Study guide
7.2 Pediatric Dermatologic Emergencies & Rashes
BCEN CPEN Certified Pediatric Emergency Nurse Exam
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1 Chapter 1: Exam Overview, Triage Process & Initial Emergency Assessment
1.1 CPEN Exam Logistics, Blueprint & Certification Overview 1.2 Pediatric Triage Systems & Acuity Categorization 1.3 Pediatric Assessment Triangle (PAT) & Initial Impression 1.4 Primary & Secondary Pediatric Emergency Assessment 1.5 Age-Specific Vital Signs, Developmental Considerations & Pain Scales
2 Chapter 2: Pediatric Respiratory Emergencies
2.1 Upper Airway Obstruction 2.2 Lower Airway Emergencies 2.3 Respiratory Distress vs. Respiratory Failure & Airway Management
3 Chapter 3: Pediatric Cardiovascular Emergencies
3.1 Pediatric Dysrhythmias & ECG Analysis 3.2 Congenital Heart Defects 3.3 Acquired Heart Disease & Heart Failure
4 Chapter 4: Pediatric Neurological Emergencies
4.1 Pediatric Seizures, Status Epilepticus & Febrile Seizures 4.2 Altered Mental Status, Increased ICP & Head Trauma 4.3 Pediatric Central Nervous System Infections
5 Chapter 5: Pediatric Gastrointestinal & Genitourinary Emergencies
5.1 Pediatric GI Surgical Emergencies 5.2 Pediatric Dehydration, Gastroenteritis & Fluid Resuscitation Protocols 5.3 Pediatric GU & Renal Emergencies
6 Chapter 6: Pediatric Endocrine, Metabolic & Hematologic/Oncologic Emergencies
6.1 Diabetic Ketoacidosis (DKA) & Hypoglycemia in Pediatric Emergency Patients 6.2 Electrolyte Imbalances & Inborn Errors of Metabolism 6.3 Sickle Cell Disease Crisis & Pediatric Oncologic Emergencies
7 Chapter 7: Pediatric Musculoskeletal, Integumentary & ENT/Ophthalmic Emergencies
7.1 Pediatric Musculoskeletal Injuries & Fractures 7.2 Pediatric Dermatologic Emergencies & Rashes 7.3 Pediatric ENT & Ocular Emergencies
8 Chapter 8: Pediatric Trauma Emergencies
8.1 Pediatric Trauma Resuscitation & Anatomical Vulnerabilities 8.2 Head, Spinal & Thoracic Trauma in Children 8.3 Abdominal, Pelvic & Extremity Trauma in Pediatric Patients
9 Chapter 9: Child Maltreatment, Toxicology & Behavioral Emergencies
9.1 Child Abuse, Neglect, Non-Accidental Trauma & Mandatory Reporting 9.2 Pediatric Toxicology, Toxidromes & Emergency Antidotes 9.3 Pediatric Behavioral & Mental Health Crisis Management
10 Chapter 10: Pediatric Multi-System Emergencies, Shock & Thermal Injuries
10.1 Pediatric Shock Recognition & Classification 10.2 Pediatric Sepsis, Septic Shock & Multiple Organ Dysfunction Syndrome 10.3 Pediatric Anaphylaxis & Severe Allergic Reactions 10.4 Submersion Injuries, Drowning & Thermal/Burn Emergencies
11 Chapter 11: Professional Practice, Legal, Ethical & Safety Standards
11.1 Legal & Ethical Considerations 11.2 Patient Safety, Medication Error Prevention & Weight-Based Dosing 11.3 Family-Centered Care, Communication & Disaster/Surge Preparedness
7.2 Pediatric Dermatologic Emergencies & Rashes
Key Takeaways Explain This Topic AI
Meningococcemia presents with rapidly spreading non-blanching petechiae and purpura fulminans requiring immediate empiric IV antibiotics, droplet isolation, and fluid resuscitation.
Stevens-Johnson Syndrome (<10% BSA) and Toxic Epidermal Necrolysis (>30% BSA) feature mucosal involvement and epidermal sloughing (positive Nikolsky sign), requiring burn-level wound care.
Staphylococcal Scalded Skin Syndrome (SSSS) is caused by exfoliative toxins and completely spares mucous membranes, distinguishing it from SJS/TEN.
Severe angioedema with airway compromise mandates immediate intramuscular epinephrine as the primary life-saving intervention.
Last updated: July 2026
7.2 Pediatric Dermatologic Emergencies & Rashes
Pediatric dermatologic conditions range from benign viral exanthems to life-threatening dermatologic emergencies. Recognizing skin signs that indicate systemic toxicity, vascular collapse, or extensive mucosal and epidermal destruction is a core competency for the Certified Pediatric Emergency Nurse (CPEN). Rapid triage, immediate stabilization, and targeted nursing interventions are essential when caring for pediatric patients with high-risk rashes.
