Introduction to Rashes – PediaCast 052
- Introduction to Rashes
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents, the In-Depth Edition. And now, direct from Birdhouse Studios, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast. It is Episode 52 for Friday, September 21st.
And this is an In-Depth Edition, but we have a guest here, so you don't have to just listen to me talking on and on and on, sometimes droning. We have Dr. Michelle. She is a Family Practice resident, third year Family Practice Resident in Hawaii. And we're going to have a discussion in a little while on rashes. So that is coming up here very soon.
But first, I wanted to share something with you. I went to the dentist — yes, the dentist — yesterday. And honestly, I have never had a cavity. OK, I'm not bragging, because this is actually getting somewhere. I did have this thing called internal resorption, which I've never even heard of before. But apparently, you can get some breakdown of the tooth, in the middle of the tooth by the nerve. And I ended up, a few months ago, I had to have a root canal.
So, you know, here I am. I've never had a cavity, never had any major problems with my teeth before. And I had to have a root canal, OK, fine. So overall though, I've had pretty good dental health. So, why is it that every time you go to the dentist — at least every time I go to the dentist — you get this, "Oh, you can floss a little bit better." "You got a lot tartar down this area." "You need to concentrate here." "You need to concentrate there."
Now, don't get me wrong. My dental hygienist is a great guy. I really like him. But they always let you know what you could do better in terms of your tooth care. And, you know, he's picking up the tartar and I'm thinking, "I come in every six months and you pick the tartar off. If I brush better and I didn't have any tartar, you wouldn't really have much to do."
Dr. Mike Patrick: It's the way I look at it. And I floss everyday. I think that's doing pretty good, but apparently, I need to rub the floss a little bit better on each side of the teeth. No, but like I said, he's a great guy and they always do a nice job at my dentist's office. But I just want all of you to know, if you have a dental hygienist who always find something when you go to the dentist, you're not alone. And I've never even had a cavity, but we still, we all hear it.
OK, enough of that rant. Let's move on. Don't forget, if there's a topic that you would like us to discuss on PediaCast, it's easy to get a hold of me, just go to pediacast.org and click on the Contact link. You can also email email@example.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.
By the way, the voice line is working now. If you try to use it during the last couple of weeks. I forgot to pay the bill and they shut the Skype line off. OK, it's been a crazy couple of weeks. But I paid the bill. We're good for another year, so the Skype line is back open and the phone number itself is the same.
And with that in mind, we'll be back with Dr. Michelle to talk about rashes. And we'll get started with that right after this break.
Dr. Mike Patrick: All right, welcome back to the program. It is time for our very first In-Depth Segment with our shorter shows and I am joined today by Dr. Michelle from Hawaii.
Hi, Dr. Michelle.
Dr. Michelle: Hi, Dr. Mike.
Dr. Mike Patrick: I'm not going to call you a guest because this is really going to be more of a discussion than an interview. And, I guess, I think we should start… I think it would be appropriate to tell everyone exactly how we met because…
Dr. Michelle: [Laughter]
Dr. Mike Patrick: I'm sure that there are some listeners out there who were not listening a few months ago. Actually, do you want to start telling everyone a little bit about that?
Dr. Michelle: Sure. Actually, I've been listening to your podcast from the very beginning. I'm a Family Medicine resident in Hawaii but originally from Ohio. And I saw your podcast come up, I thought, "Wow, this would be a great opportunity for me to improve my counseling skills with my patients." And so, I've been listening from the get go. And then you had one episode where you talked about family medicine docs and I was mildly offended I supposed, and I called you.
Dr. Mike Patrick: [Laughter] It was little disparaging, I think.
Dr. Michelle: [Laughter]
And that's how we met.
Dr. Mike Patrick: I think I had mentioned that it's better to find a pediatrician than a family practice doctor because we spend so much more time training with kids. And I didn't even think that could be an offensive comment. And I didn't even really think about how true or not true it was. But I will say this, if anything, it put us together so we could do some of these discussions which I think are going to work out really well. See, it was for the best, right?
Dr. Michelle: It absolutely was. And you know, it was nice for us to get a chance to talk about it.
Dr. Mike Patrick: Oh, I agree. Yeah, I agree.
