Tasty Morsels of EM 136 – Paediatric rashes

15 Jan

This batch of the tasty morsels series are various pearls and learning points from my most recent 6 months doing paeds EM. I’d done a fair bit of paeds before but never in a dedicated children’s hospital and it was all a long time ago. Turns out there’s always more to learn. These are mainly observations and anecdotes even more so than usual!

Hand, foot & Mouth (& Bum)

  • Should definitely have the “bum” part added as it’s clear that perineum gets a rough time of it in this disease.
  • Expect a variety of lesions in the same patient – some fine macular stuff, some papules and in the mouth and oropharynx look for the vesicles. it’s another one of the rashes for soles and feet which might help clinch it for you.
  • mainly enteroviruses (transmitted through the gut) of which coxsackie A variants are the majority of causes. There are at least 20 different coxsackie types hence the recurring infections that some poor kids get.
  • Can be shed in the stool for 10 weeks hence the almost certain likelihood that someone in your child’s creche is carrying it at some point.
  • Herpangina is HFM’s cousin that presents with oral lesions only.
  • PR diclofenac occasionally works wonders in the child who is dramatically failing their trial of fluids in the department.
  • I warn parents that don’t be surprised if the fingernails fall off after they get better. And reassure them that they grow back. That was more from family experience than reading but it’s definitely a thing.


  • I somehow missed that this existed. This is “sixth” disease. Also bizarrely known as baby measles. (think of it in the 6-18 month range mainly)
  • It’s a lovely little diagnosis to make, 3 days fever then bang, fever goes and rash appears. Always makes you look smarter than the doc before who diagnoses some non specific URTI and you come along and make a positive if somewhat obscure and irrelevant diagnosis. It’s the little things…
  • Human herpes virus 6 is the common culprit and we seem to shed that asymptomatically life long so good luck with isolating that one…
  • One report states that 13% during the febrile phase (before the rash) can have sterile pyuria which may well get treated as a UTI pending the culture. It then causes even more confusion when the fever settles (as it should in a UTI on antibiotics) and a rash appears and now you’re blaming an antibiotic reaction.


  • almost always viral and seem to respond really well to antihistamines – as opposed to adults where it seems you see lots of adults with urticaria for whom the antihistamines do little
  • as a result you don’t seem to need steroids in the way we do in adults. (when I say “need” I of course mean the “need” to do something to make the patient feel that we’re doing something for them.)
  • the one I got caught out on was multiforme. Which again is usually benign but it definitely has much clearer edges with the central clearing and has a potentially more serious differential even if it usually isn’t.

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