Life-Threatening Pediatric Rashes: Diagnostic Matrix
Emergency Condition Primary Etiology / Trigger Characteristic Cutaneous Lesions Mucosal Involvement Distinctive Clinical & Laboratory Features
Meningococcemia & Purpura Fulminans Neisseria meningitidis bacteremia & endotoxemia. Non-blanching petechiae progressing rapidly to ecchymotic purpura and tissue necrosis. Rare; cutaneous microvascular thrombosis dominates. Glass test positive (does not blanch); systemic DIC, septic shock, rapid hemodynamic collapse.
Stevens-Johnson Syndrome (SJS) Medication reaction (sulfonamides, antiepileptics) or M. pneumoniae . Erythematous macules with purpuric centers, vesiculobullous lesions covering < 10% BSA . Present (≥ 2 mucosal sites: eyes, oral cavity, genitalia). Positive Nikolsky sign; full-thickness epidermal detachment, severe systemic toxicity.
Toxic Epidermal Necrolysis (TEN) Severe drug reaction (lamotrigine, NSAIDs, allopurinol, antibiotics). Widespread painful erythema leading to sheet-like epidermal sloughing covering > 30% BSA . Present (Severe, confluent involvement of oral, ocular, GI tract). Positive Nikolsky sign; high mortality rate, massive fluid/electrolyte loss resembling severe burn.
Staphylococcal Scalded Skin Syndrome (SSSS) Staphylococcus aureus exfoliative toxins A & B. Diffuse tender erythroderma, superficial flaccid bullae, skin wrinkling and peeling. ABSENT (Spares mucous membranes completely). Positive Nikolsky sign; intraepidermal split at zona granulosum; typically affects neonates & children < 5 yrs.
Severe Urticaria & Angioedema IgE-mediated type I hypersensitivity or complement activation. Pruritic, transient, raised erythematous wheals with central pallor; deep dermal swelling. Present (Lip, tongue, uvular, and laryngeal edema). Risk of asphyxiation; stridor, dyspnea; requires immediate intramuscular epinephrine.
Meningococcemia & Purpura Fulminans
Meningococcemia is an acute, life-threatening bacteremia caused by the Gram-negative diplococcus Neisseria meningitidis . Bacterial endotoxins trigger massive inflammatory cytokine release, endothelial damage, widespread capillary leak, and severe Disseminated Intravascular Coagulation (DIC).
Clinical Progression & Assessment
Early Stage: Nonspecific flu-like symptoms, fever, irritability, cold extremities, and leg pain.
Dermatologic Progression: Starts as small, subtle, erythematous macules or petechiae on the trunk and extremities. Applying pressure with a clear glass tumbler ( the glass test ) reveals that petechiae do not blanch .
Purpura Fulminans: Within hours, petechiae coalesce into dark purple, ecchymotic, ischemic skin lesions with central cutaneous necrosis caused by microvascular thrombosis.
Emergency Nursing Priorities
Immediate Isolation: Institute Droplet Precautions immediately upon suspicion.
Aggressive Hemodynamic Resuscitation: Establish double IV/IO access; administer rapid isotonic crystalloid boluses (20 mL/kg) for septic shock.
Empiric Antimicrobial Therapy: Administer high-dose IV broad-spectrum antibiotics ( Ceftriaxone 100 mg/kg or Cefotaxime plus Vancomycin ) without delay.
Critical Rule: Diagnostic procedures such as lumbar puncture must NEVER delay the administration of parenteral antibiotics in a hemodynamically unstable child.
Stevens-Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN)
SJS and TEN represent points on a spectrum of severe, immune-mediated, life-threatening cutaneous adverse reactions characterized by extensive keratinocyte apoptosis, epidermal detachment, and mucosal erosion.
Spectrum Classification
SJS: Epidermal detachment involving less than 10% of total body surface area (BSA).
SJS/TEN Overlap: Epidermal detachment involving 10% to 30% of BSA.
TEN: Epidermal detachment involving greater than 30% of BSA.
Key Clinical Signs
Prodrome: High fever, malaise, sore throat, and cough preceding skin eruption by 1 to 3 days.
Skin Lesions: Atypical targetoid macules that coalesce into flaccid bullae.
Nikolsky Sign: Gentle lateral pressure applied to unblistered erythematous skin causes the outer layer of epidermis to slide off and detach.
Mucosal Erosion: Severe, painful hemorrhagic crusting and ulceration involving at least two mucous membrane sites (oral mucosa, conjunctiva, urethral meatus, tracheobronchial tree).
Emergency Management & Nursing Care
Admission: Direct transfer to a certified Burn Center or Pediatric Intensive Care Unit (PICU).
Fluid & Electrolyte Support: Calculate fluid requirements using modified burn formulas; monitor urine output closely (target > 1 mL/kg/hr).
Ophthalmology Consultation: Urgent, daily ophthalmologic evaluation with topical lubricants and amniotic membrane grafting to prevent corneal ulceration, symblepharon formation, and permanent blindness.
