Rashes in children
Sort the urgency, ask seven questions, describe what you see, and always look in the mouth.
A 3-year-old girl has had fever for 6 hours and is now drowsy with cold hands and feet. Capillary refill 4 seconds, pulse 170. There are small purple spots on her legs and trunk that don't fade when you press a glass on them.
A 4-year-old unvaccinated boy has had fever, cough, runny nose and red eyes for 4 days; today a red blotchy rash started behind his ears and on his face.
What do you give the girl, and how fast? What does the boy have and what does he need?
- Non-blanching rash with fever or unwellMeningococcal sepsis: IV or IO ceftriaxone now, resuscitate, senior.
- Rash with swelling, wheeze, low BPAnaphylaxis: IM adrenaline.
- Blistering, peeling, sore mouth or eyesSJS or TEN, staphylococcal scalded skin: admit.
- Punched-out erosions in eczemaEczema herpeticum: IV aciclovir.
- MeaslesCough, runny nose, red eyes, Koplik spots, unvaccinated: isolate, vitamin A, notify.
- Fever 5 days or more with red eyes, lips, handsKawasaki: echo, IVIG.
- Well child with petechiae, no feverITP: platelet count, film.
- Most rashesViral, harmless. Safety-net with the glass test.
- Non-blanching rash with fever
- Drowsy, cold hands, mottled, slow capillary refill
- Skin peeling or blistering
- Eczema with punched-out erosions
- Mouth, eye or genital involvement
- Petechiae with pallor, bruising or big liver or spleen
- Meningococcal sepsis
- Eczema herpeticum
- Staphylococcal scalded skin syndrome
- Stevens-Johnson syndrome or TEN
- Kawasaki disease
- Leukaemia (petechiae with pallor)
- Non-accidental injury (bruises in unusual places)
- Toxic shock syndrome
| Glass test | Rash not fading under a glass = non-blanching |
| Ceftriaxone | 80 mg/kg IV once (100 mg/kg if meningitis suspected), max 4 g |
| Vitamin A in measles | Under 6 months 50,000 IU, 6–11 months 100,000 IU, 12 months and over 200,000 IU, daily for 2 days |
| Kawasaki | Fever 5 days or more plus 4 of: conjunctivitis, mouth changes, rash, hand and foot changes, neck node |
| IgA vasculitis (HSP) | Purpura on legs and buttocks, well child: check BP and urine |
| Measles infectious | 4 days before to 4 days after the rash |
Check every dose against a current drug reference and your hospital protocol.
On this page
The glass test
Press a clear glass firmly against the rash. If the spots don't fade, the rash is non-blanching (petechiae or purpura). With fever or an unwell child, treat as meningococcal disease until proven otherwise.
Urgent rashes
Meningococcal: ceftriaxone now, fluids, senior
- SJS or TEN, or scalded skin
- admit
- Eczema herpeticum
- IV aciclovir
- Measles
- isolate, vitamin A, notify
- Kawasaki
- echo, IVIG
- Viral rash
- safety-net
Meningococcal sepsis
- Can kill within hours. Early signs: fever, leg pain, cold hands and feet, pale or mottled skin. The rash may start blanching and become non-blanching.
- Don't wait for the rash or for tests. Give IV (or intraosseous) ceftriaxone immediately, fluid boluses (10 mL/kg, reassess), call the senior and PICU.
- Blood cultures and PCR if quick; lumbar puncture only when safe.
- Close contacts need prophylaxis; notify public health.
Measles in Pakistan
- Outbreaks are common where vaccination is low.
- Prodrome: fever, cough, runny nose, red eyes (conjunctivitis), Koplik spots (white spots inside the cheeks).
- Rash: day 3–5, red blotchy, starts behind the ears and face, spreads down.
- Complications: pneumonia, diarrhoea, malnutrition, eye damage (vitamin A deficiency), encephalitis.
- Isolate, give vitamin A, treat complications, notify the EPI team, check contacts' vaccination.
