Rashes in Babies and Children

Rash in newborn: Dry skin with red patches on the trunk, a typical presentation of atopic dermatitis

Skin rashes are common in children. Understanding the underlying cause can help parents provide appropriate care and seek medical attention when necessary.

The age of the child can provide valuable clues about the potential cause of a rash. For example, a recent or ongoing fever may suggest an exanthem, a type of rash associated with certain childhood illnesses.

It’s important to consider the context of the rash. Is it a new rash, or has it been present for some time? Are other family members or close contacts experiencing similar symptoms? These factors can help determine if the rash is infectious or due to an infestation, such as scabies.^[1] It’s crucial to assess the child’s overall health. Is the child experiencing other symptoms, such as fever, cough, or runny nose? Is the rash causing discomfort, such as itching or pain?

Majority of childhood rashes are harmless, but if your child is becoming severely ill, irritable, complains of neck stiffness, difficulty in breathing, rash resembling bruising, rash is spreading fast with signs of superadded infections you should seek urgent medical care.

Let’s dive into the details regarding the various causes of rashes in babies and children.

How to Check a Child’s Temperature

A fever is often a sign of an underlying illness. Parents can typically identify a fever through these signs

• Physical Symptoms: Hot, red face, tired or glazed eyes, and pale skin.
• Behavioral Changes: Loss of appetite, excessive crying, or increased thirst.

A fever is typically defined as a body temperature of 38.5 °C (101.3°F) or higher in children, measured rectally. For infants under 3 months, a rectal temperature of 38°C (100.4°F) or higher is considered a fever.^[2] Using a thermometer is the most accurate way to measure a child’s temperature. Rectal temperature is generally considered the most reliable, but other methods like oral, axillary, or ear thermometers can also be used.

Rash with a High Temperature

Rashes with fever in children can be caused by different illnesses. Rash and fever are common reasons for paediatric dermatology emergencies.^[3] Each illness has its own pattern, location, and severity of rash. Recognizing these differences helps identify the cause.

Rash on the Face and Body

Scarlet Fever

Scarlet fever is a bacterial infection caused by Group A Streptococcus bacteria. It typically affects children but can also occur in adults. Encountered more commonly in children, especially under 10 years of age. Transmission is by the aerosol route but may also spread by direct skin contact, and rarely can be food borne.^[3] Symptoms include high fever, headache, sore throat, lymph node enlargement in the neck, and a characteristic rash.

The rash is typically a fine, red rash that feels like sandpaper,  appears on the first or second day of illness on the groin, axilla, and trunk and then spreads to the extremities sparing the palms and soles. The tongue may develop a white coating, followed by a red, strawberry-like appearance.  After several weeks, the rash fades and is followed by desquamation of the skin, especially on the face, in skin-folds, and on the hands and feet, potentially lasting four to six weeks .Untreated scarlet fever can lead to serious complications, such as rheumatic fever and kidney inflammation.

Measles

Measles in babies can present as red, patchy rashes on the face, often accompanied by fever and other symptoms.

Despite effective vaccines, outbreaks continue to occur due to insufficient immunization coverage to provide herd immunity. Worldwide, measles continues to be a major cause of morbidity and death where immunization is not provided.^[1]

Measles is a highly contagious viral infection that can cause serious complications. It typically starts with a prodromal phase characterized by fever, cough, runny nose, and conjunctivitis. A few days later, a distinctive pink macular and papular rash appears around the hairline and behind the ears and spreading to the body. Koplik spots, small white spots with a bluish-white center, may appear on the inside of the cheeks.

Complications of measles include pneumonia, encephalitis, and, in rare cases, subacute sclerosing panencephalitis (SSPE). Timely vaccination is crucial for preventing measles and its associated complications.

