Rash In The ChildAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

626 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Fever In The Neonate And Young Infant Pediatric Fever By Age 0 To 28 Days Pediatric Fever By Age 29 To 60 Days Pediatric Fever By Age 2 To 24 Months Pediatric Respiratory Distress Croup And Stridor In Children Pediatric Dehydration Pediatric Abdominal Pain Febrile Seizure Rash In The Child Poor Feeding And Lethargy In The Infant Vomiting In The Child Diarrhea In The Child Pediatric Trauma Evaluation Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern Lethargy And Altered Mental Status In The Child

Environmental and Exposure4▾

01History/hx79

Presenting rash overview

›Rash timeline and context

›Time of onset

›Progression pattern

›Initial site then spread pattern

›Intermittent or persistent pattern

›OPQRST

›Onset

›Sudden onset

›Gradual onset

›Provocation/Palliation

›Triggered by new medication exposure

›Triggered by infection exposure

›Triggered by food exposure

›Triggered by insect bite exposure

›Improved with antihistamine

›Improved with cool compress

›Quality

›Pruritic

›Painful

›Burning

›Non pruritic

›Region/Radiation

›Localized

›Generalized

›Palms and soles involvement

›Perioral involvement

›Genital involvement

›Flexural predominance

›Extensor predominance

›Severity

›Sleep disruption

›Functional limitation

›Timing

›Worse at night

›Worse after heat

›Worse after bathing

›Associated symptoms

›Fever pattern

›Upper respiratory symptoms

›Sore throat

›Cough

›Conjunctivitis

›Oral lesions

›Vomiting

›Diarrhea

›Abdominal pain

›Arthralgia

›Limp

›Headache

›Neck pain

›Dyspnea

›Wheeze

›Exposures and triggers

›New medication within 1 to 8 weeks

›Recent antibiotic exposure

›Recent vaccination exposure

›New foods

›New soaps

›New detergents

›New topical products

›Hot tub exposure

›Outdoor exposure

›Tick exposure

›Scabies contact exposure

›Infectious contacts

›Household sick contacts

›Daycare exposure

›School outbreak exposure

›Known varicella exposure

›Known measles exposure

›Prior episodes and baseline

›Prior similar rash

›Atopic history baseline

›Baseline skin disease

›Impact and safety

›Oral intake change

›Urine output change

›Itch driven excoriation

›Sleep disruption

02Alarm Features/alarm43

Immediate escalation triggers

›High risk physiology

›Toxic appearance

›Altered mental status

›Respiratory distress

›Shock features

›Persistent tachycardia out of proportion to fever

›High risk rash patterns

›Non blanching petechiae or purpura

›Rapidly progressive purpura

›Bullae with skin pain

›Skin sloughing

›Necrosis

›Crepitus

›High risk mucosal involvement

›Oral mucosal erosions

›Eye pain

›Conjunctival injection with photophobia

›Dysuria with genital erosions

›High risk systemic features

›Neck stiffness

›Severe headache

›Persistent vomiting

›New seizure

›New focal neurologic deficit

›Anaphylaxis features

›Hypotension

›Bronchospasm

›Stridor

›Angioedema

›Kawasaki disease and MIS-C features

›Fever at least 5 days

›Conjunctival injection

›Strawberry tongue

›Cracked lips

›Extremity swelling

›Cervical lymphadenopathy

›Severe abdominal pain

›Chest pain

›Syncope

›Neonate and immunocompromised risk

›Age under 28 days with fever

›Immunosuppression with fever

›Vesicles in neonate

03Medications/meds19

Current and recent exposures

›Medication history relevant to rash

›New prescription medications

›Recent antibiotics

›Antiepileptics

›NSAIDs

›Acetaminophen

›OTC cold remedies

›Topical exposures

›Topical antibiotics

›Topical steroids

›New emollients

›New sunscreens

›Allergy and intolerance history

›Prior drug rash

›Prior anaphylaxis

›Food allergy history

›High risk medication patterns

›Stevens Johnson syndrome risk medications

›Serum sickness like reaction risk medications

04Diet/diet12

Intake and allergen exposure

›Recent intake patterns

›Reduced intake

›Normal intake

›Poor fluid intake

›New foods exposure

›First time exposure food

›Restaurant exposure

›Hidden allergen exposure risk

›Hydration indicators

›Dry mucous membranes

›Decreased urine output

›Poor tears

05Review of Systems/ros36

System based symptoms

›General and infectious

›Fever

›Chills

›Fatigue

›Weight loss

›ENT and eyes

›Sore throat

›Rhinorrhea

›Conjunctivitis

›Eye pain

›Photophobia

›Respiratory

›Cough

›Dyspnea

›Wheeze

›GI

›Vomiting

›Diarrhea

›Abdominal pain

›GU

›Dysuria

›Genital pain

›MSK

›Arthralgia

›Joint swelling

›Limp

›Neuro

›Headache

›Neck pain

›Confusion

›Seizure

›Skin specific

›Pruritus

›Pain

›Blistering

›Facial swelling

06Collateral History and Family History/chafh16

Family and collateral context

›Collateral source and reliability

›Parent or guardian historian

›Caregiver historian

›Teen self historian

›Family history relevant to rash

›Atopy

›Asthma

›Eczema

›Psoriasis (L40.9)

