Rashes of Childhood

Ruam pada Masa Kanak-Kanak

Anthony Christanto
Aulia dr, Sp.A
Pediatrician
Pediatric Unit Internship Tarakan Hospital
UKRIDA Faculty of Medicine, Jakarta, 2014

Rashes of Childhood
Ruam Tanda yang sering ditemui pada anak
Ruam dan Demam bersama dapat menentukan
spektrum DDx 1. Infeksi (lokal / sistemik)
2. Kelainan yang diperantarai toksin
3. Kelainan pembuluh darah

Rashes of Childhood
Ruam Perubahan pada warna dan susunan kulit
Dapat bersifat primer atau sekunder.

Ruam Primer
Perubahan warna yang

Makula

Bercak datar kecil < 1 cm

Patch

Bercak datar > 1 cm

Papula

< 1 cm

Plakat

Lesi terelevasi superficial > 1 cm

sirkumskrip, datar, tidak

teraba

Massa solid yang timbul,

dapat teraba

Nodul

Wheal (bentol)
Elevasi superfisial yang
sirkumskrip, terbentuk dari
cairan bebas dalam rongga
dalam lapisan kulit

Lesi seperti kelereng > 0.5 cm, lebih dalam

dan padat dari papul
Edema kulit setempat yang superfisial,
ireguler, timbul dan hilang dengan cepat

Vesikel

< 1 cm, terisi cairan serous

Bulla

> 1 cm, terisi cairan serous

Pustula

Terisi pus

Ruam Sekunder

Hilangnya lapisan kulit

Material pada permukaan

kulit

Erosi

Hilangnya epidermis

Ulkus

Hilangnya epidermis dan dermis

Fissura

Celah linear pada kulit

Krusta
Skuama

Residu serum, darah, atau pus yang

mongering
Lapisan tipis dari epidermis yang
mengelupas

Rashes of the Childhood

Etiology and Differential Diagnosis

Ruam Makula / Makulopapular

Etiologi

Viral

Bakteri

Differential Diagnosis
Measles

Epstein Barr Virus

HBV (Papular
akrodermatitis)

Rubella

Echovirus

HIV

Roseola

Eritema infeksiosum

Eritema marginatum (d.

rematik)

Demam tifoid

Pseudomonas

Demam skarlet

Sifilis, sekunder

Meningokokal

Erisipelas

Leptospirosis

Penyakit Lyme

Rocky mountain spotted fever

Riketsia
Tifus
Penyakit Kawasaki
Lain-lain
Rheumatoid artritis (Juvenile)

Reaksi obat

Ruam Eritroderma Difus

Etiologi

Differential Diagnosis
Demam scarlet

Bakteri

Staphylococcal scalded skin syndrome

Sindrom syok toksik (S. aureus)

Jamur

Kandidiasis

Lain-lain

Penyakit Kawasaki

Ruam Vesikel, Bula, Pustul

Etiologi

Differential Diagnosis
Varicella Zoster

Viral

Herpes simpleks
Coxsackie virus
Staphylococcal Scalded Skin Syndrome

Bakteri

Impetigo bulosa
Impetigo krustosa

Riketsia

Rickettsialpox
Sindrom Lyell

Lain-lain
Eritema Multiforme

Ruam Petekiae - Purpura

Etiologi

Viral

Differential Diagnosis
Virus-virus demam dengan
perdarahan

Enterovirus

Rubella kongenital

HIV

CMV kongenital

Measles atipikal

Sepsis ( Meningokokal, Gonokokal, Pneumokokal, H. influenza tipe B )

Bakteri

Endokarditis infektif
Ektima gangrenosum

Riketsia

Rocky mountain spotted fever

Vaskulitis
Trombositopenia

Lain-lain
Purpura Henoch Schonlein
Malaria

Eritema Nodosum
Etiologi
Viral

Differential Diagnosis
Epstein - Barr
Streptokokus Grup A

Bakteri

Mikobakteria
Cat-scratch disease

Jamur

Histoplasmosis, Koksidiomikosis
Sarkoid
Inflammatory Bowel Disease

Lain-lain
Lupus Eritematosus Sistemik
Penyakit Behcet

Rashes of Childhood
Viral Infection
Measles Rubella Roseola Erythema Infectiosum Varicella HFMD
Hemorrhagic Fever viruses Mononucleosis Gianotti Crosti
Syndrome

Viral Infection
Virus dapat menginfeksi kulit dengan cara :
1. Menyebar ke kulit selama infeksi sistemik disertai replikasi

virus pada kulit, atau dengan :

2. Memproduksi tumor kulit yang diinduksi virus.

Eksantema Erupsi kulit yang berhubungan sindrom virus akut.

