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Those Bumps aren’t Moguls! An Algorithmic Approach to Rashes David Robinson MD Department of Emergency Medicine University of Texas Medical School at Houston 31rst Annual Emergencies in Medicine Conference Park City, Utah. General ‘Bump’ Terms.

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Those Bumps aren’t Moguls!An Algorithmic Approach to RashesDavid Robinson MDDepartment of Emergency Medicine University of Texas Medical School at Houston31rst Annual Emergencies in Medicine ConferencePark City, Utah
general bump terms
General ‘Bump’ Terms
  • Rash: An eruption on the skin; more extensive than a single lesion
  • Lesion: Single small, diseased area
  • Macule: Circumscribed area of change without elevation
  • Papule: Solid raised lesion ≤1 cm
  • Plaque: Circumscribed elevated confluence of papules ≥1 cm
  • Nodule: Solid raised lesion ≥1 cm
  • Pustule: Circumscribed area containing pus
  • Vesicle: Circumscribed fluid-filled area ≤1 cm
  • Bulla: Circumscribed fluid-filled area ≥1 cm
  • Petechia: Small red/brown macule ≤1 cm that does not blanche
4 major rash algorithms
4 Major Rash Algorithms

a. Erythematous

b. Vesiculo-bullous

c. Petechiae/Purpura

d. Maculopapular

your working at abem general when
Your working at ABEM general when…
  • ‘sick baby with red skin in room 5’
  • Red Skin, ‘skin is peeling off – when I push on it’, blisters
  • Fever
  • The 2 key historical points?
erythematous rashes
Erythematous Rashes

Erythema (from the Greek erythros, meaning red) is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin

erythematous rash with fever positive nikolsky sign the sick ones
Erythematous Rash with feverPositive Nikolsky Sign – the sick ones
  • Staph SSS (children <5)
    • Aka dermatitis exfoliativaneonatorum
    • Diffuse scarlatiniformerythema
    • No mucous membranes
    • Shallow skin cleavage
  • TEN (adults)
    • MC associated with sulfa drugs
    • First around face/eyesshoulders and UE
    • Mortality 30-35%
erythematous rash with fever no nikolsky sign
Erythematous Rash with feverNo Nikolsky sign
  • Toxic Shock Syndrome
    • Diffuse erythematous rash
  • Kawasaki Disease
    • High fever x 5 days
    • Red eyes, Cracked lips, Dry tongue
  • Scarlet Fever
    • Pink-red ‘sandpaper’ rash
    • Flushed face, strawberry tongue
    • Follows sore throat or impetigo
erythematous rash no fever and no nikolsky sign
Erythematous Rash, No Fever and No Nikolsky Sign
  • Anaphylaxis
    • 2 or more body systems
  • Scombroid poisoning
    • Spoiled dark fleshed fish
    • Intense histamine reaction 30-40 min after ingestion
    • Flushing, headache, abd cramps
    • Self limited, antihistamines
  • Alcohol Flush
    • MC seen in Asians (East)
    • Self limited

erythematous rash fever and nikolsky sign
Erythematous Rash, +/- Fever and (+) Nikolsky Sign
  • Toxic Epidermal Necrolysis (TEN)
    • Associated with drugs
    • Life threatening shearing of epidermis from dermis in more than 30% of body
    • Affects mucous membranes
    • TX: plasmaphoresis, IVIG, stop drug, ICU admit

a two fer
A two-fer…

Bed 3

Bed 9

60 yo with sharp back and chest pain

Blisters over specific area of chest – follows dermatome

No fever

  • 6 yo with fluid filled vesicles on face, scalp, torso, upper arms
  • Fever
  • unvaccinated

Fever and rash distribution

What are the diagnostic clues ?

vesiculo bullous rash
Vesiculo-Bullous Rash

Definitions: Circumscribed fluid filled sac less than 1 cm (vesicle) or greater than 1 cm (bullous)

Bullous erythema multiforme

Vesicles of Hand, foot and mouth

vesiculo bullous rash febrile and localized
Vesiculo-Bullous rashFebrile and Localized
  • Necrotizing Fasciitis
    • Rapidly progressing
    • Polymicrobial, gpAstrept IV ABX
  • Hand, Foot and Mouth
    • Children <10
    • Coxsackie A16
    • Vesicles to hands, feet
    • Symptomatic tx

vesiculo bullous rash febrile and diffuse
Vesiculo-Bullous rashFebrile and Diffuse
  • Varicella/ Chicken pox
  • Smallpox
    • Variola v
    • Born after 1972?
  • Disseminated GC
    • Also seen as palpable purpura
  • PurpuraFulminans / DIC
    • Fever, shock, rapid SQ hemorrhage, tissue necrosis, DIC
    • MC meningococcal or G(-) organisms
    • Trauma, multiorgan failure
vesiculo bullous rash not febrile and localized
Vesiculo-Bullous rashNot Febrile and Localized
  • Contact Dermatitis
    • Often linear at point of irritation
  • Zoster
    • VZV
    • Follows dermatome pattern
  • Burns
  • Dyshidrotic Eczema
    • Pruritic blisters on hands and feet, possibly scaly
    • Unknown etiology
vesiculo bullous rash not febrile and diffuse
Vesiculo-Bullous rashNot Febrile and Diffuse
  • BullousPemphigus (~60s)
    • NegNikolsky’s, pruritic
    • Oral lesions in 1/3
  • PemphigusVulgaris (>40 y)
    • Autoimmune blistering of skin (flaccid bullae) and mucous membranes
    • Penicillamine, ACE inh
    • Treat as burns, immunosuppressant therapy
hey doc i got these bumps on my skin
Hey Doc…I got these Bumps on my skin
  • Afebrile
  • What are the distinguishing features for these ‘bumps’
  • Are they Bumps?
    • Palpable or Nonpalpable?
  • Do they Blanch?
Petechial / Purpuric rash