So, one of my plan here — we had emailed back and forth — and I thought it would be interesting especially during the winter time when we see lots of illness, really, both in pediatrics and family practice just with kids, and talk a little about rashes. And I guess as a framework for that, so there's this classic way that you can describe — not describe, but I guess classify — childhood rashes from back long, long time ago where you do first disease, second, third, fourth, fifth and sixth. They didn't really put names to them. It was just called first disease, second disease, third disease and so on. So I thought we would just take each of these diseases one week at a time. Or not one week at a time. I think we're going to do one a month, isn't that right?
Dr. Michelle: Something like that.
Dr. Mike Patrick: Yeah, I think that's what we decided. But before we start with the six actual exanthems of childhood, we thought that we would start with the discussion on rashes in general. And I think when I had put down some notes on this, one of the first things that popped into my mind about rashes is they're not really something that you can diagnose over the phone in kids. And do you find in your clinic that you have parents that call in and just say, "Hey, my son or daughter has such and such a rash. What do I do for it?" without necessarily wanting to come in.
Dr. Michelle: Oh, absolutely. And honestly, not even just parents. People call in all the time saying "I have this, I need this." The parents are often more concerned than the people calling for themselves but you can't help them over the phone. There's no way that they would be able to describe it in such a fashion that you can definitively tell what it is.
Dr. Mike Patrick: Right. And I can't tell you the number of times that someone described something over the phone and I have a picture of it in my mind. And I still say, "Why don't you come in? Let's take a look at it." And when they get here, despite their best description, it is completely different in the picture I had in my mind.
Dr. Michelle: Yeah, always.
Dr. Mike Patrick: Yeah, it's tough. And I think, sometimes too, from parents' standpoint, they're almost offended. Like, "I've had three kids at home. My son has had this rash before. I know what it is. Why don't you just trust me?" And it's not about the trust, because that same parent, if it was wrong and we did the wrong medicine and it got worse, then they're usually the first one to say, "Why, you didn't tell me to come in."
Dr. Michelle: Yeah, it does seem to be that way. And we never ask people to come in, you know, in an effort to inconvenience them. It's always an effort to do our best to help them.
Dr. Mike Patrick: Boy, I agree with that. I agree a 100%.
OK, so let's talk a little bit about different ways that we can describe rashes. I guess this is going to be sort of a vocabulary lesson a little bit. Because it's important to distinguish before we talk. Because when we give examples of these rashes, since we can't really show you pictures in a podcast, you do have to learn some of the terminology a little bit. So I had written down some of these. If you want to start just taking these descriptive terms and explaining what they mean in terms that parents can understand.
Dr. Michelle: Sure. Two of the most common things we see are macules and papules. And a macule is non-palpable, meaning that you cannot feel it. And it's a circumscribed lesion. It's flat, so you can't feel it and it's usually less than a centimeter. Whereas a papule is essentially the same thing, except you can feel it. And sometimes, they actually go together and it comes up maculopapular.
Dr. Mike Patrick: Right. And it seems like such a big word, maculopapular, but it's one that we use a lot. Again, so it's just a rash of small red areas that has circles and bumps.
Dr. Michelle: Yeah. And there's so many different things that can actually be from. So, even like the measles and any viral illness or even a hypersensitivity.
Dr. Mike Patrick: Right, right. Exactly. So, even if you describe it as a maculopapular rash, that just gives you an idea of what it looks like, but it still can be so many different things.
Dr. Michelle: Exactly.
Dr. Mike Patrick: OK, so what are some other lesions that you can see on the skin, in terms of description?
Dr. Michelle: Let's see, there's so many. There's nodules, and those are kind of deeper, roundish lesions that are usually less than a centimeter to two centimeters in diameter. Those can be seen with like acne or even rheumatoid nodules. And then, there's plaques which are large elevations. They're greater than a centimeter. So, plaques are like papules except they're bigger.
Dr. Mike Patrick: Good, good. And pustules — I guess we should mention those, too — is kind of like a nodule except filled with pus. And then, as it gets bigger, I guess you'd start to call it a skin abscess.
Dr. Michelle: Yes. Or even a furuncle, a boil.
Dr. Mike Patrick: And then, you got your carbuncle, too.