Keterlibatan mukosa Enantema.
Semua virus dapat menimbulkan Eksantem.

Measles

Rubeola Morbilli Campak 9 hari Tampek

First Disease

Measles
Etiology

Morbillivirus, family of Paramyxoviridae

Predilection

Babies, Adolescence

Transmission

Droplets ( Resp. ) incubation period 10-12

days
Makulopapular konfluen menyebar secara
sentrifugal disertai demam tinggi. Ruam

Efflorescence

muncul pada hari ke 3-6 demam, berubah

menjadi coklat, mengalami deskuamasi
dalam 3-6 hari setelahnya.

Signs and
Symptoms

4C (Coryza, Conjunctivitis, Cough, Copliks

spot)

Prevention

Measles vaccine (12-15 mo) booster in 15

yrs.

Subacute Sclerosing
Panencephalitis
A little bit on

also called Dawson Disease and Measles Encephalitis

- A

rare,

chronic

progressive

encephalitis affecting children and

young adults
- Caused by a persistent infection of
measles virus
- Characterized by history of primary
measles before age 2, followed by 615 years of asymptomatic period,
and then gradual and progressive
psychoneuro-logical deterioration
- No cure, death usually occurs within
3 years.

Subacute Sclerosing Panencephalitis

Rubella

German Measles Campak 3 hari Third Disease

Rubella

Etiology

Rubellavirus, family of Togaviridae

Predilection

Babies (Esp. CRS) , Young adults

Transmission

Droplets ( Resp. ) incubation period 14-21

days
Makulopapular

diskrit

nonkonfluen

berwarna merah muda berukuran kecil,

Efflorescence

menyebar secara sentrifugal dalam 1-3

hari

disertai

makula

multipel

pada

palatum molle.
Signs and
Symptoms

Malaise, Febris tidak tinggi, Pembesaran

KGB

Prevention

Rubella vaccine (12-15 mo) booster in 12

yrs.

Erythema Infectiosum Fifth Disease Slapped Cheek

Syndrome

Erythema Infectiosum
Etiology

Erythrovirus (prev.
family of Parvoviridae

Parvovirus

Predilection

All ages esp. Child

Prepuberty, Adult

Transmission

Droplets (Resp.), Blood. Incubation period

5-15 days

of

5-15

B19)
yrs.

Ruam eritematous malar lokal pada pipi

Efflorescence

seperti bekas tamparan, juga eritema

pada tubuh dan ekstremitas, dapat gatal;
dapat berulang. Tidak terdapat enantema.

Signs and
Symptoms

Nyeri kepala, Malaise, Myalgia, Demam

berulang

Prevention

Roseola

Exanthema Subitum Roseola Infantum Baby Measles

Sixth Disease

Exanthema Subitum
Etiology

Human Herpes Virus type 6 and 7

Predilection

Babies (6 mo. 2 yr.)

Transmission

Unknown ; Probably saliva

Makulopapular diskrit pada tubuh dan
leher mendadak timbul setelah demam

Efflorescence

menghilang (1-2 hari) pada hari ketiga

disertai makula multipel pada palatum
molle.

Defervesen

terjadi

secara

mendadak dan cepat.

Signs and
Symptoms

Malaise, Anak rewel, demam tinggi 3-4

hari, pembesaran KGB

Prevention

Varicella

Chickenpox Cacar air

Varicella

Etiology

Varicella Zoster
Herpesviridae

Virus,

family

of

Predilection

Child of 1-14 yrs.

Transmission

Droplets (Resp.) Incubation period 12-21

days. Highly contagious
Ruam multiforme berupa papula pruritik,

Efflorescence

vesikel,

krusta;

menyebar

secara

sentripetal, berlangsung selama 7-10

hari.

Signs and
Symptoms

Demam, Malaise, Myalgia

Prevention

Varicella vaccine (>12 mo.)

immunity if given < 13 yrs.

