of survivors.

11. ComplicationsComplications
2.2. Subacute sclerosing panencephalitisSubacute sclerosing panencephalitis (SSPE)(SSPE)
-- a rare but devastating illness manifesting, on average, 7a rare but devastating illness manifesting, on average, 7
years after measles infection in about 1 in 100 000 cases.years after measles infection in about 1 in 100 000 cases.
- Most children who develop SSPE had primary measles- Most children who develop SSPE had primary measles
infection before 2 years of age.infection before 2 years of age.
- SSPE is caused by a variant of the measles virus which- SSPE is caused by a variant of the measles virus which
persists in the central nervous system.persists in the central nervous system.
- The disorder presents with loss of neurological function,- The disorder presents with loss of neurological function,
which progresses over several years to dementia and death.which progresses over several years to dementia and death.
- The diagnosis is essentially clinical, supported by finding- The diagnosis is essentially clinical, supported by finding
high levels of measles antibody in both blood andhigh levels of measles antibody in both blood and
cerebrospinal fluid and by characteristic EEG abnormalities.cerebrospinal fluid and by characteristic EEG abnormalities.

12. ComplicationsComplications
 The rash may progress to a dark red/violet colour followed byThe rash may progress to a dark red/violet colour followed by
desquamation and depigmentation, which may last weeks ordesquamation and depigmentation, which may last weeks or
months.months.
 Pre-existing malnutrition is further exacerbated by oralPre-existing malnutrition is further exacerbated by oral
infections and diarrhoea.infections and diarrhoea.
 A measles interstitial pneumonitis, known as 'giant cellA measles interstitial pneumonitis, known as 'giant cell
pneumonia', may be fatal in children with malignant disease,pneumonia', may be fatal in children with malignant disease,
even when in remission.even when in remission.
 These children are also susceptible to a measlesThese children are also susceptible to a measles
encephalopathy.encephalopathy.

13. TreatmentTreatment
 Treatment for measles isTreatment for measles is symptomaticsymptomatic..
 paracetamol for feverparacetamol for fever
 Maintain fluid intake so dehydration doesn't occurMaintain fluid intake so dehydration doesn't occur
 Provide nutritional support if necessaryProvide nutritional support if necessary
 Observe high-risk individuals carefully to prevent complicationsObserve high-risk individuals carefully to prevent complications
 Look for and treat bacterial super-infectionsLook for and treat bacterial super-infections
 Rinse eyes daily (saline or sterile water)Rinse eyes daily (saline or sterile water)
 Children who are admitted to hospital should be isolated.Children who are admitted to hospital should be isolated.
 In immunocompromised patients, the antiviral drugIn immunocompromised patients, the antiviral drug RibavirinRibavirin
may be used.may be used.
 Vitamin AVitamin A, which may modulate the immune response, should, which may modulate the immune response, should
be given in developing countries.be given in developing countries.

14. PreventionPrevention
 Prevention byPrevention by immunizationimmunization is the most successfulis the most successful
strategy for reducing the morbidity and mortality ofstrategy for reducing the morbidity and mortality of
measles.measles.
 Vaccine Immunization:Vaccine Immunization:
 Live attenuated vaccineLive attenuated vaccine
 Usually given with MMR (2 doses)Usually given with MMR (2 doses)
 AtAt 1212 months of agemonths of age
 AtAt 1818 monthsmonths

16. Chicken poxChicken pox
 Chickenpox is a highly contagious disease causedChickenpox is a highly contagious disease caused
by theby the varicella-zoster virusvaricella-zoster virus ((Herpes zosterHerpes zoster).).
 Incubation periodIncubation period  10 – 23 days10 – 23 days
 Period of CommunicabilityPeriod of Communicability  Range from 1 – 2Range from 1 – 2
days before the appearance of rash and 4 – 5 daysdays before the appearance of rash and 4 – 5 days
after rash.after rash.
 Spread bySpread by dropletdroplet Via respiratory tractVia respiratory tract

17. Cont,,Cont,,
 Virus remain in the Ant. Horn cells of spinalVirus remain in the Ant. Horn cells of spinal
cord and may lead tocord and may lead to ShingleShingle. (herpes zoster). (herpes zoster)
 Vulnerable age groupVulnerable age group: Primarily among: Primarily among
children<10 yrs age, in adults it causeschildren<10 yrs age, in adults it causes
severe infection.severe infection.
 ImmunityImmunity:: One attack gives life longOne attack gives life long
immunity,immunity, secondary attacksecondary attack raterate is veryis very lessless

18. Clinical featureClinical feature
 Sudden onset ofSudden onset of mild / moderate fevermild / moderate fever
 In children,In children, rashrash is often theis often the first signfirst sign comes on thecomes on the
day fever startsday fever starts
 Itchy vesicularItchy vesicular rash whichrash which cropscrops
 symmetricalsymmetrical
 first appears on trunkfirst appears on trunk, then comes on the face, arms & legs, then comes on the face, arms & legs
 palms and soles arepalms and soles are notnot usually affectedusually affected
 rash advances quickly through the stages of macule,rash advances quickly through the stages of macule,
papule, vesicle and scab.papule, vesicle and scab.
 PleomorphismPleomorphism is a characteristic features of the rash – allis a characteristic features of the rash – all
stages of rash (papules, vesicles) seen simultaneously atstages of rash (papules, vesicles) seen simultaneously at
one time in same area.one time in same area.