›Household context

›Sick contacts at home

›Infestation risk

›Bedbugs exposure risk

›Supervision and access

›Ability to monitor at home

›Ability to return for reassessment

07Risk Factors/rf16

Host and exposure risks

›Host risk

›Age under 3 months

›Immunocompromised state

›Asplenia

›Chronic skin disease

›Exposure risk

›Daycare exposure

›Travel exposure

›Tick exposure

›Animal exposure

›Medication risk

›Recent high risk medications

›Polypharmacy exposure

›Vaccination status risk

›Incomplete measles vaccination

›Incomplete varicella vaccination

08Differential Diagnosis/ddx86

Life threatening

›Life threatening causes

›Meningococcemia (A39.0)

›Non blanching petechiae or purpura

›Fever with toxicity

›Rapid progression over hours

›Sepsis with purpura fulminans (D65)

›Shock features

›Widespread purpura with necrosis

›Stevens Johnson syndrome and toxic epidermal necrolysis (L51.1)

›Skin pain out of proportion

›Mucosal erosions

›New medication exposure within weeks

›Anaphylaxis (T78.2)

›Urticaria with respiratory symptoms

›Hypotension

›Angioedema

›Necrotizing soft tissue infection (M72.6)

›Rapidly progressive erythema

›Severe pain

›Crepitus

›Kawasaki disease shock syndrome (M30.3)

›Fever

›Hypotension

›Mucocutaneous changes

›MIS-C

›Fever

›GI pain

›Hypotension

›Elevated inflammatory markers pattern

Common

›Common causes

›Viral exanthem

›Recent URI symptoms

›Well appearing

›Urticaria (L50.9)

›Migratory wheals

›Pruritus

›Individual lesions under 24 hours

›Atopic dermatitis (L20.9)

›Chronic relapsing itch

›Flexural distribution

›Contact dermatitis (L23.9)

›Pattern matching exposure

›Sharp demarcation

›Impetigo (L01.00)

›Honey crusted lesions

›Localized

›Hand foot and mouth disease

›Oral ulcers

›Palms and soles lesions

›Scabies (B86)

›Night itch

›Household itch

›Burrows in web spaces

›Scarlet fever (A38.9)

›Sore throat

›Sandpaper rash

›Strawberry tongue

Less common

›Less common and zebras

›Henoch Schonlein purpura IgA vasculitis (D69.0)

›Palpable purpura on legs

›Abdominal pain

›Arthralgia

›Erythema multiforme (L51.9)

›Target lesions

›HSV trigger history

›Varicella

›Vesicles in different stages

›Truncal predominance

›Measles

›Fever

›Cough

›Coryza

›Conjunctivitis

›Rocky Mountain spotted fever

›Fever with headache

›Tick exposure

›Palms and soles involvement

›Drug reaction with eosinophilia and systemic symptoms

›Facial edema

›Fever

›Lymphadenopathy

›Organ involvement pattern

›Staphylococcal scalded skin syndrome (L00)

›Tender erythema

›Periorificial crusting

›Desquamation

09Past Medical History/pmh18

Relevant prior conditions

›Chronic conditions and context

›Atopic dermatitis

›Asthma (J45.909)

›Immunodeficiency

›Sickle cell disease (D57.1)