Petechia: small (< 3 mm) red or purple spot on body due to minor hemorrhage of blood vessel

Purpura: Larger hemorrhagic lesions (3-10mm)

Ecchymosis: largest (>10mm)

petechial purpuric rash febrile and
Petechial / Purpuric rashFebrile and…


  • Meningococcemia
    • Hemorrhagic, petechial with bullae
    • From endotoxin release
  • Disseminated GC
  • Endocarditis
    • Osler’s nodes, roth spots, palpable purpura
  • RMSF
    • Early: Small, flat non-pruriticmacules on wrists forearms and ankles
    • Late: spreads to trunk, petechial
  • HSP
    • Kids (2-10)
    • Vascular palpable purpura
    • Assoc. GI and joint pain
petechial purpuric febrile and not palpable
Petechial / PurpuricFebrile and Not Palpable
  • TTP
    • Microangiopathic hemolytic anemia, neurologic sx, HUS
    • Tx with plasma exchange, immunosuppressants
    • 2° TTP assoc with ca, platelet agginh, immunosuppresants, HIV, SLE
  • PurpuraFulminans / DIC
    • Associated with G- sepsis
    • Debridement, eschar/amput often necessary
  • HSP (anaphylactoidpurpura)
    • Systemic vasculitis, children
    • Associated with infection (pharyngitis)
    • Triad: purpura, arthritis, abd pain
petechial purpuric rash not febrile and
Petechial / Purpuric rashNot Febrile and…


Not Palpable

ITP (idiopathic thrombocytopenic purpura)

Autoimmune in 60%

½ new cases in children, 70% end in remission

  • Vasculitis
    • Vascular damage to capillary sized vessels
what are these bumps
What are these bumps?

Macule: Circumscribed area of change without elevation

Papule: Solid raised lesion ≤1 cm

Nodule: Solid raised lesion ≥1 cm

Plaque: Circumscribed elevated confluence of papules ≥1 cm

Morbilliform: has both macular and papular features

Drug eruption


maculopapular rash with fever and central distribution
Maculopapular Rashwith Fever and Central distribution
  • Viral exanthum
    • From Gr: ‘breaking out’
    • Measles, rubella, erythemainfectiosum, roseola…
  • Lyme Disease (erythema migrans)
    • Target lesions (EM) 3-30 d after bite
    • Progresses to neuro (10-15%), cardiac complications
maculopapular rash with fever and peripheral distribution
Maculopapular RashwithFever and Peripheral Distribution

Target Lesions

No Target Lesions




Lyme Disease

  • Stevens-Johnson Syndrome (SJS)
    • Caused from drugs, infections, malignancies
  • Erythemamultiforme

Clinical presentation, history, and presence of toxicity or neurologic deficits will clue the practitioner to the correct diagnosis

maculopapular rash no fever and central lesions
Maculopapular RashNo Fever and Central Lesions
  • Drug Reaction
    • Fixed or centrally located
  • Pityriasisrosea
    • Assoc. with URI, ha, n,v
    • Herald’s Patch (2-10 cm oval red) seen
    • Last 6 weeks
maculopapular rash no fever and peripheral lesions
Maculopapular RashNo Fever and Peripheral Lesions

Lesions on Flexor Surfaces

Lesions on Extensor Surfaces


Immune mediated, pruritic

Red and white scaly plaques, patches

30% with arthritis

Tx with ointments, cr, phototherapy

  • Scabies
  • Eczema
bonus clues to bump identification
Bonus clues to bump identification

Clues to Diagnosis Rash

Patient Age

0 to 5 years: Meningococcemia, Kawasaki disease, viral exanthem

>65 years: Pemphigusvulgaris, sepsis, meningococcemia, TEN, SJS, TSS

Rash Characteristics

Diffuse erythema: Staphylococcal SSS, staphylococcal or streptococcal TSS, necrotizing fasciitis

Mucosal lesions: EM major, TEN, SJS, pemphigusvulgaris

Petechiae/purpura: Meningococcemia, necrotizing fasciitis, vasculitis, DIC, RMSF


Hypotension Meningococcemia, TSS, RMSF, TEN, SJS

key summary points
Key Summary Points
  • Rash with fever is a bad thing
  • Organize rashes to the 4 major types:
    • erythematous
    • macular/papular
    • petechial/purpura
    • vesicular-bullous
  • Secondary signs (Nikolsky, distribution, location (peripheral vs central, extensor vs flexor)
references and acknowledgments
References and Acknowledgments
  • Hanson, S, Nigro, J. Pediatric Dermatology. Medical Clinics of North America. 82(6):1381-1403, 1998
  • Lampell, MS.Childhood Rashes that Present to the ED. Pediatric EM Practice. 4:3,2007
  • CDC homepage (
  • Papulosquamous Diseases. dermatitis
  • Murphy-Lavoie, HM. “Approach to Rashes”. Notes from lecture Oct 27,2008 . ACEP Scientific Assembly
  • Special thanks to Dr. Ronald Rapini, MD Chair, Dermatology at University of Texas Medical School at Houston for various photos