Rash on Cheeks with a High Temperature

Slapped Cheek Syndrome

Slapped cheek syndrome, also known as fifth disease, causes distinctive redness on the cheeks, especially in young children

Slapped cheek syndrome, also known as erythema infectiosum, is a common childhood illness caused by parvovirus B19. It typically affects children between the ages of 4 and 10 years.^[4] The illness begins with a mild prodrome of fever, headache, malaise, and myalgia. A characteristic “slapped cheek” rash appears on the face, followed by a lacy rash on the trunk, arms, and legs.

The rash typically clears up on its own within three weeks without causing any lasting effects. While most cases are mild, complications like arthritis and transient aplastic crisis can occur, especially in adults. Treatment is typically supportive, focusing on managing symptoms like fever and discomfort.

Blisters on Hands and Feet Plus Mouth Ulcers

Hand, Foot, and Mouth Disease

Rashes in infant, such as those caused by hand-foot-and-mouth disease, can appear as red spots on the forehead, face, and scalp.

Hand, foot, and mouth disease (HFMD) is a common viral infection, primarily affecting young children under 5 years.^[3] It is caused by various enteroviruses, most commonly coxsackievirus A16. Symptoms typically include fever, malaise, and painful sores in the mouth. A characteristic rash, consisting of small, red triangular or elliptical-shaped blisters, often appears on the hands, feet, and sometimes the buttocks. Additionally, painful sores may develop on the tongue, gums, and inner cheeks. In some cases, nail changes, such as onychomadesis (nail loss), may occur after the acute phase of the infection.

Hand-foot-and-mouth disease in infants often causes red spots on the feet, a characteristic symptom of this viral infection

There is no specific treatment for HFMD, supportive care will be given.

Rash with Itching

Small, Itchy Spots

Chickenpox

Chickenpox, a highly contagious viral infection, transmitted by droplets or direct person-to-person contact, typically affects children. It’s characterized by an itchy rash that begins as small, red bumps and progresses to fluid-filled blisters, starts from scalp and face, spreading to trunk and limbs respectively, eventually forming crusts. Other symptoms may include fever, fatigue, and loss of appetite. While most cases are mild, complications like bacterial skin infections, pneumonia, or encephalitis can occur, especially in severe cases or immunocompromised individuals. Vaccination is the most effective way to prevent chickenpox.

Raised, Itchy Spots or Patches

Hives (Urticaria)

Urticaria, commonly known as hives, is a skin condition characterized by itchy, raised wheals that can vary in size and shape. These wheals can appear suddenly and disappear within a few hours or days. In 40% of patients, wheals are associated with swelling on the face, lips, abdomen or limbs.^[7] While the exact cause of urticaria is often unknown, it can be triggered by various factors, including allergies, infections, medications, physical stimuli (such as heat, cold, or pressure), and stress.

In some cases, urticaria may be chronic, lasting for months or even years. Treatment for urticaria focuses on managing symptoms, such as itching, and identifying and avoiding potential triggers. Antihistamines are commonly used to relieve itching and reduce inflammation. In severe cases, additional medications may be prescribed.

Dry, Scaly Patches

Eczema

Atopic dermatitis, a common inflammatory skin condition, often presents in infancy and early childhood, affects approximately 20% of children in the United States.^[8] It typically manifests as dry, itchy, red, and scaly patches on the skin. The distribution of these lesions can vary, affecting the face, scalp, and extremities in infants, and the flexural surfaces (elbows, knees, and behind the neck) in older children and adults.

The underlying cause of atopic dermatitis involves a combination of genetic and environmental factors, including a defective skin barrier and allergic triggers. Atopic eczema is rare in the first two months of life, unlike infantile seborrhoeic dermatitis, which is more common. A family history of atopic disorders like eczema, asthma, or hay fever is often present. About one-third of children with atopic eczema develop asthma.

Exclusive breastfeeding may delay eczema onset in vulnerable children but doesn’t significantly affect its prevalence later in childhood. Atopic eczema primarily affects children, being most severe in the first year of life, and improves in 50% of instances by age 12 and 75% by age 16.^[1]

Treatment focuses on managing symptoms, preventing flare-ups, and improving skin barrier function. This often involves the use of emollients, topical corticosteroids, and antihistamines. In severe cases, systemic therapies may be necessary.

