Dr. Bob: I am very worried about periodic rashes in my 2-year-old daughter. They seem to be very itchy and tend to get very irritated. The skin seems to be thicker in certain areas. Should I be worried? What could be causing the rash?
Answer: Let me preface my remarks by saying that I would never presume to make a diagnosis or suggest treatment without a seeing a patient. Too many erroneous decisions have been made without an adequate history and physical examination. I cannot emphasize that enough.
Remember that the skin is the largest organ in the body. As an organ in the body, it might react to changes in other organs. For example, liver problems might be expressed as a yellowish tint to the skin or kidney problems with a unique change in the skin color. Bone marrow problems might lead to a very pale appearance or pinpoint bruises. I say this to remind you that a quick view of the skin will not always provide the underlying answer. Decades of experience has taught me that very rarely is the interpretation of a rash a simple matter and always needs to be considered in the context of other factors.
To answer your question, we should consider some other causes that can cause rashes –
- Infections – the most common rash due to an infection would be due to a virus. Rashes due to viruses usually have very characteristic findings yet mild infections can present in uncharacteristic ways. Some viral rashes can be quite serious in infants. Bacteria can also cause skin rashes and usually need more immediate attention. Infections of the skin due to bacteria can sometimes be treated with topical antibiotics and sometimes need oral antibiotics. We have learned over the years to avoid overuse of antibiotics so that is why a proper history and physical examination are necessary.
- Allergies – allergies to specific things that contact the skin (like soaps, chemicals, poison ivy), or to specific things that are breathed in (like pollutants), or to specific things that are ingested (like foods, medicines) can present in so many ways. They might be discrete patches or splotchy areas that people often refer to as hives. The time frame of the rash and other symptoms that might be present (flushing, headache, itching) can often help to determine the diagnosis and treatment.
- Other systemic diseases – lupus, psoriasis and even cancers can present as a change in the skin.
The rash that you describe sounds very typical of eczema, a very common rash in children and even adults. I remember in my training that my mentors would talk about rashes that itch. They referred to eczema as the itch that rashes – that is, it very often starts as an intense itching that develops into a rash as the irritation of itching continues. Areas of concentration tend to be in the skin fold areas – elbow crease, knee crease, and neck. Thickening of the skin can be a prominent sign. Eczema tends to have an allergic basis and is more common in children and families with other allergic diseases, like asthma or hay fever.
I have seen over the course of my career hundreds (maybe more) of children with eczema. I have seen mostly mild cases but have seen cases of children that need to be hospitalized due to the severity of the rash and its side effects. It is not always easy to treat but there are potentially multiple treatments available.
The take home message here – please seek the advice of your doctor. Rashes need interpretation by professionals.
Dr. Saul is Professor of Pediatrics (Emeritus) at Prisma Health and his website is www.mychildrenschildren.com. Contact Dr. Bob at askdrbobsaul@gmail.com with more questions.