›Prior severe reactions

›Prior anaphylaxis

›Prior drug rash

›Prior SJS or TEN

›Recent infections

›Recent streptococcal infection

›Recent varicella

›Recent healthcare exposures

›Recent hospitalization

›Recent surgery

›Baseline function

›Baseline oral intake

›Baseline activity level

10Physical Exam/exam73

General and vitals

›General assessment

›Toxic appearance

›Comfort level

›Hydration status

›Vitals interpretation

›Fever pattern

›Tachycardia

›Hypotension

›Hypoxia

Skin and mucosa

›Rash characterization

›Morphology

›Maculopapular

›Urticarial

›Vesicular

›Pustular

›Petechial

›Purpuric

›Bullous

›Targetoid

›Distribution

›Trunk

›Face

›Extremities

›Palms

›Soles

›Flexural surfaces

›Extensor surfaces

›Blanching

›Non blanching

›Tenderness

›Painful

›Non painful

›Skin barrier

›Excoriations

›Crusting

›Weeping

›Desquamation

›Secondary infection signs

›Warmth

›Purulence

›Mucosal exam

›Oral ulcers

›Lip cracking

›Strawberry tongue

›Genital lesions

›Eye exam

›Conjunctival injection

›Discharge pattern

›Periorbital edema

›Nikolsky related findings

›Epidermal sloughing with shear

›Skin pain out of proportion

Systems relevant to rash etiologies

›ENT and lymph nodes

›Cervical lymphadenopathy

›Pharyngeal erythema

›Tonsillar exudate

›Cardiopulmonary

›Work of breathing

›Wheeze

›Perfusion

›Capillary refill

›Abdomen

›Tenderness

›Hepatosplenomegaly

›MSK and joints

›Joint swelling

›Range of motion limitation

›Limp

›Neuro

›Mental status

›Neck stiffness

›Focal deficits

11Lab Studies/labs57

Core labs by scenario

›Inflammatory and hematologic evaluation

›CBC with differential

›Leukocytosis pattern

›Neutropenia pattern

›Thrombocytopenia pattern

›Eosinophilia pattern

›CRP

›Elevated supports inflammatory syndrome

›Normal does not exclude early serious infection

›ESR

›Elevated supports vasculitis

›Slower response than CRP

›Infection and sepsis evaluation

›Blood culture

›Prior antibiotics reduce yield

›Draw before antibiotics when feasible

›Lactate

›Elevated supports hypoperfusion

›Normal does not exclude sepsis

›End organ evaluation

›CMP

›Transaminases elevation

›Creatinine baseline

›Electrolytes for dehydration

›Coagulation studies

›PT

›INR

›aPTT

›Kawasaki disease and MIS-C supportive labs

›BNP or NT-proBNP

›Elevated supports myocardial involvement

›Interpret with age norms

›Troponin

›Elevated supports myocarditis

›Serial trend when suspected

›Ferritin

›Elevated supports hyperinflammation

›Not specific

›D-dimer

›Elevated supports MIS-C pattern

›Not specific

›Urinalysis

›Sterile pyuria supports Kawasaki pattern

›Hematuria suggests vasculitis

›Targeted microbiology

›Rapid strep test

›Supports scarlet fever when positive

›Negative may need culture local protocol dependent

›Throat culture

›Backup when rapid strep negative local protocol dependent

›Delayed results

›Viral PCR panel

›Supports viral exanthem

›Does not exclude bacterial coinfection

›Varicella or HSV PCR from lesion

›Higher yield from fresh vesicle

›Lower yield after crusting

12Imaging/img31

Scoring Systems

›Clinical decision aids and structured criteria

›Kawasaki disease classic criteria

›Fever at least 5 days

›Conjunctival injection

›Oral mucosal changes

›Peripheral extremity changes

›Polymorphous rash

›Cervical lymphadenopathy

›Incomplete Kawasaki disease pathway

›Fever at least 5 days with fewer than 4 features

›CRP and ESR supportive

›Echocardiography threshold local protocol dependent

MRI

›MRI indications in rash presentations

›Suspected osteomyelitis with overlying cellulitis

›Deep space infection when ultrasound nondiagnostic

›MRI limitations

›Need for sedation in young children

›Access and timing limitations

›CT indications in rash presentations

›Suspected deep neck infection with rash and toxic appearance

›Suspected necrotizing soft tissue infection with severe pain

›CT cautions

›Ionizing radiation risk

›Contrast allergy risk

›Contrast nephrotoxicity risk

Ultrasound

›Ultrasound uses

›Abscess evaluation in cellulitis

›Soft tissue gas evaluation adjunct for necrotizing infection

›Ultrasound limitations

›Limited sensitivity for early necrotizing infection

›Operator dependent findings

13Special Tests/spec12

Bedside maneuvers and focused tests

›Blanching and petechiae assessment

›Glass test for non blanching lesions

›Distribution mapping over time

›Dermatologic bedside signs

›Dermatographism

›Nikolsky sign support for SJS and TEN

›Infection focused bedside tests

›Point of care glucose in toxic child

›Rapid antigen testing local protocol dependent

›Ophthalmic screening when mucosal involvement

›Visual acuity screen if cooperative

›Urgent ophthalmology trigger with eye pain

14ECG/ecg8

When ECG is relevant in rash presentations

›Cardiac involvement triggers

›Suspected MIS-C with tachycardia

›Suspected myocarditis with chest pain

