The patient
This well-behaved 11-year-old girl came to see me late on Tuesday surgery. These irregularly shaped, ovoid, discrete, slightly red patches had come up almost overnight. Her mother had first noticed them on the child's back but when I examined her, I uncovered more on the postero-lateral aspect of her right thigh. She hadn't even noticed these herself. I also pointed out a similar small lesion on her left temple. Interestingly, they weren't itchy at all.
She felt well but had a sore throat. Her oropharynx was inflamed on examination but her temperature normal.
First instinct
I was stumped. I asked the senior partner for some assistance and thought through some differentials with the mother while we waited for him to come in.
Differential diagnoses
• Ringworm
• Discoid eczema
• Urticaria
• Viral exanthema
Some of the lesions looked like ringworm. But I had never seen ringworm in so many different areas, and I had certainly not seen it come up over such a short period of time. But I must admit I was tempted to use an antifungal-steroid combination cream.
Discoid eczema was a possibility but these lesions weren't itchy at all. And why would eczema come up overnight?
If we didn't have a history, urticaria would be spot on for the appearances.
Like all GPs I have seen dozens of viral rashes in children, but usually these are maculo-papular, diffuse rashes on the abdomen after a clearly documented viral illness, with a pyrexia.
Getting on the right track
The senior partner, who has been in general practice as long as I have been alive, was none the wiser. He suggested treating the lesions as urticaria, with an antihistamine syrup. But something didn't add up. I'm not aware of any urticarial rash that isn't itchy. So I stuck to my instinct and suggested my favourite management plan: do nothing.
I saw the girl and her mother on the Friday and all the lesions had completely resolved. Her throat was no longer red either. In retrospect we were dealing with an unusual viral exanthem.
This case illustrates nicely the importance of following up patients, even as a locum, and of not using drugs unless you know what you're treating.
Dr Oliver Starr is a sessional GP in Hertfordshire
Lesions on girl's back Lesions on girl's back
