What is the management approach for a 2-year-old with a bumpy rash on the cheeks and back of the arms, accompanied by upper respiratory infection (URI) symptoms?

Keratosis Pilaris with Concurrent Viral URI

This presentation is consistent with keratosis pilaris ("chicken skin"), a benign skin condition commonly affecting the cheeks and extensor surfaces of the arms in toddlers, which requires only reassurance and emollients—the concurrent URI symptoms are unrelated and should be managed supportively without antibiotics. 1

Understanding the Rash

• Keratosis pilaris presents as rough, bumpy skin texture on the cheeks and posterior/lateral upper arms (extensor surfaces), appearing as small flesh-colored or slightly red papules that feel like sandpaper 1
• This is an extremely common, benign condition in young children caused by keratin plugging hair follicles, often worsening in dry weather 1
• The rash is not related to the URI symptoms—these are two separate, concurrent conditions 1

Key Distinguishing Features

• No fever with the rash itself (though URI may cause low-grade fever in first 24-48 hours) 2
• No pruritus typically associated with keratosis pilaris, unlike atopic dermatitis 1
• Bilateral and symmetric distribution on extensor surfaces (back of arms) and cheeks 1
• The bumps are persistent, not transient like urticaria, and don't have central umbilication like molluscum contagiosum 3, 1

Management of the Rash

• Reassure parents that keratosis pilaris is a harmless, self-limited condition that often improves with age 1
• Apply emollients liberally 2-3 times daily, especially after bathing, to soften the bumpy texture 1
• Avoid harsh soaps and use gentle, fragrance-free cleansers 1
• No prescription medications are needed for typical keratosis pilaris in a 2-year-old 1

Management of the URI Symptoms

• Provide supportive care only—most viral URIs in toddlers are self-limited, lasting 5-7 days with symptoms peaking at days 3-6 4, 5, 2
• Use nasal saline drops or spray frequently throughout the day to help clear congestion and facilitate feeding 4, 2
• Ensure adequate hydration with frequent small feeds 4, 2
• Acetaminophen or ibuprofen can be used for fever or discomfort if present 5

When Antibiotics Are NOT Indicated

• Do not prescribe antibiotics for uncomplicated viral URI symptoms, even if nasal discharge becomes purulent—this is a normal phase of viral illness and does not indicate bacterial infection 4, 5, 2
• Purulent nasal discharge alone does not meet criteria for acute bacterial sinusitis 6, 5
• Antibiotics should only be considered if the child meets stringent criteria for acute bacterial sinusitis: (1) persistent symptoms >10 days without improvement, (2) worsening course after initial improvement, or (3) severe onset (fever ≥39°C with purulent discharge for 3-4 consecutive days) 6, 5, 2

Medications to Avoid

• Avoid oral decongestants, antihistamines, cough suppressants, mucolytics, and expectorants—these lack evidence of benefit in children with viral URIs 4, 5

When to Reassess

• Instruct parents to return if URI symptoms persist beyond 10 days without improvement, worsen after initial improvement, high fever with purulent discharge persists for 3+ consecutive days, or new concerning symptoms develop 5, 2
• The keratosis pilaris itself requires no follow-up unless parents have concerns about cosmetic appearance 1

Critical Pitfall to Avoid

• Do not prescribe antibiotics based on purulent nasal discharge alone—this is the most common error in managing pediatric URIs and contributes to antibiotic resistance 5
• Do not confuse keratosis pilaris with infectious rashes requiring treatment—the bumpy texture, distribution, and chronicity distinguish it from viral exanthems, urticaria, or tinea 3, 1