Dr. Michelle: Yes. Boy, we come up with a lot of gross terms in medicine, don't we?
Dr. Mike Patrick: [Laughter]
That's right, yeah.
And then, there's the whole sort of allergic spectrum of rashes which we call hives. And when you have a bunch of hives we call that urticaria. I guess vesicles are going to be fluid-filled blisters, small ones.
Dr. Michelle: Yes.
Dr. Mike Patrick: And what else do we have?
Dr. Michelle: My favorite has to be excoriations, actually.
Dr. Mike Patrick: [Laughter]
Dr. Michelle: Because parents are always describing those or concerned about them, but they're almost always caused the child itself, by scratching.
Dr. Mike Patrick: Yeah, and fingernails. And some of the babies, well, I tell you, if you don't keep their fingernails trimmed, they can really scratch up their face pretty good.
Dr. Michelle: Oh, yeah, they're very good at that.
Dr. Mike Patrick: And there's the ones that I think make doctors the most worried.
Dr. Michelle: Oh, petechia.
Dr. Mike Patrick: Yes, and purpura. And these are very serious — well, they're not always serious — but they can mean serious things. And, definitely, it's not something to put off. And when I talk to people on the phone to try to figure out is this a kind of rash that can wait till morning or is this something that the child need to be seen now — when you have the rash, if you push down on the skin, with most rashes, the redness is going to go away because you're basically squeezing the blood out of the capillaries in the skin. And then, when you let go, for just a moment, it stays sort of a pale or white color. And then, gradually, the redness comes back.
But with the petechia and the purpura which is just bigger areas, it's basically blood that has left the blood vessels and it's under the skin and it doesn't squeeze out of the skin. So, you can't blanch these lesions.
And we can talk a little bit more in the future weeks about what those mean. But they can be a sign definitely of serious disease, right?
Dr. Michelle: Absolutely. Any child who has that should be evaluated pretty quickly.
Dr. Mike Patrick: Yup, not something to wait even till morning.
Dr. Michelle: Not at all. If I hear something that is similar to that over the phone, I ask them to come in right away or if they're even closer to the emergency room, that's where they got to go.
Dr. Mike Patrick: Right. And I guess, it's probably not fair to say how terrible they are and then not tell them not causes them later on. So, I guess we should mention, there is a bacterial infection over the blood called meningococcemia that is caused by a particular bacteria and that can cause meningitis. Or even worse, they can cause internal bleeding type disorder that progress incredibly rapidly in kids. So that's really the main reason we take those seriously.
And then, also, bleeding disorders like DIC. Then, I'm going to get a little too technical but think things that are bad.
Dr. Michelle: All the abbreviations.
Dr. Mike Patrick: Yes, yes. Things that are bad, I'll say that.
Dr. Michelle: Yeah.
Dr. Mike Patrick: OK. In addition to knowing what the rash looks like, what are some other important features of a rash that you have to consider when you're trying to figure out exactly what it is?
Dr. Michelle: Very important is where it is — where it is, where it started and where it's going.
Dr. Mike Patrick: Yes, very important. I guess some examples of that… What would be some good examples of that? I think, if you have a rash that's round and it's on the scalp versus on the skin and you're thinking that it's going to be ringworm — a lot of parents deal with that in their kids — but where it is on the skin kind of end up making a difference how you treat it. Whether it's on the skin or the scalp, so I guess that's one example.
Dr. Michelle: Exactly. But, you know, it's also the basic history of the rashes can help you determine what they are. Like the measles usually begins in the face and then, spreads moving in an outward pattern. And there are only a few things that will show up on the palms and soles.
Dr. Mike Patrick: Right.
Dr. Michelle: So that helps the doctor a lot in determining what it can possibly be.
Dr. Mike Patrick: And one that I like are the wrists, so you can see it. And between the fingers, like scabies oftentimes will show up there.
Dr. Michelle: Yes.
Dr. Mike Patrick: Doesn't the Rocky Mountain spotted fever oftentimes start on the wrist area, too?
Dr. Michelle: Yeah, shows up on the palms and soles a lot.
Dr. Mike Patrick: As well.
Dr. Michelle: The Rocky Mountain spotted fever.