19. Skin TerminologiesSkin Terminologies
 MaculeMacule:: A change in the color of the skin <1 cm in size.A change in the color of the skin <1 cm in size.
 PapulePapule:: It is a circumscribed,solid elevation with no visibleIt is a circumscribed,solid elevation with no visible
fluid,varies from pin head to 1 cm in size.fluid,varies from pin head to 1 cm in size.
 VesicleVesicle:: a liquid filled cavity under epidermis (Blister)a liquid filled cavity under epidermis (Blister)
 ScabScab:: skin crusting over.skin crusting over.

21. ComplicationsComplications
1.1. Secondary bacterial infection:Secondary bacterial infection:
- with staphylococci, streptococci.- with staphylococci, streptococci.
- May lead to complications such as toxic shock syndrome or necrotising- May lead to complications such as toxic shock syndrome or necrotising
fasciitis.fasciitis.
2.2. Encephalitis:Encephalitis:
- Most characteristic is a VZV-associated cerebellitis.- Most characteristic is a VZV-associated cerebellitis.
- usually occurs within a week of the onset of rash.- usually occurs within a week of the onset of rash.
- Child is ataxic with cerebellar signs. It resolves over a few days.- Child is ataxic with cerebellar signs. It resolves over a few days.
3.3. Purpura fulminans.Purpura fulminans.
4.4. Strokes:Strokes:
-- Although very rare, there is an increased incidence of strokes in childrenAlthough very rare, there is an increased incidence of strokes in children
after VZV infection, due to either vasculitis or protein S deficiencyafter VZV infection, due to either vasculitis or protein S deficiency

22. Cont,,Cont,,
 In the immunocompromised, primary varicellaIn the immunocompromised, primary varicella
infection may result ininfection may result in severe progressivesevere progressive
disseminated diseasedisseminated disease
 It has a mortality of up to 20%..It has a mortality of up to 20%..
 The vesicular eruptions persist and frequentlyThe vesicular eruptions persist and frequently
become haemorrhagicbecome haemorrhagic..

24. TreatmentTreatment
 Symptomatic therapySymptomatic therapy
 Trimming children's fingernails to minimizeTrimming children's fingernails to minimize
scratching.scratching.
 ParacetamolParacetamol to reduce fever and painto reduce fever and pain
 Calamine lotionCalamine lotion and/orand/or oral antihistaminesoral antihistamines toto
relieve itching.relieve itching.
 ConsiderConsider oral acicloviroral aciclovir in people older than 12in people older than 12
years who may be at increased risk of severeyears who may be at increased risk of severe
varicella infections.varicella infections.
 Antibiotics for secondary infectionAntibiotics for secondary infection

25. PreventionPrevention
 Specific protection bySpecific protection by VaccineVaccine ((livelive
attenuated vaccineattenuated vaccine “Varivax”) been Proved“Varivax”) been Proved
safe and 80% effective in preventing disease.safe and 80% effective in preventing disease.
 human varicella zoster immunoglobulinehuman varicella zoster immunoglobuline
((ZIGZIG))  forfor immunosuppressedimmunosuppressed patientpatient whowho
in contact with chicken poxin contact with chicken pox

26. Hand, foot and mouth diseaseHand, foot and mouth disease
 Painful vesicular lesionsPainful vesicular lesions on the hand, feet,on the hand, feet,
mouth and tonguemouth and tongue
 Systemic features are mild and the diseaseSystemic features are mild and the disease
subside within a few dayssubside within a few days
 Caused by theCaused by the enterovirusesenteroviruses
 Most commonlyMost commonly coxsackie A16, enteroviruscoxsackie A16, enterovirus
7171
 Transmission byTransmission by faecal-oral routefaecal-oral route

27. Clinical FeaturesClinical Features
 More than 90% of infections due toMore than 90% of infections due to
enterovirusesenteroviruses are asymptomatic or causeare asymptomatic or cause
undifferentiated febrile illnessundifferentiated febrile illness
 Short incubation period of 2 to 5 daysShort incubation period of 2 to 5 days
(coxsackie)(coxsackie)
 Oral lesionsOral lesions
 Ulcers on tongue and buccal mucosaUlcers on tongue and buccal mucosa
 Results in food refusal because of tender lesionsResults in food refusal because of tender lesions
 Hand and Feet lesionsHand and Feet lesions
 Vesicular and tenderVesicular and tender
 Both dorsal and ventral surfacesBoth dorsal and ventral surfaces
 CNSCNS
 Rarely meningitis, encephalitis, paralysisRarely meningitis, encephalitis, paralysis