Lifelong

Secondary bacterial infection, Cerebellar

HFMD

Hand, Foot, and Mouth Disease

Hand, Foot, and Mouth Disease

Etiology

Enteroviruses of Picornaviridae family;

mainly Coxsackie virus and Enterovirus
71

Predilection

Babies and Childs < 10 yrs. of age

Transmission

Faecal Oral, Incubation period 4-6 days

Vesikel pada tangan, kaki dan mulut, lesi
lain

Efflorescence

tidak

spesifik;

biasa

nonkonfluen,

makular atau papular. Jarang ptekue atau

urtikaria.

Dapat

disertai

enantema.

Berlangsung 3-7 hari. Ruam dapat timbul

dengan demam atau setelah defervesen.
Signs and
Symptoms

Anak rewel, Demam, Nyeri tenggorokan,

Myalgia, Sakit kepala

Mononucleosis

Mono Glandular Fever Pfeiffers

disease

Mononucleosis Infectiosa
Etiology

Epstein Barr Virus, family of

Herpesviridae (90%)
10% - Adenovirus, Cytomegalovirus,
and Toxoplasma gondii

Predilection

Adolescence and young adults

Transmission

Oral, by saliva (direct); blood. Incubation

period 28-49 days.
Ruam makulopapular (morbiliformis) pada

Efflorescence

tubuh dan ekstremitas, 15-50% adalah

drug-induced (terutama ampisilin). Selflimiting.

Signs and
Symptoms

Demam dan adenopati, Edema palpebral,

Nyeri tenggorok, Hepatosplenomegali,
Malaise.

Gianotti-Crosti Syndrome

Papular Acrodermatitis

of Childhood

Papular Acrodermatitis of Childhood

Etiology

Hepatitis B Virus and Epstein-Barr

Virus (Most Frequent)

Predilection

Infants (as low as 1.5 mo. old) and young

children

Transmission

Varies depends on viral agent

Papula, papulovesikel diskrit atau konfluen

Efflorescence

pada

wajah

dan

distal

keempat

ekstremitas. Self limiting.

Signs and
Symptoms

Varies depends on viral agent

Prevention

If agent is HBV, Vaccines are available as

regular HBV Vaccine

Complication

Varies depends on viral agent

Viral Hemorrhagic Fever

Viral Hemorrhagic Fever
Etiology

Dengue virus (in Indonesia) family of

Flaviviridae

Predilection

All ages

Transmission

Arthropod-borne,
genus Aedes

Efflorescence

Dengue fever : Ruam mirip morbilli,

muncul dengan demam
Dengue Hemorrhagic Fever : Ruam
ptekie
dan
purpura
terutama
di
ekstremitas.

Signs and
Symptoms

Classic triad of Dengue fever: Rash,

Headache, Fever
Haemoconcentration
and
Thrombocytopenia in DHF

especially

mosquito,

No vaccine currently available; Current

Rashes of Childhood
Bacterial Infection
Scarlet Fever SSSS Meningococcemia

Bacterial Infection
Ekspresi klinis infeksi bakteri yang memiliki manifestasi
kulit sangat bervariasi.
Contoh : Infeksi Staphylococcus pada bayi akan mengakibatkan
ruam, sedangkan pada dewasa muda tidak mengakibatkan ruam.
Meski

jumlah

kasus

ruam

akibat

bakteri

tidak

sebanyak

eksantema viral, infeksi bakteri memegang peranan penting

mengingat kemungkinan derajat beratnya penyakit tersebut.

Scarlet Fever

Scarlatina

Scarlet Fever
Etiology

Streptococcus Group A (S.pyogenes)

Predilection

Children, most common age 4-8 yrs. old

Transmission

Skin
contact,
respiratory
Incubation period 1-4 days

Efflorescence

Eritema difus yang kasar pada perabaan,

menghilang pada penekanan; Circumoral
pallor; Muncul 12-72 jam setelah demam,
biasa bermula di dada dan ketiak dan di
belakang
telinga.
Dapat
muncul
di
selangkangan.
Lebih buruk di daerah
lipatan (Pastia Line). Deskuamasi pada
hari ke 3-4.

