Strep infections can cause a variety of rashes

It was about 1 o’clock in the afternoon and I got an email from a parent with a photo attached. Her 5-year-old daughter had a rash on her foot. It looked like a little blister on her toe with some redness and swelling around it and a reddish streak leading up her leg. She didn’t mention any other symptoms in the email, but I suspected the toe might be infected and encouraged them to come in.

She arrived about 3:45 and by then had a fever over 102 and was just starting to have a rash around her neck and upper chest that was mildly red, nearly confluent and slightly rough. Her toe was more swollen and somewhat more red. She looked like she was feeling pretty lousy but her blood pressure was ok. Her throat looked fine but a strep test on her throat was done anyway since her rash and fever were consistent with scarlet fever. The rapid test was negative. Her foot rash with the blister, though, and the growing rash in other areas was consistent with a strep infection on her foot called erysipelas in which a toxin from the strep infection enters the blood stream causing a more generalized rash. She was treated with antibiotics and her fever and sick look improved quickly.

Another patient arrived this week with a sandpaper-like rash on her chest, under her armpits, and in her groin. She had no fever and wasn’t complaining of sore throat. The rash was progressing quickly and she seemed much less active than usual, complaining of some body aches. Her throat looked very mildly red and her rapid strep test was positive. She had a variation on scarlet fever in which a strep bacteria infects the throat and liberates a toxin that causes a rough rash. Usually scarlet fever is accompanied by fever (no surprise) but not always. She was started on antibiotics and she perked up and the aches and pain improved but the rash continued to progress. Once the toxin is in the blood stream it has a life of its own and even though the bacteria can be easily killed, the toxin has to burn itself out.

A third patient came in this week complaining of an itchy butt. He was having pain when he pooped and felt that his anal area was always “wet.” He had no fever or any other symptoms, but when I looked at his anus the skin around it was intensely red and weepy. A rapid strep test from the area was positive and he had perianal strep. When the skin in any area gets irritated the strep bacteria on our skin normally can multiply and cause infection. Perianal strep is particularly common in kids who are just learning to wipe themselves and don’t always do a great job, leading to irritation in the area.

The last example for the “week of strep” I had was a girl who had a cold for about two weeks and came with with a wet cough and crusty nose with little pimples around her nose and mouth. She didn’t have fever and didn’t seem particularly sick but her nose was red, tender and crusty right at the opening to the nostril and with the crusty “pimples” around it, she had impetigo. When the nose gets irritated from the snot and rubbing and picking inevitable with the cold, the skin at the edge of the nostril gets irritated and strep (or staph) can start to grow there. When the infection takes hold, the skin is quite tender and red often with a honey-colored crust to it. The pimples around the nose are little satellite infections from the nostril. This sort of strep can often be treated topically with an antibiotic ointment but sometimes requires an oral antibiotic.

Keeping an eye out for a variety of rashes caused by strep can ensure prompt and proper treatment.