Visual Diagnosis in Pediatrics
1st Edition

Nonblanching Rashes
William R. Graessle
Approach to the Problem
The child who presents with a nonblanching rash requires careful evaluation. Purpuric lesions, including petechiae and ecchymoses, usually result from vascular injury or disorders of hemostasis. The underlying etiology may be trauma, a simple viral infection, or a more serious condition such as leukemia or a bleeding disorder. When a nonblanching rash is seen in association with fever, serious bacterial infection, including meningococcemia, must be considered.

Mongolian Spots 757.33 Blue-gray lesions with indistinct borders present from birth, no color or size changes with time as one would see with ecchymoses Most commonly in lumbosacral area, but upper back, shoulders, and extremities also commonly affected No reddened appearance Congenital
Ethnicities with darker skin, including Asians, Hispanics, and those of African descent
Child Physical Abuse 995.54 Ecchymoses in unusual locations or unusual patterns Anywhere on the body Retinal hemorrhages, swelling of extremities, unusual skin marks, bucket handle fractures, spiral fractures, multiple rib fractures, subdural hematomas Teens and single parents, poverty, substance abuse, domestic violence, and parents who were physically abused as children
Young and mentally retarded children are at greater risk
Henoch-Schönlein Purpura 287.0 Initially urticarial, progresses to palpable purpura Typically, buttocks and extensor surfaces of extremities, but any area of body may be involved Abdominal pain, vomiting, periarticular and joint swelling, scrotal edema
Elevated ESR and thrombocytosis
Preceding upper respiratory infection (URI) or other viral syndrome
Rocky Mountain Spotted Fever 082.0 Initially macular, gradually develops petechial, purpuric, and ecchymotic features Begins around ankles and wrists; progresses to involve the entire body, including palms and soles Fever, chills, severe headache, myalgias, and GI symptoms (nausea, vomiting and diarrhea) Tick bite
Most commonly eastern and southern United States 90% occur between April and September
Idiopathic Thrombocytopenic Purpura 287.3 Petechiae, ecchymoses, and mucosal bleeding Generalized petechiae Child otherwise well-appearing Preceding viral illness in 50% to 65% of cases
Most commonly 1–4 years of age
Purpura Fulminans 286.6 Palpable purpura, undergoes necrosis Symmetrical distribution
Often begins on dependent surfaces
III-appearing child with features of septic shock—hypotension, poor perfusion Commonly caused by meningococcemia, but may be seen with other bacterial causes of sepsis
Coining 782.7 Linear ecchymotic lesions Usually back or chest Usually performed on an individual with an acute illness Vigorous rubbing with coin or spoon after application of a medicated ointment
Cupping 782.7 Petechiae, ecchymoses, and occasionally first-degree and second-degree burns Cups placed in area of discomfort—back, abdomen Usually performed on an individual with an acute illness Cup applied to skin after igniting alcohol to create a vacuum

Figure 67-1 Mongolian spots. Blue nevi in the typical sacral area. (Courtesy of Sidney Sussman, MD.)
Figure 67-2 Mongolian spot on the hand. (Courtesy of Esther K. Chung, MD.)
Figure 67-3 Child physical abuse. Curvilinear bruising from a looped cord. (Used with permission from
Fleisher GR, Ludwig S, Baskin MN. Atlas of pediatric emergency medicine. Philadelphia: Lippincott Williams & Wilkins; 2004:425
Figure 67-4 Ecchymoses in a patient with hemophilia. (Courtesy of Sidney Sussman, MD.)
Figure 67-5 Henoch-Schönlein purpura (HSP). Note the palpable purpura on the posterior aspects of this child’s leg. (Courtesy of Steven Manders, MD.)
Figure 67-6 Rocky Mountain spotted fever (RMSF). Note the multiple petechial lesions on the forearm. (Courtesy of Steven Manders, MD.)

Figure 67-7 Rocky Mountain spotted fever. (Courtesy of Sidney Sussman, MD.)
Figure 67-8 Petechiae and ecchymoses in a patient with idiopathic thrombocytopenic purpura. (Courtesy of Sidney Sussman, MD.)
Figure 67-9 Purpura fulminans in a patient with meningococcemia. (Courtesy of Steven Manders, MD.)
Figure 67-10 Purpura fulminans. Purpura on the foot of the same patient in Figure 67.9. (Courtesy of Steven Manders, MD.)
Figure 67-11 Coining. Note the linear petechiae and ecchymoses over the back that are characteristic for this healing practice used by some Asian cultures. (Courtesy of Philip Siu, MD.)
Figure 67-12 Cupping. Note the circular bruises on the mother’s arm and the child’s back that are the result of cupping, a healing practice used by some Asian cultures. (Courtesy of Philip Siu, MD.)

Other Diagnoses to Consider
  • Leukemia
  • Aplastic anemia
  • Hemolytic-uremic syndrome
  • Systemic lupus erythematosus (SLE)
  • Liver disease
  • Coagulation disorders
  • Drug-induced thrombocytopenia
  • Wiskott-Aldrich syndrome
Suggested Readings
Darmstadt GL. Purpura. In: Long SS ed. Principles and practice of pediatric infectious diseases. 2nd ed. New York: Churchill Livingstone; 2003:437–440.
Fleisher GR, Ludwig S, Baskin MN. Atlas of pediatric emergency medicine. Philadelphia: Lippincott Williams & Wilkins; 2004:425.
Leung AKC, Chan KW. Evaluating the child with purpura. Am Fam Physician. 2001;64(3):419–28.
Mudd SS, Findlay JS. The cutaneous manifestations and common mimickers of physical child abuse. J Pediatr Health Care. 2004;18(3):123–129.
Singh-Behl D, LaRosa SP, Tomecki KJ. Tick-borne infections. Dermatol Clin. 2003;21(2):237–244.