Dr. Mike Patrick: So, OK, the location and distribution of the rash is going to be important as well as what it looks like. And then, another important thing is so the context of the rash. So, I mean, what else is going on other than just the rash? What are some examples of that?
Dr. Michelle: Obviously, the age of the child. That's always important because, you know, some sort of illnesses occur in a younger population versus a teenage population.
Dr. Mike Patrick: Right.
Dr. Michelle: And then, obviously, if there's a fever associated with it. And whether the fever occurred before or after the rash was initiated.
Dr. Mike Patrick: Right. That's very important. One of the reasons, too, that I think it's so important to figure out, so the context of the rash, is because there's so many kids who will see a doctor and yeah, maybe their eardrums look a little bit red and they get put on antibiotics. And then, the next day, they break out in a rash. And now, you have the ask why — is the rash from the underlying illness or is this an allergic reaction to the antibiotic? Because you hate to label them allergic to an antibiotic the rest of their life if it's just a virus that's causing the rash. You know what I mean?
Dr. Michelle: Absolutely. Or even if it's just mono which can cause a rash if you add amoxicillin to that.
Dr. Mike Patrick: That's right. Great.
Dr. Michelle: So you have to put the whole puzzle, not just the little pieces.
Dr. Mike Patrick: Yes, right. And as you can see folks, this is one of the things that make rashes so difficult. Because you have to take into account so may different things that's going on — where it's located, how it has progressed, what it looks like, what else is going on. So, I mean, this is something that you get with experience. So, when we say we need to come in and look at the rash and really get a good history, it's another reason why we shouldn't be offended.
Dr. Michelle: People, you should never be offended when your doctor says, "Please come. Let me help you."
Dr. Mike Patrick: Right, right. Exactly. And in terms, I guess of other things that are important, the treatments that parents have already tried. I had written that down. I think that's important because what's worked and what hasn't worked, that sort of thing.
Dr. Michelle: Absolutely. You know, a fungal rash, if you try a steroid first will actually get worse and that helps with the diagnosis.
Dr. Mike Patrick: Right. And scabies is the same way. Scabies will get worse with a hydrocortisone.
Dr. Michelle: Yeah. So that can help us piece together what's going on. In addition to the parents knowing that clearly wasn't working.
Dr. Mike Patrick: Right.
Dr. Michelle: And then, sometimes, that can get confusing, too. Because if another doctor had thought they knew what the rash was and then called something in. And then, the parents will say, "Well, we'd been trying this or that." Well, then when you look at the rash, it makes it a little more obvious why this didn't work and why this did work, that kind of thing. Something else to keep in mind.
Dr. Michelle: Right. Also, if another physician called something in, it's really important to find out if that doctor actually visualized the rash. Because it can change. So, it could have looked different when that doctor saw it.
Dr. Mike Patrick: Right. Exactly. And that's important, too, because when you hear "Oh, a doctor prescribed XY or Z," then you have in your mind, "Oh, they must have been treating this disease." But if the doctor didn't see it, they might have had in their mind that the rash look like something different, called in this medicine, and then you have a big communication issue. So, you don't really know what that other doctor was thinking.
Dr. Michelle: Yeah, it just makes it a little more difficult.
Dr. Mike Patrick: Yes. So even more reason to go in and see the doctors.
Dr. Mike Patrick: All right, so if we had to sort of categorize the most common rashes — so you take into account what they look like, the distribution, the background context of the rash, and whether they've tried treatments before — what are the big groups of types of rashes?
Dr. Michelle: Well, the big three would be contact, allergic and infectious.
Dr. Mike Patrick: Right. And, I guess, contact and allergic are sort of the same. Although, contact is more — the way that I look at it — contact is more right in the spot where something contacted the skin, sort of topical. You know, poison ivy or if you're allergic to a certain soap or shampoo or detergents that make up a lot of different things. Whereas allergic is more widespread or a site distant to whatever happened.
Dr. Michelle: Right. There's obviously some overlap there. You can get a localized reaction like poison ivy, you can get that general localized reaction. But then, if you have a big allergy to it, it can really bloom.
Dr. Mike Patrick: Yes, that's right. And then, people think that it's spreading.
Dr. Michelle: Yes. They get very worried. But I'd like to point out, we don't have poison ivy here in Hawaii.
