What are the treatment options for a nonblanchable (non-blanching) rash?

Management of Nonblanchable (Non-Blanching) Rash

The immediate priority when encountering a nonblanchable rash is to rapidly exclude meningococcal disease, which represents a medical emergency requiring antibiotic administration within 1 hour—treatment must never be delayed for diagnostic procedures. 1

Immediate Emergency Assessment

The presence of a non-blanching petechial or purpuric rash carries significant mortality risk and demands urgent evaluation for life-threatening meningococcal sepsis. 1

High-risk features requiring immediate intervention include: 1

• Non-blanching petechial or purpuric rash
• Cyanosis of skin, lips, or tongue
• NEWS2 score ≥7
• Systemic signs of sepsis with fever

Critical management principles:

• Administer antibiotics within 1 hour for high-risk patients 1
• Do not delay antibiotics for diagnostic procedures 1
• Ensure immediate senior clinician review for suspected meningococcal infection 1

Children with meningococcal infection typically present ill with purpuric rash, fever >38.5°C, and capillary refill time >2 seconds, though absence of fever does not exclude the diagnosis. 2

Risk Stratification

Calculate NEWS2 score systematically: 1

• Score 0: Very low risk
• Score ≥7: High risk of severe illness or death from sepsis

Clinical features predicting meningococcal infection include: 2

• Ill appearance
• Purpuric (not just petechial) rash
• Temperature >38.5°C
• Capillary refill time >2 seconds
• Abnormal neutrophil count
• Prolonged INR
• C-reactive protein ≥6 mg/L (no child with CRP <6 mg/L had meningococcal infection) 2

Reassuring features (lower risk): 2

• Rash confined to superior vena cava distribution (no meningococcal cases in this pattern)
• CRP <6 mg/L

Drug-Induced Nonblanchable Rashes

Severe Cutaneous Adverse Reactions (SCAR)

For patients on immune checkpoint inhibitors or other medications, consider Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), or drug reaction with eosinophilia and systemic symptoms (DRESS). 3

Immediate workup for suspected SCAR: 3

• Complete blood count with differential
• Comprehensive metabolic panel
• Urinalysis to assess for associated nephritis
• Blood cultures if febrile
• Skin biopsy for full-thickness epidermal necrosis assessment
• Serial clinical photography

Management by grade: 3

Grade 3 (skin sloughing covering ≥10% BSA with mucosal involvement):

• Hold immune checkpoint inhibitor therapy 3
• Consult dermatology immediately 3
• Admit to burn unit with wound care consultation 3
• Administer IV methylprednisolone 0.5-1 mg/kg, convert to oral when responding, taper over ≥4 weeks 3
• Apply topical emollients, petrolatum-based products, oral antihistamines, high-strength topical corticosteroids 3
• Consult ophthalmology, otolaryngology, urology, or gynecology for mucosal involvement 3

Grade 4 (≥10% BSA with systemic symptoms):

• Permanently discontinue immune checkpoint inhibitor 3
• Immediate admission to burn unit or ICU 3
• IV methylprednisolone 1-2 mg/kg, taper when toxicity resolves 3
• Consider IVIG or cyclosporine for severe or steroid-unresponsive cases 3
• Pain/palliative consultation for DRESS manifestations 3

EGFR Inhibitor-Induced Rash

For papulopustular (acneiform) rash from EGFR inhibitors, management differs from infectious causes. 3

Grade 1-2 (mild to moderate):

• Continue EGFR inhibitor therapy 3
• Topical antibiotics: clindamycin 2%, erythromycin 1%, metronidazole 0.75%, or nadifloxacin 1% 3
• Oral antibiotics for grade ≥2: doxycycline 100 mg twice daily or minocycline 100 mg twice daily for ≥6 weeks 3
• Short-term topical corticosteroids (prednicarbate 0.02% cream) 3
• Skin-type-adjusted moisturizers 3

Grade 3 (severe):

• Reduce EGFR inhibitor dose per label 3
• Continue topical and systemic treatments as above 3
• Add short course of oral prednisone 0.5-1 mg/kg for 7 days with 4-6 week taper 3
• Reassess after 2 weeks; refer to dermatology 3

Grade 4 (life-threatening):

• Dose interruption or permanent discontinuation 3
• Systemic steroids recommended 3
• Individual treatment concept with dermatology consultation 3

General Rash Management (Non-Emergency)

For grade 1-2 generalized rash without high-risk features: 3

• Continue therapy if rash covers <10% body surface area 3
• Topical emollients and mild-to-moderate potency topical corticosteroids 3
• Avoid skin irritants 3

For grade 3 (>30% BSA with moderate-to-severe symptoms): 3

• Hold therapy and consult dermatology 3
• Oral prednisone 1 mg/kg/day tapering over ≥4 weeks 3
• High-potency topical corticosteroids, oral antihistamines 3
• Consider phototherapy for severe pruritus 3

Critical Pitfalls to Avoid

Common diagnostic errors include: 1

• Sending children home at first presentation when fever, diarrhea, or vomiting present without rash initially
• Missing that blanching rashes can evolve to non-blanching
• Delaying treatment while awaiting diagnostic confirmation

Treatment errors to avoid: 3

• Using alcohol-containing lotions or gels on xerotic skin (enhances dryness)
• Applying topical corticosteroids routinely for acneiform rash without antibiotics
• Frequent washing with hot water
• Using over-the-counter anti-acne medications on drug-induced rashes