Circular, Itchy Rash

Ringworm (Tinea infection)

Ringworm, is a fungal infection, affects the skin, hair, and nails. It’s caused by dermatophyte fungi that thrive on keratin, a protein found in these structures. The appearance of ringworm can vary depending on the affected area. On the skin, it often presents as a circular, scaly rash with a raised border. The term
‘ringworm’ is used because of the often ringed (annular)
appearance of skin lesions.

Tinea capitis, a type of ringworm that affects the scalp, can cause hair loss and inflammation. Diagnosis of ringworm is typically made through a physical examination and may involve microscopic examination of skin scrapings or a fungal culture. Treatment for ringworm typically involves topical antifungal medications, but in severe cases, oral antifungals may be necessary.

Rash Without Fever or Itching

While the above will present with associated fever, the following will be characteristic due little or no fever associated with the rash.

Tiny Spots

Milia

Milia are tiny, white bumps that often appear on the face in about half of full term newborns. They are caused by a buildup of keratin, a protein that protects the skin. While they may look concerning, milia are harmless and usually disappear on their own within a few weeks. No specific treatment is typically required, and the skin should be kept clean and moisturized.

Red, Yellow, and White Spots

Erythema Toxicum

Erythema toxicum neonatorum is a common, benign skin rash affecting approximately 48% to 72% of full-term newborns.^[9] It typically appears as small, red, raised bumps or blisters, often with a white or yellow center.The rash may be scattered or clustered and can occur anywhere on the body, except for the palms and soles.While the exact cause is unknown, it’s believed to be an immune response.

The rash usually appears within the first few days of life and resolves spontaneously within a few weeks. No specific treatment is required, and the rash typically does not cause discomfort to the infant.

Skin-Colored or Pink Spots

Molluscum Contagiosum

Rashes in babies, such as molluscum contagiosum, appear as skin-colored or pink shiny bumps with a characteristic central indentation.

Molluscum contagiosum is a benign skin infection caused by a poxvirus. This highly contagious viral infection most commonly affects children two to 11 years of age.^[8]

It typically presents as small, flesh-colored or pearly white bumps with a dimple in the center. These bumps can appear anywhere on the body but are most common on the face, trunk, arms, and genitals. The infection can spread through direct contact or autoinoculation.

While most cases resolve on their own, treatment options like cryotherapy or topical medications may be considered for faster resolution or to address cosmetic concerns.

Red Patches on a Baby’s Bottom

Nappy Rash

Nappy rash is a skin condition in infants and young children. It’s often caused by prolonged contact with wet or soiled diapers, which can irritate the delicate skin in the diaper area resulting in irritant dermatitis. Symptoms of nappy rash include redness, soreness, and a rash on the buttocks, genitals, and inner thighs. In severe cases, the skin may become raw and cracked.

To prevent nappy rash, it’s important to change diapers frequently, clean the baby’s bottom gently with warm water, and apply a barrier cream to protect the skin. If a nappy rash develops, mild topical corticosteroids or antifungal creams may be used to soothe the irritation and promote healing.

Yellow, Scaly Patches on the Scalp

Cradle Cap (pityriasis capitis)

Rashes in babies, like cradle cap, appear as yellow, scaly patches on the scalp, often resolving naturally with gentle care

Cradle cap, also known as infantile seborrheic dermatitis, is a harmless skin condition that affects infants. It typically appears as yellowish, greasy scales on the scalp, but can also affect other areas like the eyebrows, face, and diaper area. In contrast to atopic eczema, it is not itchy and the child is unperturbed by it. However, it is associated with an increased risk of subsequently developing atopic eczema.^[1]

While the exact cause is unknown, it’s believed to be related to overactive sebaceous glands. Cradle cap usually resolves on its own within a few months. Gentle cleansing with baby shampoo and the application of a light oil or moisturizer can help loosen the scales. In severe cases, a doctor may recommend a medicated shampoo or cream.