›Kawasaki disease with shock features

›ECG patterns and actions

›Conduction abnormalities

›ST and T wave changes suggesting myocarditis

›If unstable rhythm then resuscitation pathway activation

15Assessment/ax19

Problem representation and risk stratification

›Working diagnosis categories

›Benign self limited viral exanthem

›Allergic urticaria

›Bacterial skin infection

›Systemic inflammatory syndrome

›Severity stratification

›Well appearing with stable vitals

›Moderate illness with dehydration

›Toxic appearance or shock

›Cannot miss complications

›Meningococcemia

›SJS and TEN

›Anaphylaxis

›Kawasaki disease coronary involvement

›MIS-C myocardial involvement

›Diagnostic uncertainty management

›Reassessment after antipyretic and fluids when indicated

›Serial rash photos for evolution tracking

›Lower threshold for observation in infants

16Plan/plan41

First 5 minutes and stabilization

›Critical rash workflow

›Continuous monitoring for toxic appearance

›IV or IO access if shock features

›Oxygen if hypoxia or distress

›Isotonic fluid bolus if shock local protocol dependent

›Epinephrine IM immediately if anaphylaxis

›Empiric antibiotics within 60 minutes if sepsis suspected local protocol dependent

Targeted management by likely etiology

›Urticaria without anaphylaxis

›Non sedating antihistamine dosing by weight local protocol dependent

›Trigger avoidance when identified

›Short course steroid only for severe refractory symptoms local protocol dependent

›Atopic dermatitis flare

›Emollient barrier therapy

›Topical steroid potency by site local protocol dependent

›Treat secondary infection when present

›Cellulitis and impetigo

›Antibiotic choice based on local resistance patterns

›MRSA risk assessment

›Abscess drainage pathway if fluctuance present

›Suspected meningococcemia or sepsis

›Ceftriaxone IV or IM local protocol dependent

›Blood culture before antibiotics when feasible

›Droplet precautions for suspected meningococcal disease

›Suspected SJS and TEN

›Immediate stop suspected trigger medications

›Burn center or ICU consultation early

›Ophthalmology consultation early

›Avoid empiric steroids unless specialist guided local protocol dependent

›Kawasaki disease

›IVIG 2 g per kg single infusion local protocol dependent

›Aspirin regimen local protocol dependent

›Echocardiography and cardiology involvement

›MIS-C

›Early pediatric critical care consultation

›Broad lab panel for inflammation and cardiac injury

›Immunomodulation local protocol dependent

Reassessment loop

›Time based reassessment

›Repeat vitals every 30 to 60 minutes if moderate illness

›Repeat perfusion exam after fluids

›Repeat rash distribution check for progression

›Repeat airway assessment if urticaria evolving

17Disposition/dispo23

Level of care criteria

›ICU

›Shock requiring vasoactive support

›Respiratory failure

›Suspected SJS and TEN with significant skin involvement

›MIS-C with cardiac dysfunction

›Inpatient admission

›Non blanching rash with fever pending evaluation

›Kawasaki disease suspected

›Dehydration requiring IV fluids

›Cellulitis requiring IV antibiotics

›Immunocompromised with fever and rash

›Observation pathway

›Diagnostic uncertainty with stable vitals

›Moderate symptoms needing serial exams

›Discharge criteria

›Well appearing

›Stable vitals

›No alarm rash pattern

›Oral intake adequate

›Reliable follow up and return ability

›Follow up timing

›Primary care within 24 to 72 hours when uncertain diagnosis

›Dermatology referral if persistent rash over 1 to 2 weeks

18Discharge Instructions/di30

Copy discharge instructions

›Rash summary

›Today you were seen for a rash

›The exam did not show signs of a dangerous rash at this time

›Home care

›Keep skin cool

›Avoid new soaps and scented products until resolved

›Use fragrance free moisturizer

›Medications

›Use antihistamine as directed if itchy

›Use prescribed topical medication only on the areas instructed

›Hydration

›Encourage fluids

›Watch urine output

›Follow up

›See your primary care clinician within the recommended timeframe

›Return sooner if you cannot get follow up

›Return to ED now for

›Trouble breathing

›Swelling of lips or tongue

›Fainting

›New vomiting that will not stop

›New severe headache

›Neck stiffness

›Confusion

›Purple or non blanching spots

›Rash rapidly spreading over hours

›Skin pain

›Blistering

›Mouth sores

›Eye pain

19References/r7

Guidelines and high quality sources

›Pediatric rash evaluation references

›American Heart Association Kawasaki Disease scientific statement 2017

›CDC measles clinical guidance updated regularly

›CDC varicella clinical guidance updated regularly

›IDSA practice guidelines for skin and soft tissue infections 2014

›NICE fever in under 5s assessment and initial management updated regularly

›British Association of Dermatologists SJS and TEN guidance local protocol dependent