Wound Care: Meticulous non-adherent dressing application; strictly avoid adhesive tapes or aggressive skin rubbing.
Staphylococcal Scalded Skin Syndrome (SSSS)
SSSS is an exfoliative dermatosis primarily affecting neonates and young children under 5 years of age. It is caused by systemic hematogenous dissemination of exfoliative toxins A and B produced by localized Staphylococcus aureus infections (e.g., bullous impetigo, conjunctivitis, or umbilical omphalitis).
Pathophysiology & Diagnostic Differentiation
The exfoliative toxins specifically cleave desmoglein-1 , a cell adhesion protein located exclusively in the superficial zona granulosum of the epidermis.
Clinical Appearance: Starts with facial erythema and perioral crusting, rapidly spreading to a generalized tender "sunburn-like" erythroderma. The skin becomes wrinkled, forming large, clear, flaccid bullae.
Nikolsky Sign: Positive (superficial skin peels easily with light pressure).
Mucosal Sparing: SSSS completely spares mucous membranes. Unlike SJS/TEN, the lips, conjunctiva, and genitalia remain unaffected. Furthermore, because the cleavage plane is superficial, healing occurs within 7 to 14 days without scarring.
Treatment
Parenteral antistaphylococcal antibiotics ( Nafcillin , Oxacillin , or Cefazolin ; Vancomycin if community-acquired MRSA is prevalent).
Gentle skin care, barrier ointments (petroleum jelly), and effective pain control.
Severe Urticaria & Angioedema
Urticaria (hives) and angioedema represent cutaneous and subcutaneous vascular reactions. While isolated urticaria is benign, angioedema involving the upper respiratory tract is a fatal airway emergency.
Assessment
Urticaria: Raised, circumscribed, intensely pruritic, erythematous plaques with central edema that blanch with pressure and migrate across skin locations over 24 hours.
Angioedema: Non-pruritic, non-pitting, asymmetric swelling of the deep dermis and subcutaneous tissues, commonly affecting the lips, tongue, uvula, periorbital tissue, hands, and feet.
Airway Risk & Immediate Interventions
Airway Compromise Signs: Hoarseness, inspiratory stridor, tongue swelling, difficulty swallowing, or feeling of "throat tightness."
First-Line Pharmacotherapy: If airway angioedema, stridor, wheeze, or hypotension is present, treat as anaphylaxis immediately with IM epinephrine using the dosing and monitoring protocol in Section 10.3 (do not delay for antihistamines or steroids).
Secondary Agents: H1 antihistamines (Diphenhydramine, Cetirizine), H2 antihistamines (Famotidine), and IV corticosteroids (Methylprednisolone) to reduce biphasic reaction risk.
Pediatric Cellulitis vs. Cutaneous Abscess
Characteristic Cellulitis Cutaneous Abscess
Definition Acute spreading bacterial infection of the deep dermis and subcutaneous fat. Localized collection of pus within the dermis and deeper skin tissues.
Physical Exam Poorly demarcated erythema, warmth, edema, and tenderness; no fluctuance . Painful, tender, erythematous nodule with fluctuance (boggy center).
Primary Pathogens Group A Streptococcus , Staphylococcus aureus . Community-Acquired Methicillin-Resistant S. aureus (CA-MRSA).
Primary Treatment Systemic antimicrobial therapy; elevate affected extremity. Incision and Drainage (I&D) is primary; antibiotics reserved for high-risk features.
Nursing Actions Mark leading border of erythema with surgical marker; monitor for spreading. Assist with I&D, obtain wound culture, apply warm compresses post-procedure.
Communicable Childhood Diseases and MDRO Precautions
Special Considerations includes communicable diseases —classic childhood infections, multidrug-resistant organisms, and emerging pathogens—because isolation decisions begin at triage.
High-Consequence Childhood Exanthems and Respiratory Pathogens
Disease Key ED Clues Isolation Priority
Measles High fever, cough/coryza/conjunctivitis, Koplik spots, descending maculopapular rash; unimmunized contacts Airborne; notify public health
Varicella (chickenpox) Pruritic vesicles in crops at multiple stages Airborne + contact until lesions crusted
Pertussis Paroxysmal cough, post-tussive emesis, apnea in infants Droplet; treat index and consider prophylaxis for close contacts per public-health guidance
Mumps Parotitis, orchitis risk in adolescents Droplet
Ask immunization status at triage (Domain 1 intake). Ill-appearing unimmunized children with measles-compatible illness should bypass open waiting areas when feasible.
Multidrug-Resistant Organisms (MRSA, VRE) and Emerging Infections
Community-associated MRSA drives many pediatric abscesses and some invasive infections—cover empirically when local prevalence is high. VRE precautions matter for known colonized patients and device-related infections. Emerging infectious diseases (novel influenza, viral hemorrhagic concerns, unusual travel-related syndromes) require early infection-prevention consultation, travel history, and escalation of PPE before confirmation when suspicion is high.