Other rashes
| Rash | Features | Action |
|---|---|---|
| Scarlet fever | Sandpaper rash, strawberry tongue, sore throat | Penicillin V; notify |
| Kawasaki disease | Fever 5 days or more, red eyes, cracked lips, rash, swollen hands and feet, neck node | Echo, IVIG, aspirin per specialist |
| IgA vasculitis (HSP) | Purpura on legs and buttocks, joint pain, abdominal pain, well child | BP and urine; follow up for kidney involvement |
| ITP | Well child, petechiae and bruises, often after a virus | Platelet count and film; usually observe |
| Chickenpox | Spots, blisters and crusts together | See chickenpox guide |
| Hand, foot and mouth | Ulcers in mouth, spots on hands and feet | Supportive |
| Eczema herpeticum | Painful punched-out erosions in eczema, unwell | IV aciclovir |
| Staphylococcal scalded skin | Red, tender skin that peels in sheets, young child | Admit, IV flucloxacillin |
| SJS or TEN | Target lesions, blisters, mouth and eye ulcers, after a drug | Admit, stop drug, specialist care |
| Urticaria | Itchy wheals, come and go | Antihistamine; check for anaphylaxis |
Investigations
| Situation | Tests |
|---|---|
| Non-blanching rash with fever | CBC, CRP, blood culture, meningococcal PCR, clotting, gas |
| Petechiae in a well child | CBC and film |
| Kawasaki | CBC, CRP, ESR, LFTs, albumin, urine, echo |
| IgA vasculitis | BP, urine dipstick, creatinine |
| Measles | Clinical; serology or PCR for public health |
Treatment
Common mistakes
- Waiting for the rash to become non-blanching before treating a sick febrile child.
- Delaying ceftriaxone for an LP or blood test.
- Not isolating a child with measles.
- Missing Kawasaki disease after 5 days of fever.
- Calling eczema herpeticum an eczema flare and giving steroid cream.
- Forgetting leukaemia in a child with petechiae and pallor.
Frequently asked questions
What does a non-blanching rash mean?
Spots that don't fade under a glass. With fever or an unwell child it may be meningococcal disease: give antibiotics immediately.
Why give vitamin A in measles?
It reduces complications and deaths, especially in malnourished children.
What are the signs of Kawasaki disease?
Fever for 5 days or more with red eyes, red cracked lips or strawberry tongue, rash, swollen red hands and feet, and a swollen neck node.
Is a rash with fever always serious?
No. Most are viral and harmless. Use the glass test and look at how the child looks. A non-blanching rash or an unwell child needs urgent assessment.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A drowsy febrile 3-year-old has a non-blanching rash and cold hands. What should be given first?
Answer: IV ceftriaxone. Suspected meningococcal sepsis: antibiotics immediately, resuscitation.
- Oral amoxicillin: Inadequate.
- Antihistamine: No.
- Paracetamol and review: Dangerous delay.
- Platelet transfusion: No.
2. An unvaccinated child has fever, cough, red eyes and a rash starting on the face. Which supplement is given?
Answer: Vitamin A. Measles: vitamin A daily for 2 days reduces complications.
- Zinc only: For diarrhoea.
- Iron: No.
- Vitamin D: No.
- Vitamin K: No.
3. A child with eczema suddenly has painful punched-out erosions and fever. What is the diagnosis?
Answer: Eczema herpeticum. Herpes simplex in eczema needs urgent aciclovir.
- Eczema flare: No punched-out lesions.
- Chickenpox: Different pattern.
- Scabies: No.
- Impetigo: Crusts.
4. A 2-year-old unvaccinated child in a Karachi slum has had measles for 5 days. He now has fast breathing, chest indrawing and fever returning after the rash appeared. Which complication is most likely?
