Technically Speaking: Let’s Not Be Rash!

Can you identify this rash?

Public Health Image Library, CDC; content provider: CDC/Joe Miller They say that a picture is worth a thousand words, so these Vaccine Education Center (VEC) resources are each worth many thousands of words:

• Rashes: What You Should Know (booklet)
• Name That Rash (poster)
• Rash Information (webpage)

These resources are more valuable to me than ever because I am increasingly being asked to see undervaccinated children — one of the many side effects of the COVID-19 pandemic. As a result, we are being called upon to sort out, often during a telehealth visit, who has a mundane viral rash and who has a vaccine-preventable infection that could wreak havoc in the daycare center and the community at large.

To see what I’m talking about, please consider these scenarios:

Scenario #1

Go to page 18 of the booklet (page 11 of the PDF), “Rashes: What You Should Know.” Imagine that you are seeing a child with a rash that looks like roseola. If you guess that this patient has roseola, caused by a virus in the human herpes family, it’s not a particularly big deal. Roseola is not fun — it often causes three to five days of high fever, which can be associated with febrile seizures, before the rash erupts. In daycares it spreads, via respiratory droplets, like white cat hair through a tuxedo shop.

However, if this rash is actually a manifestation of rubella (also called German measles, page 11 of the booklet PDF), it becomes imperative to prevent spread of the virus, particularly to susceptible pregnant people. When rubella virus infects people in the first 12 to 18 weeks of pregnancy, the results can be devastating, including miscarriages, stillbirths and a constellation of severe birth defects. Common congenital defects associated with congenital rubella syndrome (CRS) include cataracts, congenital heart disease, hearing impairment and developmental delays.

Scenario #2

When you last saw a patient with red eyes, some runny nose, and a viral exanthem, did you reflexively reassure the parent that “it’s just a virus” or did you consider measles (page 9 of the booklet PDF)? To see a memorable infographic on health problems caused by rubella and measles, and the overlap between them, see this CDC webpage.

Scenario #3

I also worry about mistakenly diagnosing impetigo (page 8 of the booklet PDF) when the patient’s rash is actually the first sign of varicella (chickenpox) infection (page 5 of the booklet PDF and the answer to the question at the start of the article). The rash of chickenpox is itchy and includes sometimes painful, fluid-filled blisters that usually first appear on the face and chest … not so terribly different from the oozing pimples of impetigo. The patient with chickenpox often has signs of illness such as fever and malaise around the time that the rash develops, or these may precede the rash by a day or two. But these days, how many children don’t have fever and malaise?

My points are simple

1. Our level of suspicion for vaccine-preventable diseases must be elevated or we may overlook them because we are not used to seeing them anymore.
2. The VEC has several wonderful tools that can help you and your trainees review key facts about pediatric rashes, including their appearances.

Resources alert!

• In addition to being freely available online, the VEC booklet and poster can be ordered for a small fee to cover production and fulfillment. Shipping charges are also added. See “booklet” and “miscellaneous items” sections of the ordering site.
• The Pediatric Infectious Disease Society (PIDS) offers a 20-30 minute, self-paced, online module, “The Rash or Vaccine Preventable Disease?: Clinical Scenarios.” The module utilizes VEC and other resources and is free. For instructions and registration, visit the “Vaccine Education from Training to Practice” webpage.
• “Brown Skin Matters” is an Instagram account that shows images of rashes on dark skin.