What is the management for a child who develops a rash after a fever?

From the Guidelines

The management for a child who develops a rash after a fever primarily involves supportive care while monitoring for complications. First, ensure the child stays well-hydrated with plenty of fluids and consider acetaminophen or ibuprofen for comfort if the child has fever or discomfort. Acetaminophen can be given at 10-15 mg/kg every 4-6 hours (maximum 5 doses in 24 hours), while ibuprofen dosing is 5-10 mg/kg every 6-8 hours for children over 6 months. Keep the child's skin clean and apply calamine lotion or a cool compress if the rash is itchy. Avoid harsh soaps or hot water which can worsen irritation. This presentation often indicates a viral exanthem such as roseola (sixth disease), which typically resolves on its own within a week. However, seek immediate medical attention if the child develops any concerning symptoms such as difficulty breathing, lethargy, persistent high fever, severe headache, stiff neck, or if the rash appears as small purple spots that don't blanch when pressed. These could indicate more serious conditions requiring prompt medical intervention. Most post-febrile rashes are benign and self-limiting, representing the body's immune response to the viral infection as it resolves 1.

Key Considerations

• Ensure the child stays well-hydrated with plenty of fluids
• Consider acetaminophen or ibuprofen for comfort if the child has fever or discomfort
• Keep the child's skin clean and apply calamine lotion or a cool compress if the rash is itchy
• Avoid harsh soaps or hot water which can worsen irritation
• Monitor for concerning symptoms such as difficulty breathing, lethargy, persistent high fever, severe headache, stiff neck, or if the rash appears as small purple spots that don't blanch when pressed

Potential Causes

• Viral exanthem such as roseola (sixth disease)
• Bacterial infections such as RMSF, HME, or streptococcal disease with exanthem
• Other infectious and noninfectious etiologies

When to Seek Medical Attention

• If the child develops any concerning symptoms such as difficulty breathing, lethargy, persistent high fever, severe headache, stiff neck, or if the rash appears as small purple spots that don't blanch when pressed.

From the FDA Drug Label

1. 2 Severe Cutaneous Adverse Reactions Amoxicillin may cause severe cutaneous adverse reactions (SCAR), such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) If patients develop skin rash they should be monitored closely, and amoxicillin discontinued if lesions progress.
2. 5 Skin Rash in Patients with Mononucleosis A high percentage of patients with mononucleosis who receive amoxicillin develop an erythematous skin rash. Thus, amoxicillin should not be administered to patients with mononucleosis.
3. 1 Clinical Trials Experience ... rash ... were observed in clinical trials of amoxicillin for oral suspension

The management for a child who develops a rash after a fever and is taking amoxicillin includes:

• Monitoring the child closely
• Discontinuing amoxicillin if the rash progresses
• Considering alternative treatments or seeking medical attention if necessary 2 2. Key considerations:
• Severe cutaneous adverse reactions (SCAR) can occur with amoxicillin
• Skin rash is a common adverse reaction to amoxicillin
• Mononucleosis patients have a high risk of developing a skin rash when taking amoxicillin.

From the Research

Management of a Child with a Rash after a Fever

The management of a child who develops a rash after a fever involves a systematic approach to diagnose the underlying cause.

• Considerations include the appearance and location of the rash, the clinical course, and associated symptoms, such as pruritus or fever 3.
• A fever is likely to occur with roseola, erythema infectiosum (fifth disease), and scarlet fever 3.
• The key feature of roseola is a rash presenting after resolution of a high fever, whereas the distinguishing features in pityriasis rosea are a herald patch and a bilateral and symmetric rash in a Christmas tree pattern 3.

Diagnostic Considerations

• The association of fever with illness has been known for years, and a febrile child may have a rash, which can be either infectious or non-infectious 4.
• With scrupulous, methodical history taking and careful, serial physical examination, the treating physician will find hints to assess and solidify an appropriate diagnosis, and choose an appropriate treatment 4.
• A systematic approach involving detailed history taking, careful clinical examination along with particular attention to epidemiological features are the most important factors to make a diagnosis 5.

Treatment and Prevention

• Reye's syndrome is a serious, acute encephalopathy that has been linked with aspirin (acetylsalicylic acid) use in children and teenagers <18 years of age 6, 7.
• The decline in case numbers of Reye's syndrome has been remarkable since government health warnings were appended to aspirin-containing formulations 6, 7.
• It is essential to avoid aspirin use in children with fever to prevent Reye's syndrome 6, 7.