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Non-blanching rash in a child

A quick visual on the common causes of a non-blanching rash ( NBR ) in childhood. NBR is any rash in which the colour does not change with direct pressure.

A NBR can be petechiae or purpura or both. It happens due to extravasation of blood from the vasculature into the skin or mucus membranes. It does not fade with pressure. It can happen due to-physical trauma to capillaries , inflammatory injury to capillary wall , low circulating levels of platelets

Causes can be

Infective-Viral – several viral infections as
◘ Enterovirus
◘ Parvovirus B19
◘ Dengue
◘ Cytomegalovirus ( CMV )
◘ Respiratory synctical virus ( RSV )
◘ Epstein-Barr virus ( EBV )
◘ Rotavirus
◘ Adenovirus
◘ Influenza rhinovirus
◘ Meningococcal
◘ Scarlet fever
◘ Infective endocarditis

Trauma – Accidental injury NAI e.g child abuse Increased pressure following bouts of coughing , vomiting or straining Seat belt compression in RTAs

Haematological and malignancy – Leukaemia Platelet disorders e.g 
Idiopathic thrombocytopenic purpura Fanconi anaemia Disseminated intravascular coagulation ( DIC ) Haemoltyic uraemic syndrome ( HUS ) Splenomegaly Neuroblastoma Neonatal alloimmune thrombocytopenia ( NAIT )

Vasculitic and Inflammatory- HSP and SLE

Others –Ehler Danlos Drug reactions Vitamin K deficiency


Idiopathic immune thrombocytopenic purpura Autoantibody mediated destruction of platelets leading to isolated thrombocytopenia Commonest reason for thrombocytopenia in childhood ( age 2-10 yrs )
level at which petechiae appear are usually in range of 10-20 A h/o viral URTI or vaccination is common Child is otherwise well – but may present with sudden onset of bruises , purpura , mucosal haemorrhage and petechiae Runs a benign self limiting course but platelet count 
platelet count recovers in 6-12 wks

Acute Leukaemia –ALL ( acute lymphatic leukaemia ) most common malignancy seen in children Presentation depends on
○ how bad are the blood counts – marrow infiltration leading to for e.g pancytopenia
○ extramedullary and organ inflitration ( hepatosplenomegaly , lymphadenopathy , bony pains )
○ systemic symptoms due to cytokine release Based on above
○ may not be acutely unwell
○ may have widespread petechial haemorrhage or ecchymoses on limbs and trunks
○ lethargy, pallor , fever
○ bony pain or limp
○ recurrent infection , sepsis
○ lymphadenopathy and hepatosplenomegaly Prognosis has improved dramatically now and almost 85 % of childhood leukaemias can be now cured

henoch-Schonlen purpura –Acute vasculitis of unknown cause Commonest childhood vasculitic disease- in children aged 3-10 yrs Characterized by

○ cutaneous palpable purpura ( not thrombocytopenic )
 symmetric distribution
 dependent parts , extensors of both legs , buttocks , around ankles
 painful s/c oedema
○ arthralgia / arthritis
○ gastrointestinal involvement
 abdominal pain , vomiting , intussception
○ renal involvement which can include
 microscopic haematuria , proteinuria , nephrotic syndrome , nephritis , hypertension and renal impairment
 Seasonal variations – most cases in autumn and winter A preceding h/o URTI is common Rash may be be urticarial at onset which becomes maculopapular with petechiae and purpura
 Diagnosis is clinical – no biomarker Management is supportive – runs a self limiting course BP and urine dipstick in 1° care to monitor for renal damage in uncomplicated cases

Image from Public health image Library ( PHIL ) content provider CDC / Mr.Gust

 This image depicts an anterior view of the lower legs of an 8-year-old patient, who presented with numerous erythematous lesions, which had been identified as anaphylactoid purpura, also known as Henoch–Schönlein purpura (HSP). The precise cause for this reaction is unknown, but HSP involves an inflammatory process of small blood vessels, including the deposition of immune complexes, specifically antibody IgA. This reaction is self-limited, resolving itself within a few weeks. However, statistics show that there can be a secondary onset in one-third of cases, with 1% of cases including permanent kidney damage.


  1. Fifteen-minute consultation: the child with a non-blanching rash Waterfield T, et al. Arch dis Child Educ Pract Ed 2018 ;103:236-240
  2. Petechial rash in children: a clinical dilemma: Why emergency nurses must be aware if the differential diagnoses associated with petechial rash before initiating treatment for invasive meningococcal disease Article in Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association May 2016
  3. The child with a non-blanching rash Jothsana Srinivisan Paediatrics and Child Health , Volume 29 , Issue 2, 80-84
  4. Evaluating the child with Purpura Alexander K C Leung , MBBS AFP August 1, 2001 / Volume 64, Number 3
  5. Purpuric and petechial rashes in adults and children : initial assessment BMJ 2016 ;352 :i285
  6. McGrath A, Barrett MJ . Petechiae . ( Updated 2019 Jun 8 ). in : StatPearls ( Internet ). Treasure Island ( FL) : StatPearls Publishing; 2019 Jan-. available from : https ://


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