Dr. Mike Patrick: Is that right?
Dr. Michelle: That's right. One more reason to move here.
Dr. Mike Patrick: There you go.
Dr. Mike Patrick: And the weather. I think the weather is another big reason to move there.
Dr. Michelle: Yeah. I'm originally from Ohio. So when my parents call me with the blizzards updates, I definitely rub it in.
Dr. Mike Patrick: Yeah, I bet so. And we can have a whole other discussion on island fever, too, right?
Dr. Michelle: Oh, indeed.
Dr. Mike Patrick: [Laughter]
OK, there are some disadvantages.
Dr. Michelle: [Laughter]
Dr. Mike Patrick: OK, we were getting off topic, aren't we?
Dr. Mike Patrick: So we talked about the contact stuff and the allergic type rashes. We talked about poison ivy can be allergic component to it. But this would also be talking about like bee stings and eczema, that sort of thing.
OK, and then, I guess the rest of our discussion are really going to focus on infectious types of rashes. So, maybe at some other point in the future, we'll go into the contact and the allergic type rashes a little bit more. But I think, especially heading in to the winter season, the infectious rashes are going to be the most important. So, can you talk a little bit about what kinds of infectious rashes that we see?
Dr. Michelle: Oh, sure, just like any other infection, there's pretty much three things that can cause it — a yeast, a bacteria or a virus. Those are the three things that make us sick in general.
Dr. Mike Patrick: Right.
Dr. Michelle: And examples of yeast infections are candida or even the tinea ringworm. We see that a lot in the wrestlers…
Dr. Mike Patrick: And babies… I don't mean to interrupt you.
Dr. Michelle: Oh, that's OK.
Dr. Mike Patrick: I do want to mention in babies, we see diaper rashes a lot. And this is another reason why it's helpful for us to see it. Because there's definitely a difference in appearance from just an irritated diaper rash or contact type diaper rash and a yeast diaper rash. And sometimes both are present. But in order to get the right medicine, you really have to know what's going on with the skin and a lot of times, that takes us looking at it.
Dr. Michelle: Yes. You don't want to treat a yeast with a topical steroid. That will not be helpful to anyone.
Dr. Mike Patrick: Right. Because it decreases your immune system which is all you have at that time fighting the infection and then, the yeast can kind of go wild.
OK, so we have the yeast. And then, we have bacterial type rashes. And I look at this, there are really two different kinds of bacterial type rashes that you could have. And the same, I guess, with the viruses, too. And that is, a localized infection of the skin and then an infection that really involves the whole body and the skin is just showing one sign or symptom of that overall infection.
Dr. Michelle: Right. You can get the impetigo. You see that a lot in the kids from a strep. Then, you also get the localized sort of things, like a local abscess, or even a cellulitis.
Dr. Mike Patrick: Right. And with the abscesses, are you guys in Hawaii seeing much of the MRSA, the MRSA or methicillin-resistant staph?
Dr. Michelle: Absolutely, it's been rampant here for years. I know that when I trained in Ohio, the instant you heard the words MRSA, there is essentially a shutdown of that floor of the hospital.
Dr. Mike Patrick: Right. Right.
Dr. Michelle: But we have so much community-acquired MRSA out here, and I heard you talking about that in the recent episode.
Dr. Mike Patrick: Oh, we have, yeah. I don't think… Well, maybe one or two days go by that I don't see it. But I bet every day, I see at least one MRSA abscess in a kid. And three or four years ago, I mean you maybe saw it once a month.
Dr. Michelle: Yeah, it's such a difference for me moving out here, because it's been common out here for quite some time.
Dr. Mike Patrick: Oh, I see, yeah.
Dr. Michelle: And they actually did some studies and unfortunately found it in some of the water.
Dr. Mike Patrick: So, it's Hawaii's fault.
Dr. Michelle: Yeah, you can blame them.
Dr. Mike Patrick: That it came stateside.
Dr. Michelle: I thought it was interesting. I did — and again, off topic, sorry — but I did a rotation in Alaska when I was in medical school. And up there, they have a similar strain to what we have here in Hawaii. And I thought that was kind of bizarre because they're not quite close together.
