b. Candida nappy rash. Bright red, well-demarcated rash. The rash occurs in skin folds and there may be satellite lesions. Look for oral thrush. Treatment: topical antifungal creams.

c. Seborrhoeic nappy rash. Yellow, scaly, greasy lesions. May also have cradle cap. Treatment: mild topical steroids or combined steroid antifungal/antibacterial cream if secondary infection suspected. (Treat cradle cap with olive oil/combing or antiseborrhoeic shampoo.)

Common birthmarks These include Mongolian blue spots (benign; more common in black children; occur in the sacral area; resolve spontaneously; do not confuse with bruises), haemangiomas and port-wine stains (Figures 17d,e).

d. Strawberry naevus (haemangioma) appears at 1–3 months increasing in size. 70% resolve by 7 years. Consider referral if the lesion is near the eyes, resulting in obstructed vision, which can lead to amblyopia. If the lesion is situated near other orifices (e.g. anus or lips) it may lead to problems.

e. Port-wine stain. Present from birth (due to dilated dermal capillaries). Be alert to the association with Sturge–Weber syndrome if the lesion is in the distribution of the ophthalmic division of the trigeminal nerve with an underlying meningeal haemangioma and possible subsequent CNS problems like epilepsy/learning difficulties. All should be referred for laser treatment and to exclude underlying abnormalities.

Exanthems

Exanthems are mostly caused by a viral infection (occasionally by drugs or toxins). With immunisations the incidence has markedly decreased. The rashes are typically macular or maculo-papular, associated with a prodromal phase and fever.

Roseola infantum. Sixth disease (herpes virus 6). Incubation 5–15 days. Occurs in children <2 years old. High fever in well child. Macular rash over the trunk. Associated rhinitis, fever and malaise.

Kawasaki disease. From 6 months to 5 years. It is a systemic vasculitis. Fever > than 5 days. Clinical signs: bilateral conjunctivitis, strawberry tongue, morbilliform rash, dry and fissured lips, red hands and feet becoming swollen followed by desquamation. The disease carries significant morbidity with complications of coronary artery aneurysms.

f. Measles. Incubation period 10–14 days (paramyxovirus). Rash begins behind the ears spreading down the trunk. Discrete papulo-macular rash becoming blotchy. Followed by desquamation. Koplick spots on the buccal mucosa. Associated symptoms: fever, cough, coryza and conjunctivitis. Rare serious complications include chest infection, encephalitis.

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