28. DiagnosisDiagnosis
• ClinicalClinical
• Isolation of virus from secretions and stoolsIsolation of virus from secretions and stools

29. TreatmentTreatment
• Symptomatic, by controlling fever and ensuringSymptomatic, by controlling fever and ensuring
hydrationhydration
• Isolation of infective personIsolation of infective person

31. Scarlet feverScarlet fever
 bacterial illness that often presents with abacterial illness that often presents with a
distinctive rashdistinctive rash
 caused by certain strains of thecaused by certain strains of the group Agroup A
streptococcus bacteria.streptococcus bacteria.
 A toxin released by the streptococcal bacteriaA toxin released by the streptococcal bacteria
causes tiny pinkish-red spots that cover thecauses tiny pinkish-red spots that cover the
whole bodywhole body

32. Clinical featureClinical feature
 usually starts with ausually starts with a sudden feversudden fever associatedassociated
with sore throatwith sore throat
 Enlarged Cervical glands.Enlarged Cervical glands.
 Headache, nausea, vomiting, loss of appetite,Headache, nausea, vomiting, loss of appetite,
 Swollen andSwollen and red strawberry tonguered strawberry tongue..
 Abdominal pain, body aches, and malaiseAbdominal pain, body aches, and malaise
 The characteristicThe characteristic rash appears 12-48 hoursrash appears 12-48 hours
after the start of the feverafter the start of the fever

33. RashRash
 Sand paper rashSand paper rash
 first appears on the neck and chest, thenfirst appears on the neck and chest, then
spreads over the bodyspreads over the body
 The texture of the rash is more importantThe texture of the rash is more important
than the appearance to confirm the diagnosisthan the appearance to confirm the diagnosis
 Flushed face /red cheecks with circumoralFlushed face /red cheecks with circumoral
pallor.pallor.

35. TreatmentTreatment
 10 Days10 Days penicillinpenicillin ( erythromycin for penicillin allergy)( erythromycin for penicillin allergy)
 ParacetamolParacetamol
 Eating soft foods and drinking plenty of cool liquids,.Eating soft foods and drinking plenty of cool liquids,.
 Oral antihistamines or calamine lotion to relieve the itch ofOral antihistamines or calamine lotion to relieve the itch of
rash.rash.
 Keep fingernails short on young children to prevent themKeep fingernails short on young children to prevent them
from damaging the skin.from damaging the skin.

36. ComplicationsComplications
 Rheumatic feverRheumatic fever
 Otitis mediaOtitis media
 PneumoniaPneumonia
 SepticaemiaSepticaemia
 GlomerulonephritisGlomerulonephritis
 OsteomyelitisOsteomyelitis

38. ImpetigoImpetigo
 LocalizedLocalized highly contagious staphylococcal and/ orhighly contagious staphylococcal and/ or
streptococcal skin infectionstreptococcal skin infection
 Common in infant and young childrenCommon in infant and young children
 Lesions are usually inLesions are usually in face, neck and handsface, neck and hands
 Begin asBegin as erythematous maculeerythematous macule which become vesicularwhich become vesicular
 Rupture of vesicle with exudation of fluid leads to confluentRupture of vesicle with exudation of fluid leads to confluent
honey colored crusted lesionshoney colored crusted lesions
 Spread to adjacent area and other part of the body bySpread to adjacent area and other part of the body by
autoinoculation of the infected exudateautoinoculation of the infected exudate
 If it is over a skin of a cartilage such as the nose and notIf it is over a skin of a cartilage such as the nose and not
managed it can lead to cartilage degeneration and miss themanaged it can lead to cartilage degeneration and miss the
shape of it.shape of it.

39. TransmissionTransmission
 The infection is spread by direct contact withThe infection is spread by direct contact with
lesionslesions or withor with nasal carriersnasal carriers..
 The incubation period isThe incubation period is 1–3 days1–3 days..

40. PreventionPrevention
 Affected children should not go to nurseryAffected children should not go to nursery
or school until the lesions are dryor school until the lesions are dry
 Nasal carriage is an important source ofNasal carriage is an important source of
infection which can be eradicated with ainfection which can be eradicated with a
nasal cream containing mupirocin ornasal cream containing mupirocin or
chlorhexidine and neomycinchlorhexidine and neomycin

41. TreatmentTreatment
Mild:Mild:
Use topical antibiotics (e. gUse topical antibiotics (e. g
mupirocinmupirocin))
Severe:Severe:
Flucloxacillin (floxacillin) orFlucloxacillin (floxacillin) or
erythromycinerythromycin

42. THANK YOUTHANK YOU