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Rash In The ChildAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

626 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx79

Presenting rash overview

›Rash timeline and context

›Time of onset

›Progression pattern

›Initial site then spread pattern

›Intermittent or persistent pattern

›OPQRST

›Onset

›Sudden onset

›Gradual onset

›Provocation/Palliation

›Triggered by new medication exposure

›Triggered by infection exposure

›Triggered by food exposure

›Triggered by insect bite exposure

›Improved with antihistamine

›Improved with cool compress

›Quality

›Pruritic

›Painful

›Burning

›Non pruritic

›Region/Radiation

›Localized

›Generalized

›Palms and soles involvement

›Perioral involvement

›Genital involvement

›Flexural predominance

›Extensor predominance

›Severity

›Sleep disruption

›Functional limitation

›Timing

›Worse at night

›Worse after heat

›Worse after bathing

›Associated symptoms

›Fever pattern

›Upper respiratory symptoms

›Sore throat

›Cough

›Conjunctivitis

›Oral lesions

›Vomiting

›Diarrhea

›Abdominal pain

›Arthralgia

›Limp

›Headache

›Neck pain

›Dyspnea

›Wheeze

›Exposures and triggers

›New medication within 1 to 8 weeks

›Recent antibiotic exposure

›Recent vaccination exposure

›New foods

›New soaps

›New detergents

›New topical products

›Hot tub exposure

›Outdoor exposure

›Tick exposure

›Scabies contact exposure

›Infectious contacts

›Household sick contacts

›Daycare exposure

›School outbreak exposure

›Known varicella exposure

›Known measles exposure

›Prior episodes and baseline

›Prior similar rash

›Atopic history baseline

›Baseline skin disease

›Impact and safety

›Oral intake change

›Urine output change

›Itch driven excoriation

›Sleep disruption

02Alarm Features/alarm43

Immediate escalation triggers

›High risk physiology

›Toxic appearance

›Altered mental status

›Respiratory distress

›Shock features

›Persistent tachycardia out of proportion to fever

›High risk rash patterns

›Non blanching petechiae or purpura

›Rapidly progressive purpura

›Bullae with skin pain

›Skin sloughing

›Necrosis

›Crepitus

›High risk mucosal involvement

›Oral mucosal erosions

›Eye pain

›Conjunctival injection with photophobia

›Dysuria with genital erosions

›High risk systemic features

›Neck stiffness

›Severe headache

›Persistent vomiting

›New seizure

›New focal neurologic deficit

›Anaphylaxis features

›Hypotension

›Bronchospasm

›Stridor

›Angioedema

›Kawasaki disease and MIS-C features

›Fever at least 5 days

›Conjunctival injection

›Strawberry tongue

›Cracked lips

›Extremity swelling

›Cervical lymphadenopathy

›Severe abdominal pain

›Chest pain

›Syncope

›Neonate and immunocompromised risk

›Age under 28 days with fever

›Immunosuppression with fever

›Vesicles in neonate

03Medications/meds19

Current and recent exposures

›Medication history relevant to rash

›New prescription medications

›Recent antibiotics

›Antiepileptics

›NSAIDs

›Acetaminophen

›OTC cold remedies

›Topical exposures

›Topical antibiotics

›Topical steroids

›New emollients

›New sunscreens

›Allergy and intolerance history

›Prior drug rash

›Prior anaphylaxis

›Food allergy history

›High risk medication patterns

›Stevens Johnson syndrome risk medications

›Serum sickness like reaction risk medications

04Diet/diet12

Intake and allergen exposure

›Recent intake patterns

›Reduced intake

›Normal intake

›Poor fluid intake

›New foods exposure

›First time exposure food

›Restaurant exposure

›Hidden allergen exposure risk

›Hydration indicators

›Dry mucous membranes

›Decreased urine output

›Poor tears

05Review of Systems/ros36

System based symptoms

›General and infectious

›Fever

›Chills

›Fatigue

›Weight loss

›ENT and eyes

›Sore throat

›Rhinorrhea

›Conjunctivitis

›Eye pain

›Photophobia

›Respiratory

›Cough

›Dyspnea

›Wheeze

›GI

›Vomiting

›Diarrhea

›Abdominal pain

›GU

›Dysuria

›Genital pain

›MSK

›Arthralgia

›Joint swelling

›Limp

›Neuro

›Headache

›Neck pain

›Confusion

›Seizure

›Skin specific

›Pruritus

›Pain

›Blistering

›Facial swelling

06Collateral History and Family History/chafh16

Family and collateral context

›Collateral source and reliability

›Parent or guardian historian

›Caregiver historian

›Teen self historian

›Family history relevant to rash

›Atopy

›Asthma

›Eczema

›Psoriasis (L40.9)