Dr. Mike Patrick: Yeah, that is interesting. Definitely. Well, yeah, that would be a whole another interesting discussion that we could have too, just in terms of the … I want to say, how common diseases are there versus here.
Dr. Michelle: It's a lot different out here.
Dr. Mike Patrick: [Laughter]
All right, well, I think that's a pretty good introduction, the rashes in general. We talked about what they look like, distribution, what's going on in the background, the characteristics, what treatments have you already tried. I think we've made the point that it's a complex thing and you have to take in into account so many different factors when trying to diagnose and treat rash.
So what we're going to do in the upcoming visits that we have together is just take each of these classic childhood exanthems or rashes and talk about them.
Again, it's sort of a historical thing that a long time ago, they were called first disease, second disease, third, fourth, fifth and sixth. So why don't you just give everybody a rundown real quick of what each number corresponds to. Then, of course, we won't go to any detail because we'll do that in the weeks to come.
Dr. Michelle: Sure. It's kind of fun to pull this out at trivia games. So pay attention.
Dr. Mike Patrick: [Laughter]
Dr. Michelle: But, first disease is actually measles, which is also known as rubeola. And second disease is scarlet fever. Third disease is rubella and the common name for rubella is German measles. Fourth disease, which is pretty controversial about whether it exists or not is Filatow-Dukes' Disease. Fifth disease, which is the only one that still goes by the name fifth disease, is also known as erythema infectiosum. And sixth disease is roseola.
Dr. Mike Patrick: Great. And roseola is one that very frequently, is a kind of a culprit with being blamed for being an antibiotic rash, especially if the doctor doesn't take a look at the rash. And let me just give you an example. Because I have even been guilty of this before myself. And that's, you have a kid who really does have an ear infection. They have a high fever, no rash. And then, you put them on the antibiotic and they get better. The fever goes away and then, they break out in a rash. And if the parent just called you and told you the story, this sounds like they're allergic to the penicillin.
But with roseola, of course, what happens is, you have fever that lasts for three or four days. And then you have the rash that last for three or our days and they don't really overlap. You have the fever phase and the rash phase. Pretty much all babies get this at some point or another. And when you see the rash, you can tell that it's more of viral rash than an allergic reaction to a drug. Because they're quite a bit different looking. But again, if you don't take the kid in and take a look at the skin, you could label them allergic pretty easily with that scenario.
Dr. Michelle: Yeah. Most of us have antibodies to those by the time we enter school and this commonly occurs in infants less than two years old. So it's really important that we get to look at it to make sure that we're not giving them an allergy to something they don't really have an allergy to.
Dr. Mike Patrick: Right, exactly.
Well, Dr. Michelle, thank you so much for stopping by. It was really fun and it's kind of nice not just hearing my own voice. It's kind of fun having someone here with me.
Dr. Michelle: Well, thanks for having me, Dr. Mike.
Dr. Mike Patrick: Oh, no, my pleasure. So we will you at some point in October and we will do a show on measles. That will be our first one, right?
Dr. Michelle: Sounds excellent.
Dr. Mike Patrick: OK. Well, thanks for stopping by and we'll see you soon.
Dr. Michelle: OK. Take care.
Dr. Mike Patrick: All right. I know I said this about yesterday's guest. When we had Dr. Pommering on, I said "Isn't he great?" And I'm going to say the same thing about Dr. Michelle. Isn't she great? It was really wonderful doing that together. And like I said, we are going to talk about measles, the two of us. So that should be fun, I think. So thanks to Dr. Michelle for stopping by.
And as always, thanks to Vlad over at Vlad Studio, V-L-A-D-S-T-U-D-I-O. Please visit him at vladstudio.com, wonderful artist, great artwork there. And thanks to him for providing the artwork for our website and for the Feed.
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So, we've done our first three daily shows. What do you think? Is this a good thing? Should we go back to once a week, with a really long show or do you like these shorter shows several times during the week. That's my question for you. So, if you get a chance this weekend, drop me an email, firstname.lastname@example.org, and let me know what's on your mind with that.
And everyone out there, please have a wonderful weekend. And stay safe and all those things, I'll see you again on Monday. And as usual, this is Dr. Mike, saying stay safe, stay healthy and hey, stay involved with your kids. So long everybody!