Answer: Secondary bacterial pneumonia. Measles is caused by a paramyxovirus; prodrome of cough, coryza, conjunctivitis and Koplik spots, then a maculopapular rash spreading from behind the ears downwards on about day 4. Pneumonia (viral giant-cell or secondary bacterial) is the commonest cause of death; others are diarrhoea, otitis media, croup, encephalitis (acute), corneal ulceration with vitamin A deficiency, and SSPE (7–10 years later). WHO recommends vitamin A on two consecutive days for all children with measles (200 000 IU if ≥ 12 months). Return of fever after the rash is a red flag for a bacterial complication.
- Subacute sclerosing panencephalitis: SSPE develops years later.
- Koplik spot ulceration: Koplik spots are a prodromal sign only.
- Acute rheumatic fever: Rheumatic fever follows streptococcal throat infection.
5. A 4-year-old has sudden widespread petechiae and bruising 2 weeks after a viral illness. He is well, with no hepatosplenomegaly. Platelets are 12 × 10⁹/L; Hb and WBC normal; film normal apart from large platelets. What is the management?
Answer: Observation and reassurance. Childhood ITP often follows a viral infection; isolated thrombocytopenia with a normal film and a well child. Most resolve within 6 months regardless of treatment. Observation is recommended for children with no or mild (skin) bleeding; IVIG or short-course steroids for significant mucosal bleeding. Avoid contact sports and NSAIDs. Atypical features (hepatosplenomegaly, lymphadenopathy, bone pain, abnormal cells) need marrow examination to exclude leukaemia.
- Platelet transfusion: Platelet transfusion is only for life-threatening bleeding.
- Bone marrow biopsy for all: Bone marrow is not needed in typical ITP.
- Splenectomy: Splenectomy is not used in acute childhood ITP.
6. A young girl bleeds heavily after a dental extraction. Her platelet count is mildly low and the blood film shows giant platelets. Platelets do not aggregate with ristocetin, even when normal plasma is added. What is the diagnosis?
Answer: Bernard–Soulier (GpIb). Bernard–Soulier syndrome is an inherited deficiency of platelet GpIb, the receptor for von Willebrand factor. Platelets cannot stick to damaged vessel walls. Features: giant platelets, mild thrombocytopenia and absent ristocetin aggregation not corrected by normal plasma.
- Glanzmann (GpIIb/IIIa): Normal platelet size and count; no aggregation with ADP or collagen, but normal ristocetin response.
- Von Willebrand disease: Ristocetin aggregation is corrected by adding normal plasma (it supplies vWF).
- Immune thrombocytopenia: Platelets are low but function normally; no giant platelets with this pattern.
- Haemophilia A: Clotting factor problem; platelets are normal.
7. A girl with meningococcal septicaemia has fever, a spreading purpuric rash and becomes profoundly hypotensive. Autopsy shows bilateral adrenal haemorrhage. What is this?
Answer: Waterhouse–Friderichsen syndrome. Meningococcal endotoxin (lipo-oligosaccharide) causes septic shock and DIC with bilateral adrenal haemorrhage and acute adrenal failure. Treat urgently with IV antibiotics (benzylpenicillin or ceftriaxone), fluids and steroids if needed. Contacts receive prophylaxis (rifampicin or ciprofloxacin).
- Sheehan's syndrome: Pituitary necrosis after postpartum haemorrhage.
- Addison's disease from tuberculosis: Chronic, not acute septic.
- Conn's syndrome: Aldosterone excess.
- Cushing's syndrome: Cortisol excess.
References and dose sources
- DermNet — terminology in dermatology
- DermNet — herpes simplex
- NICE NG240
- DermNet
- Resus Council UK — anaphylaxis
- DermNet
- DermNet — SJS/TEN
- DermNet — SSSS
- DermNet — TSS
- DermNet
- Ceftriaxone dosing: Drugs.com: Ceftriaxone dosage (see also our ceftriaxone dose page)
- Vitamin A dosing: WHO: Measles fact sheet (see also our vitamin a dose page)
- Aciclovir dosing: Drugs.com: Acyclovir (aciclovir) dosage (see also our aciclovir dose page)
- Adrenaline (epinephrine) dosing: Drugs.com: Epinephrine dosage (see also our adrenaline (epinephrine) dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.