Signs and
Symptoms

Strawberry Tongue, Forchheimer spots

(ptekiae di palatum molle), Demam akut,
Nyeri tenggorokan

droplets.

Staphylococcal Scalded Skin Syndrome

Pemphigus Neonatorum Von Ritters Disease
Staphylococcal Scalded Skin Syndrome

Etiology

Staphylococcus aureus

Predilection

Children under 6 years, Neonates

Transmission

Skin contact
Eritroderma dengan onset akut yang nyeri
disertai bulla flaksid difus; mudah ruptur

Efflorescence

dan mengelupas (Nikolsky sign) nyata di

sekitar

mulut

dan

hidung.

Tidak

ada

mukosa yang terkena.

Signs and
Symptoms

Demam akut, Toksik, Konjungtivitis, Coryza

Complication

Sepsis, Shock

Meningococcemia
Meningococcal Disease
Etiology

Neisseria
meningitidis
Meningococcus

a.k.a

Predilection

All ages, especially < 5 years of age

Transmission

Skin contact, saliva. Incubation period 5-15

days

Efflorescence

Fase awal: papul diskrit, non konfluen,

eritematous; ptekie dan purpura setelahnya
disertai ekimosis. Lesi khas berupa ruam
star-shaped. Dapat meninggalkan bercak
titik berwarna merah atau kecoklatan.

Signs and
Symptoms

Terbanyak adalah meningitis disertai sepsis

dan DIC yang berat.

Complication

DIC, Sepsis shock, Carditis, Gangrene

Rashes of Childhood
Vascular Disease
Henoch-Schnlein Purpura Kawasaki Disease

Henoch Schnlein Purpura

Henoch Schnlein Purpura
Etiology

Autoimmune systemic vasculitis

post infection

Predilection

50% under age 6, 90% under age

10

Efflorescenc
e

Purpura terutama di pantat dan

kaki; dapat juga terjadi di tangan,
tubuh dan wajah. Penampakan
Raindrops on Glass

Signs and
Symptoms

Purpura, Arthritis, Abdominal Pain

Triad

Complication

Gastrointestinal
hemorrhage,
Kidney Failure, Nephrotic Syndrome

Purpura Rheumatica

Kawasaki Disease

Lymph Node Syndrome

Kawasaki Disease
Etiology

Autoimmune
systemic
vasculitis
affecting
medium-sized blood vessels

Predilection

Children under age < 5 years

Efflorescence

Ruam makulopapular eritematous yang

difus, terletak di tubuh dan menyebar
ke wajah, ekstremitas, dan perineum.
Dapat
berubah
menjadi
ruam
skarlatinaformis,
urtikariaformis,
multiformis, dan purpura. Tidak pernah
bulous atau vesikular. Ruam khas
adalah eritema di telapak tangan
dan kaki, disertai edema yang
nyeri.

Signs and
Symptoms

Multiple organ manifestations, some

specific include strawberry tongue

Other Rashes of Childhood

Urticaria and Erythema Nodosum

Urticaria Hives Biduran Giduan Kaligata

Urticaria

Etiolog
y

Efflores
-cence

Drug Induced

Aspirin,
Ibuprofen,
Penicillin,
Sulfonamide,
Anti
convulsants,
Antidiabetic

Infection/
Environmental

Parasitic (Ascaris, Fasciola), Various

viral
and
bacterial
infections,
Various ivy and grasses

Hypersensitivity

Heat urticaria, Water urticaria, Cold

urticaria, Exercise urticaria, Food
urticaria (Kerang, Kacang, Telur,
Gandum, Soya)

Penonjolan berwarna merah pucat, gatal,

dapat menimbulkan sensasi terbakar atau
menyengat.

Erythema Nodosum
Erythema Nodosum
Etiology

Inflammation of fat cells under the skin

Predilectio
n

Very common in age 12-20 years

Nodul berwarna merah yang hangat dan

nyeri; biasa terjadi di betis bagian depan.
Dapat terjadi dimanapun di seluruh tubuh.
Efflorescen
Seiring waktu berjalan, warna lesi berubah
ce
menjadi biru, coklat, kuning, dan kemudian
hijau. Nodul biasanya menghilang dalam 26 minggu tanpa bekas.