›Household context

›Sick contacts at home

›Infestation risk

›Bedbugs exposure risk

›Supervision and access

›Ability to monitor at home

›Ability to return for reassessment

07Risk Factors/rf16

Host and exposure risks

›Host risk

›Age under 3 months

›Immunocompromised state

›Asplenia

›Chronic skin disease

›Exposure risk

›Daycare exposure

›Travel exposure

›Tick exposure

›Animal exposure

›Medication risk

›Recent high risk medications

›Polypharmacy exposure

›Vaccination status risk

›Incomplete measles vaccination

›Incomplete varicella vaccination

08Differential Diagnosis/ddx86

Life threatening

›Life threatening causes

›Meningococcemia (A39.0)

›Non blanching petechiae or purpura

›Fever with toxicity

›Rapid progression over hours

›Sepsis with purpura fulminans (D65)

›Shock features

›Widespread purpura with necrosis

›Stevens Johnson syndrome and toxic epidermal necrolysis (L51.1)

›Skin pain out of proportion

›Mucosal erosions

›New medication exposure within weeks

›Anaphylaxis (T78.2)

›Urticaria with respiratory symptoms

›Hypotension

›Angioedema

›Necrotizing soft tissue infection (M72.6)

›Rapidly progressive erythema

›Severe pain

›Crepitus

›Kawasaki disease shock syndrome (M30.3)

›Fever

›Hypotension

›Mucocutaneous changes

›MIS-C

›Fever

›GI pain

›Hypotension

›Elevated inflammatory markers pattern

Common

›Common causes

›Viral exanthem

›Recent URI symptoms

›Well appearing

›Urticaria (L50.9)

›Migratory wheals

›Pruritus

›Individual lesions under 24 hours

›Atopic dermatitis (L20.9)

›Chronic relapsing itch

›Flexural distribution

›Contact dermatitis (L23.9)

›Pattern matching exposure

›Sharp demarcation

›Impetigo (L01.00)

›Honey crusted lesions

›Localized

›Hand foot and mouth disease

›Oral ulcers

›Palms and soles lesions

›Scabies (B86)

›Night itch

›Household itch

›Burrows in web spaces

›Scarlet fever (A38.9)

›Sore throat

›Sandpaper rash

›Strawberry tongue

Less common

›Less common and zebras

›Henoch Schonlein purpura IgA vasculitis (D69.0)

›Palpable purpura on legs

›Abdominal pain

›Arthralgia

›Erythema multiforme (L51.9)

›Target lesions

›HSV trigger history

›Varicella

›Vesicles in different stages

›Truncal predominance

›Measles

›Fever

›Cough

›Coryza

›Conjunctivitis

›Rocky Mountain spotted fever

›Fever with headache

›Tick exposure

›Palms and soles involvement

›Drug reaction with eosinophilia and systemic symptoms

›Facial edema

›Fever

›Lymphadenopathy

›Organ involvement pattern

›Staphylococcal scalded skin syndrome (L00)

›Tender erythema

›Periorificial crusting

›Desquamation

09Past Medical History/pmh18

Relevant prior conditions

›Chronic conditions and context

›Atopic dermatitis

›Asthma (J45.909)

›Immunodeficiency

›Sickle cell disease (D57.1)

