Non-blanching rashes are rashes which do not disappear with pressure, particularly using the ‘glass test’.
Most children with a non-blanching rash who are well will not have a serious underlying cause. In many cases, a simple viral illness (often adenovirus) is the final diagnosis. Other differentials include Henoch-Schonlein purpura (HSP), immune thrombocytopenic purpura (ITP) or mechanical causes including physical abuse.
However, for a small number of children, a non-blanching rash can indicate a more significant underlying cause such as meningococcal sepsis or haematological malignancy.
It therefore is important to assess all children with a non-blanching rash promptly to enable early diagnosis and treatment. All children with a non-blanching rash with or without fever require same-day assessment by the paediatric team in hospital unless there is a clear, accidental mechanical cause.
Non-blanching rashes occur from bleeding from small blood vessels in to the skin or mucosa. Petechiae are non-blanching pinpoint spots which are less than 3mm in diameter.
Purpura are non-blanching, greater than 3mm in diameter, and are sometimes palpable.
It is important to consider the following when taking a history of a non-blanching rash in children.
| Characteristics of rash | General symptoms |
| Location | Fever |
| Spread | Fatigue or lethargyPhotophobia or neck stiffness |
| Onset | Pallor (looking very pale) |
| Irritability (inconsolable) | |
| Associated symptoms | Other |
| Upper respiratory tract infectionCough | TraumaAbdominal pain |
| Vomiting and/or diarrhoeaPain on urinationEpistaxis/haematuria/gum bleed | Testicular painShortness of breathJoint pain/swellingSafeguarding concerns |
Please consider the following in the examination of a child with a non- blanching rash.
| General | Rash |
| Is the child well or ill?Observations including capillary refill | LocationPetechiae/purpura |
| Fever | Distribution |
| Lethargy/irritability | Shape |
| PallorEasy/widespread bruising | Spread |
| Rest of systems | |
| ENT | Abdomen |
| Respiratory: Orthopnea/ StridorCardiovascularHeadache/Irritability/drowsiness | Musculoskeletal if symptomsHepatosplenomegalyAny suggestion of mediastinal massSafeguarding concerns |
All children with a non-blanching rash and fever will require a period of observation in hospital. They may be discharged if they remain well and investigations are normal, but some will require admission to the ward overnight.
Children with a non-blanching rash depending on the distribution and spread will require blood tests to check for possible causes (Usually FBC, clotting profile, infection screen if pyrexial). They will be observed in the Paediatric Assessment Unit (PAU) to ensure the rash is not rapidly spreading.
A diagnostic work up will help to identify the cause leading to non-blanching rash and a serious medical case can be identified and treated. If the child is well, and there is a clear history of a mechanical cause, then it may be decided that observation only is sufficient. This may include petechiae in the SVC distribution (above the nipple line) where there is a history of forceful coughing or vomiting.
Children unwell with fevers and non-blanching rash will be initiated on IV antibiotics (usually ceftriaxone). They may be admitted if unwell, or may be ambulated with ongoing doses either on PAU or in the community by our community nursing team.
We would recommend a face-to-face consultation for these children in primary care, as opposed to telephone or video consultation. This enables assessment of how well or unwell they are. However, if this is not possible, it should not delay referral for paediatric assessment.
All children with a non-blanching rash will require same-day assessment by the paediatric team in hospital unless the child is well with a very clear accidental mechanical cause is identified. Please refer to the paediatric registrar or consultant on call via switchboard – you will be put through to the PAU phone daytime or registrar bleep out of hours.
If the child is clinically unwell with a rapidly spreading rash, they need to be sent in immediately by calling 999. Please follow national guidance on administration of IM benzylpenicillin in primary care prior to the arrival of the ambulance if invasive meningococcal disease is suspected, but do not allow this to delay transfer to hospital.
Here is the relevant NICE guidance for the management of suspected meningococcal disease in under 16’s
https://www.nice.org.uk/guidance/cg102
Below is the NICE guidance of assessing the risk of serious illness in under 5’s
The following can be useful information for parents regarding signs/symptoms to look out for:
https://www.meningitis.org/getmedia/f14a583a-f137-48a5-8321-d007db5ffaf5/Babywatch-Poster-Dec-2017
