Guideline for the management of non-blanching rash
Summary statement: How does the document
support patient care?
Staff/stakeholders involved in development:
Job titles only
The purpose of this policy is to provide evidence
based guidance for staff on the management of nonblanching rashes
Paediatric Specialist Registrars,
Consultant Paediatrician,
Paediatric Specialist Pharmacist
Paediatric Matron, Anaesthetics
Division:
Women & Child Health
Department:
Paediatrics
Responsible Person:
Chief of Service
Author:
Dr D. Bhatra
For use by:
All medical and nursing staff assessing and managing
children who present with a non-blanching rash
Purpose:
This guideline is to aid staff in the assessment and
management of children presenting with a nonblanching rash
This document supports:
Standards and legislation
NICE clinical guidance
Key related documents:
Bacterial Meningitis (NICE CG102) 2012
HSP guidelines 2012
Approved by:
Joint Paediatric Guidelines Group
Divisional Governance/Management Group
Approval date:
October 2012
Ratified by Board of Directors/ Committee of
the Board of Directors
No Applicable – Divisional ratification only required
Ratification Date:
No Applicable – Divisional ratification only required.
Expiry Date:
November 2015
Review date:
August 2015
If you require this document in another format such as Braille, large print,
audio or another language please contact the Trusts Communications Team
Reference Number:
To be added by the Library
Management of Non-Blanching Rash Guideline
Version 1
Page 1 of 6
Oct 2012
Version
date
Author
Status
1.0
Oct 2012
Dr D Bhatra
Live
Comment
2.0
3.0
4.0
Management of Non-Blanching Rash Guideline
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INDEX
1.0
2.0
3.0
Purpose
Differential Diagnosis
Algorithm
References
Management of Non-Blanching Rash Guideline
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4
4
5
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1.0
Purpose:
To guide medical and nursing staff in assessment and management of children presenting with nonblanching rash
Children commonly present with a non-blanching rash. The minority with invasive meningococcal
disease and other invasive bacterial infections (about 10%) need to be distinguished from the majority
with benign self-limiting illnesses. Recent studies 1-5 have allowed us to derive an evidenced-linked
guideline for the management of these children.
2.0
Differential Diagnosis.
The differential diagnosis of a non-blanching rash includes:
 Meningococcal disease (MCD)
 Sepsis with other bacteria (uncommon)
 Viral illnesses
 Trauma/Mechanical/NAI
 Thrombocytopenia of various causes
The following groups are distinct and usually not difficult to diagnose:
 Idiopathic thrombocytopenia (ITP)
 Henoch Schonlein purpura (HSP)
 Acute leukaemia
 Haemolytic uraemic syndrome (HUS)
They have other specific signs or symptoms:
ITP: Usually well children with multiple bruises and petechiae noted over several days
HSP: Usually a classical distribution of purpura, bruising and urticaria on the buttocks and extensor
surfaces of the limbs, sometimes associated with joint or abdominal pain
Acute leukaemias: Symptoms of slower onset associated with anaemia, lymphadenopathy or
hepatosplenomegaly
HUS: Oliguria/ anuria associated with anaemia, usually following a diarrhoeal illness
This leaves a further group of children in whom we need to distinguish MCD and other bacterial
sepsis, from self- limiting viral illness or trauma.
The following algorithm is based on observation and investigation of these children and provides a
simple guide to their assessment and management. Prior administration of penicillin does not alter
the algorithm but these children should have a senior review prior to discharge in order to
reassure parents.
Management of Non-Blanching Rash Guideline
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3.0
ALGORITHM FOR PETECHIAL RASH
Non Blanching Rash
Purpura
(lesions>2mm)
Treat as MCD
(Follow meningococcal
guideline)
ILL criteria
(Irritable, Lethargic,
toxic, Low BP
and/or Capillary
refill >2sec
No
Petechiae confined to
SVC distribution (above
nipple line)
No
Yes
Vomiting or persistent
cough which can explain
petechiae in SVC
distribution
Yes
Admit & Observe
Do FBC, CRP, Blood Culture,
Meningococcal PCR
No
If clinically well, no
spread of rash, normal
bloods then discharge,
otherwise treat as MCD
Management of Non-Blanching Rash Guideline
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If bloods normal and clinically
well during 6hr observation
then discharge otherwise treat
as MCD
Oct 2012
References
1. Mandl KD, Stack AM, Fleisher GR. Incidence of bacteraemia in infants and children with fever
and petechiae Journal of Pediatrics 1997;131:398-404
2. Brogan P, Raffles A. The management of fever and petechiae: making sense of rash decisions.
Arch Dis Child 2000;83:506-507.
3. Marzouk O, Bestwick K, Thomson AP, Sills JA, Hart CA. Variation in serum C-reactive protein
across the clinical spectrum of meningococcal disease. Acta Paediatr 1993 82:729-33.
4. Nielson HE et al. Diagnostic assessment of haemorrhagic rash and fever. Arch Dis Child 2001
85:160-165.
5. Wells LC, Smith JC, Weston V, Collier J, Rutter N. The child with a non-blanching rash: How
likely is meningococcal disease? Arch Dis Child 2001 85:218-222.
Management of Non-Blanching Rash Guideline
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Oct 2012