The skin. It’s a window to the rest of the body, and it’s easy to worry when we notice any changes at all on our children. I find it rewarding to see and treat skin conditions in real life. And, they’re one of my least favorite to address by just looking at a photo. I usually have so many follow up questions. It helps to see the rash from different angles. Many times, touching the rash helps. And, during an exam, I may notice other things that are important. Things left out of a photo or text.
But, how is that helpful when a parent doesn’t know whether a rash is worth a medical visit? What follows are reasons to make that appointment. At the very least, here are reasons to investigate a bit more or call your child’s doctor. It’s not a complete list, obviously. Dermatology is a huge field for a reason. These are just starting points, things we might chat about on the phone when deciding if an appointment is needed.
For the purposes of this post, we’ll define “rash” as anything not-quite-normal on the skin.
1. The rash is bothersome or painful.
Let’s not let children suffer needlessly. This is true of almost all things pediatrics. If something is bothering you or your child, please seek care. For rashes, this may mean it itches. Itching can be a sign of many things, from eczema to poison ivy to a scabies infection. Most itches are treatable! And, if the itch itself isn’t treatable, then we need to investigate more anyway.
Maybe “just” the appearance is bothersome. Even if not life-threatening, appearance, especially to children, matters. A wart or acne come to mind. We know that acne (for one concrete example) can affect mental health and quality of life. Acne, warts, and other seemingly cosmetic conditions can be treated!
If skin is painful, it can be a sign of infection or injury. If a parent doesn’t know why their kid’s skin hurts or doesn’t know how to treat it, please seek care. A sunburn here is a good example. Sometimes they can be treated at home, and sometimes more help is needed.
2. There’s also a fever.
A fever is more than 100.4°F or 38°C. It often means infection. (We discussed fever a lot more a few weeks ago). A fever with a rash often helps diagnose the type of infection. Depending on the rash, some need emergent treatment. Some don’t need any specific treatment at all. Either way, it’s worth a phone call or office visit.
Before an in-person appointment, it’s a good idea to notify the office of your concerns. This is true for most rashes, but especially for a rash with a fever. The office may need to take some extra precautions. Or, they may have other recommendations, based on what else is going on. They may suggest anything from waiting a few more days to going to the nearest emergency room.
As always, if a baby under age 90 days has a fever, they need immediate medical attention, regardless of a rash.
3. The rash does not “blanch.”
Blanching means that when you press on the rash it changes color or appearance before turning back to the original color. We literally press on the rash then quickly lift our finger. Another way to check is to press a glass against the skin. If something does not change color when pressed, this would be “non-blanching.”
If it does not blanch, this can be a sign the blood vessels are involved. Small pinpoint spots that don’t blanch may be something called “petechiae.” This can happen on the face or chest from something like forceful coughing or vomiting. The tiny blood vessels near the skin’s surface have broken with the force of a cough. Or, petechiae can appear due to changes in someone’s blood counts, specifically platelets. Platelets help with clotting, and if they go down in number, this type of rash is one possible symptom.
If there are large non-blanching patches (called “purpura”), this is often more serious in children. (If someone called and said that their child had a fever and then described purpura, I would advise them to go to the ER. It could be a sign of a life-threatening infection). There are less serious causes as well, but still usually warrant prompt medical attention.
4. There are blisters filled with fluid.
In this case, I’m thinking of various viral infections. Herpes (also the cause of cold sores) is one of the most common causes. Does every cold sore need a doctor’s appointment? Probably not. However, if a baby under age 3 months has anything that looks like a cold sore anywhere, they should be seen. Herpes is just one of several viruses that cause blisters.
Some bug bites or minor injuries (like a foot rubbing against a tight shoe) can also cause blisters. So before worrying too much, we have to remember to think about the big picture.
A burn can also blister, and it’s probably worth a phone call to see if a child needs to be seen. Either way, if there is a blister after a burn, leave it alone unless directed otherwise. The skin underneath needs to heal, and the overlying blister protects it while that is happening. The blister also helps keep the healing skin underneath clean.
5. Skin is draining or oozing.
Pus drainage is usually the sign of a bacterial infection. Sometimes such infections need antibiotics. Sometimes they don’t. If any other symptoms above are present (fever or pain, for example), it’s more likely that the child needs to be seen and/or treated.
6. The rash began at the site of an injury.
An animal bite (or human bite, especially with toddlers!) or other wound that leads to a rash is a reason to get it checked out. We would be concerned here about infection or poor healing. Either way, further evaluation is a good idea.
7. The rash won’t go away.
Maybe none of the above apply specifically. But if there are skin changes that aren’t getting better on their own, it’s probably a good idea to get them checked out. It may not be a serious, but it could be a sign of something more literally “beneath the surface.” I’m not going into specific examples I’ve seen in practice (mostly because individually they represent rare conditions; I’m really trying to not be in the business of scaring people). But. I’ve seen enough things that were “just a bump,” that ended up being something that needed to be addressed.
So, if an inexplicable change in the skin lingers, please seek care.
8. Symptoms evolve quickly.
In addition, if a child’s symptoms change rapidly, they may need to be seen. In this case, I’m referring to a rash that may have started as a small tender spot that now appears much larger, for example. Or mild itching that is now severe. If a parent notices a new rash, and they are concerned about a skin infection, they can trace its border with a permanent marker or pen. Make note of the time. This way, families have objective information about whether and how much a rash or skin infection has spread.
9. The child looks sick or the parent is worried.
This is always my ongoing theme. Parents know their kids. If something feels off, check it out. If nothing about your child’s rash is on this list, but they just aren’t acting like themselves, still get them evaluated.
Skin reveals a lot about a child’s overall health. Most rashes in children are nothing to worry about and can be monitored at home. However, fever, bothersome symptoms, non-blanching rashes, drainage, blisters, injury, persisting or worsening symptoms, or a parent’s concern are all excellent reasons to seek care. A phone call may be the perfect start to getting everyone feeling better.
A quick note. As is already well known, most publicly available rash photographs depict pale skin. This is a disservice. Thankfully, it’s being addressed, little by little. skinofcolorsociety.org has many resources. Depending on your child’s doctor’s education and training, they may not have seen some skin conditions in darker skin. I mention this partly to continue to raise awareness about systemic biases in medicine, but also to emphasize my last point. If you are worried about your child, seek care. And, please never worry about asking for a second opinion if something still doesn’t feel right.
Dreno, B., Bordet, C., Seite, S., Taieb, C., & ‘Registre Acné’ Dermatologists (2019). Acne relapses: impact on quality of life and productivity. Journal of the European Academy of Dermatology and Venereology : JEADV, 33(5), 937–943. https://doi.org/10.1111/jdv.15419