Causes

50% idiopathic
Infection : Streptococcal (most in children),
TB primary infection
Autoimmune : IBD, Behcets disease,
Sarcoidosis
Pregnancy

Specific Rashes
Ada beberapa eksantema dan enantema yang
dapat memberi petunjuk penting karena merupakan
ruam patognomonik.
Adanya ruam tersebut menegaskan diagnosis penyakit
tersebut

Specific Rashes of Childhood

Ecthyma
Gangrenosum

Pseudomonas
aeruginosa Infection

Erythema
Chronicum
Migrans

Lyme Disease

Aspergilosis,
Necrotic Eschar
Mucormycosis

Specific Rashes of Childhood

Erysipelas
Rashes

Group A
Streptococcus
Erysipelas

Kopliks Spots

Measles

Erythema
Marginatum

Rheumatic Fever

Appendix

Rashes of Neonates

Rashes of Neonates
Bagaimana dengan ruam pada masa neonatus?
Ruam pada neonatus memiliki spektrum diagnosis yang sempit,
diantaranya ada sedikit kelainan yang merupakan kelainan
fisiologik atau kongenital yang tidak memiliki makna klinis,
sehingga penting bagi klinisi untuk membedakan mana ruam yang
penting

secara

klinis

penanganan klinis.

dan

mana

yang

tidak

membutuhkan

An infant of 2-days old being

observed in TARAKAN Hospital
Perinatology unit presents with
erythematous,

maculo-papular

rash all over the trunk.

The

baby

associated

does

not

have

any

symptoms

prior

the

beginning of the rash.

What kind of rash is it? And is it
dangerous?
therapy?

Should

we

start

Erythema Toxicum, Toxic Erythema of Newborn or

Its called
Urticaria Neonatorum

Erythema Toxicum
Etiology

Unknown,
Several
theory
includes
activation
of
immune
system,
or
hypersensitivity to detergents and bed
sheets.

Predilection

Very common (up to 50%) in newborns 2-5

days after birth.

Patch eritematous pada kulit disertai papula

multipel yang berkumpul, jarang disertai
Efflorescenc
pustula. Ruam ini bersifat benigna, tidak
e
menimbulkan
ketidaknyamanan
pada
neonatus.
Differentials

Consider Herpes Simplex, Impetigo, Sepsis,

and Varicella.

Treatment

None. The rash will

approximately 2 weeks

resolve

itself

in

A newborn being observed in

TARAKAN

hospital

Perinatology

unit

presents

with multiple bluish macules in

left leg and buttock.
The

baby

Caesarian

is
section

delivered

via

without

any

complications whatso-ever.
The father asked you what kind of
rash is it and whether it will
resolve spontaneous-ly. What is
your answer?

Its called

Mongolian Spot, or Common Birthmark

Mongolian Blue Spot

Etiology

Congenital

Predilection

90-95% in East Asian, 80-85% in African.

Ruam diskolorasi berwarna mulai dari

Efflorescence biru pucat, biru, coklat, atau gelap.
Biasa terdapat di punggung bawah.
Differentials

Consider Bruising.

Treatment

None. The rash will resolve itself in age

5-6 (mostly) and puberty (nearly all).
However, some adults may still have a
visible rash.

A picture of a similar bluish rash in the volar

part in the hand of a 1-day old infant in
TARAKAN perinatology unit. It is due to trauma of
applications of injection needle.
Bruising rashes are very similar to Mongolian
spots,

especially

if

it

is

located

in

common

predilections as Mongolian spots (buttocks and legs).

These rashes should be differentiated carefully, as
misdiagnosis

towards

bruising

unneeded concerns about abuse.

could

raise

Other common rash in neonates is

Haemangioma)

Strawberry Nevus (Capillary

Strawberry Haemangioma
Etiology

Congenital Vascular Anomaly

Predilection

10% of all births mostly in Caucasian

populations. LBWI has a 26% chance to
develop haemangiomas

Penonjolan berupa daging yang lunak,

berwarna
merah,
dapat
terjadi
Efflorescence
dimanapun di seluruh area tubuh, meski
83% terdapat di kepala atau leher.

Treatment

None. Strawberry naevus is rapid

growing, some gone by age 2 years, 60%
by 5 years, and 90-95% by 9 years.
However, if the haemangioma is in the
way of vision or blocking the nostrils,
surgery intervention may be needed

Terima Kasih