Article Text

Download PDFPDF
Fifteen-minute consultation: the child with a non-blanching rash
  1. Thomas Waterfield1,
  2. Emma M Dyer2,
  3. Mark D Lyttle3,4
  1. 1 Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
  2. 2 Paediatric Department, Royal Free London NHS Foundation Trust, London, UK
  3. 3 Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
  4. 4 Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
  1. Correspondence to Dr Thomas Waterfield; thomas.waterfield{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Case scenario

It’s 2am and you are called to review a ‘well-looking child’ in the emergency department who has presented with a new non-blanching rash. He has been hot at home with some coryzal symptoms. Mum is worried, she thinks the rash has spread in the last hour!

What are you going to do?

In this article, we discuss the aetiology and initial assessment of non-blanching rashes in children.


Non-blanching rash (NBR) is a term for any rash in which the colour is unchanged with direct pressure. The presence of a NBR is of concern to both parents and clinicians as it is associated with a wide range of underlying diagnoses, some of which are life threatening. The term is usually used to refer to the presence of petechiae/purpura (figure 1), and in this form it is a relatively common presentation to the emergency department (ED), accounting for around 2% of all attendances.1 2

Figure 1

Petechiae and purpura typical of invasive meningococcal disease. Petechiae are non-blanching spots that are <2 mm in size and are due to capillary haemorrhage. As more haemorrhages occurs the petechiae coalesce into purpura (>2 mm).  Images used with permission of the Meningitis Research Foundation.

In this article, we discuss the aetiology and an initial assessment of NBR in children.


The most common causes of NBR in children can be broadly classified as infective or mechanical. Other causes are less common and are classified as vasculitic, haematological and ‘other’1–6 (table 1).

Infectious causes

Any serious bacterial infection (SBI) can result in a NBR via disseminated intravascular coagulation (DIC). Some infections, however, feature a NBR as an early sign. The most common infections associated with a NBR as an earlier sign are as follows.

  • Viral:

    • Enterovirus and adenovirus are the most common infectious causes of NBR in children.3

  • Bacterial

    • Streptococcal infections1–4

    • Meningococcal disease (MD).6

Of …

View Full Text


  • Contributors TW conceived the idea and wrote the majority of the article. ED contributed to sections on haematological causes, vasculitic causes and mechanical causes. ML provided a comprehensive review of the article and expert analysis. All authors agreed the final version.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.