›Prior severe reactions

›Prior anaphylaxis

›Prior drug rash

›Prior SJS or TEN

›Recent infections

›Recent streptococcal infection

›Recent varicella

›Recent healthcare exposures

›Recent hospitalization

›Recent surgery

›Baseline function

›Baseline oral intake

›Baseline activity level

10Physical Exam/exam73

General and vitals

›General assessment

›Toxic appearance

›Comfort level

›Hydration status

›Vitals interpretation

›Fever pattern

›Tachycardia

›Hypotension

›Hypoxia

Skin and mucosa

›Rash characterization

›Morphology

›Maculopapular

›Urticarial

›Vesicular

›Pustular

›Petechial

›Purpuric

›Bullous

›Targetoid

›Distribution

›Trunk

›Face

›Extremities

›Palms

›Soles

›Flexural surfaces

›Extensor surfaces

›Blanching

›Non blanching

›Tenderness

›Painful

›Non painful

›Skin barrier

›Excoriations

›Crusting

›Weeping

›Desquamation

›Secondary infection signs

›Warmth

›Purulence

›Mucosal exam

›Oral ulcers

›Lip cracking

›Strawberry tongue

›Genital lesions

›Eye exam

›Conjunctival injection

›Discharge pattern

›Periorbital edema

›Nikolsky related findings

›Epidermal sloughing with shear

›Skin pain out of proportion

Systems relevant to rash etiologies

›ENT and lymph nodes

›Cervical lymphadenopathy

›Pharyngeal erythema

›Tonsillar exudate

›Cardiopulmonary

›Work of breathing

›Wheeze

›Perfusion

›Capillary refill

›Abdomen

›Tenderness

›Hepatosplenomegaly

›MSK and joints

›Joint swelling

›Range of motion limitation

›Limp

›Neuro

›Mental status

›Neck stiffness

›Focal deficits

11Lab Studies/labs57

Core labs by scenario

›Inflammatory and hematologic evaluation

›CBC with differential

›Leukocytosis pattern

›Neutropenia pattern

›Thrombocytopenia pattern

›Eosinophilia pattern

›CRP

›Elevated supports inflammatory syndrome

›Normal does not exclude early serious infection

›ESR

›Elevated supports vasculitis

›Slower response than CRP

›Infection and sepsis evaluation

›Blood culture

›Prior antibiotics reduce yield

›Draw before antibiotics when feasible

›Lactate

›Elevated supports hypoperfusion

›Normal does not exclude sepsis

›End organ evaluation

›CMP

›Transaminases elevation

›Creatinine baseline

›Electrolytes for dehydration

›Coagulation studies

›PT

›INR

›aPTT

›Kawasaki disease and MIS-C supportive labs

›BNP or NT-proBNP

›Elevated supports myocardial involvement

›Interpret with age norms

›Troponin

›Elevated supports myocarditis

›Serial trend when suspected

›Ferritin

›Elevated supports hyperinflammation

›Not specific

›D-dimer

›Elevated supports MIS-C pattern

›Not specific

›Urinalysis

›Sterile pyuria supports Kawasaki pattern

›Hematuria suggests vasculitis

›Targeted microbiology

›Rapid strep test

›Supports scarlet fever when positive

›Negative may need culture local protocol dependent

›Throat culture

›Backup when rapid strep negative local protocol dependent

›Delayed results

›Viral PCR panel

›Supports viral exanthem

›Does not exclude bacterial coinfection

›Varicella or HSV PCR from lesion

›Higher yield from fresh vesicle

›Lower yield after crusting

12Imaging/img31

Scoring Systems

›Clinical decision aids and structured criteria

›Kawasaki disease classic criteria

›Fever at least 5 days

›Conjunctival injection

›Oral mucosal changes

›Peripheral extremity changes

›Polymorphous rash

›Cervical lymphadenopathy

›Incomplete Kawasaki disease pathway

›Fever at least 5 days with fewer than 4 features

›CRP and ESR supportive

›Echocardiography threshold local protocol dependent

MRI

›MRI indications in rash presentations

›Suspected osteomyelitis with overlying cellulitis

›Deep space infection when ultrasound nondiagnostic

›MRI limitations

›Need for sedation in young children

›Access and timing limitations

›CT indications in rash presentations

›Suspected deep neck infection with rash and toxic appearance

›Suspected necrotizing soft tissue infection with severe pain

›CT cautions

›Ionizing radiation risk

›Contrast allergy risk

›Contrast nephrotoxicity risk

Ultrasound

›Ultrasound uses

›Abscess evaluation in cellulitis

›Soft tissue gas evaluation adjunct for necrotizing infection

›Ultrasound limitations

›Limited sensitivity for early necrotizing infection

›Operator dependent findings

13Special Tests/spec12

Bedside maneuvers and focused tests

›Blanching and petechiae assessment

›Glass test for non blanching lesions

›Distribution mapping over time

›Dermatologic bedside signs

›Dermatographism

›Nikolsky sign support for SJS and TEN

›Infection focused bedside tests

›Point of care glucose in toxic child

›Rapid antigen testing local protocol dependent

›Ophthalmic screening when mucosal involvement

›Visual acuity screen if cooperative

›Urgent ophthalmology trigger with eye pain

14ECG/ecg8

When ECG is relevant in rash presentations

›Cardiac involvement triggers

›Suspected MIS-C with tachycardia

›Suspected myocarditis with chest pain

›Kawasaki disease with shock features

›ECG patterns and actions

›Conduction abnormalities

›ST and T wave changes suggesting myocarditis

›If unstable rhythm then resuscitation pathway activation

15Assessment/ax19

Problem representation and risk stratification

›Working diagnosis categories

›Benign self limited viral exanthem

›Allergic urticaria

›Bacterial skin infection

›Systemic inflammatory syndrome

›Severity stratification

›Well appearing with stable vitals

›Moderate illness with dehydration

›Toxic appearance or shock

›Cannot miss complications

›Meningococcemia

›SJS and TEN

›Anaphylaxis

›Kawasaki disease coronary involvement

›MIS-C myocardial involvement

›Diagnostic uncertainty management

›Reassessment after antipyretic and fluids when indicated

›Serial rash photos for evolution tracking

›Lower threshold for observation in infants

16Plan/plan41

First 5 minutes and stabilization

›Critical rash workflow

›Continuous monitoring for toxic appearance

›IV or IO access if shock features

›Oxygen if hypoxia or distress

›Isotonic fluid bolus if shock local protocol dependent

›Epinephrine IM immediately if anaphylaxis

›Empiric antibiotics within 60 minutes if sepsis suspected local protocol dependent

Targeted management by likely etiology

›Urticaria without anaphylaxis

›Non sedating antihistamine dosing by weight local protocol dependent

›Trigger avoidance when identified

›Short course steroid only for severe refractory symptoms local protocol dependent

›Atopic dermatitis flare

›Emollient barrier therapy

›Topical steroid potency by site local protocol dependent

›Treat secondary infection when present

›Cellulitis and impetigo

›Antibiotic choice based on local resistance patterns

›MRSA risk assessment

›Abscess drainage pathway if fluctuance present

›Suspected meningococcemia or sepsis

›Ceftriaxone IV or IM local protocol dependent

›Blood culture before antibiotics when feasible

›Droplet precautions for suspected meningococcal disease

›Suspected SJS and TEN

›Immediate stop suspected trigger medications

›Burn center or ICU consultation early

›Ophthalmology consultation early

›Avoid empiric steroids unless specialist guided local protocol dependent

›Kawasaki disease

›IVIG 2 g per kg single infusion local protocol dependent

›Aspirin regimen local protocol dependent

›Echocardiography and cardiology involvement

›MIS-C

›Early pediatric critical care consultation

›Broad lab panel for inflammation and cardiac injury

›Immunomodulation local protocol dependent

Reassessment loop

›Time based reassessment

›Repeat vitals every 30 to 60 minutes if moderate illness

›Repeat perfusion exam after fluids

›Repeat rash distribution check for progression

›Repeat airway assessment if urticaria evolving

17Disposition/dispo23

Level of care criteria

›ICU

›Shock requiring vasoactive support

›Respiratory failure

›Suspected SJS and TEN with significant skin involvement

›MIS-C with cardiac dysfunction

›Inpatient admission

›Non blanching rash with fever pending evaluation

›Kawasaki disease suspected

›Dehydration requiring IV fluids

›Cellulitis requiring IV antibiotics

›Immunocompromised with fever and rash

›Observation pathway

›Diagnostic uncertainty with stable vitals

›Moderate symptoms needing serial exams

›Discharge criteria

›Well appearing

›Stable vitals

›No alarm rash pattern

›Oral intake adequate

›Reliable follow up and return ability

›Follow up timing

›Primary care within 24 to 72 hours when uncertain diagnosis

›Dermatology referral if persistent rash over 1 to 2 weeks

18Discharge Instructions/di30

Copy discharge instructions

›Rash summary

›Today you were seen for a rash

›The exam did not show signs of a dangerous rash at this time

›Home care

›Keep skin cool

›Avoid new soaps and scented products until resolved

›Use fragrance free moisturizer

›Medications

›Use antihistamine as directed if itchy

›Use prescribed topical medication only on the areas instructed

›Hydration

›Encourage fluids

›Watch urine output

›Follow up

›See your primary care clinician within the recommended timeframe

›Return sooner if you cannot get follow up

›Return to ED now for

›Trouble breathing

›Swelling of lips or tongue

›Fainting

›New vomiting that will not stop

›New severe headache

›Neck stiffness

›Confusion

›Purple or non blanching spots

›Rash rapidly spreading over hours

›Skin pain

›Blistering

›Mouth sores

›Eye pain

19References/r7

Guidelines and high quality sources

›Pediatric rash evaluation references

›American Heart Association Kawasaki Disease scientific statement 2017

›CDC measles clinical guidance updated regularly

›CDC varicella clinical guidance updated regularly

›IDSA practice guidelines for skin and soft tissue infections 2014

›NICE fever in under 5s assessment and initial management updated regularly

›British Association of Dermatologists SJS and TEN guidance local protocol dependent

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.