Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Miliaria Rubra (Heat Rash)
“Heat rash” or “prickly heat” characterized by an erythematous papular rash, distributed in areas where sweat glands are concentrated.
I. Etiology: Heat and high humidity from external environment cause sweating that leads to swelling and plugging of the sweat gland orifice. The duct becomes distended and ruptures, leaking sweat into the skin, thereby causing the irritation.
II. Incidence
A. Infants and children are most prone.
B. Seen most often in the summer months and in obese and overdressed infants
III. Subjective data
A. Pruritus
B. Fine, red, raised rash
C. Pustules may be present in neck and axillae.
D. History of overdressing
E. History of predisposing environmental factors (e.g., hot spell in summer or house kept too warm)
IV. Objective data
A. Rash is erythematous and vesiculopapular. Lesions are pinhead size and may coalesce on an erythematous patch or remain isolated.
B. Distribution: Found in areas of sweat gland concentration and areas of friction (e.g., neck, axillae, face, shoulders, chest, antecubital and popliteal fossae, diaper area)
C. Check entire body: Intertrigo may be present as well.
V. Assessment
A. Diagnosis made by appearance and history (hot, humid environment).
B. Differential diagnosis
1. Contact dermatitis: Distribution different according to contact; edematous; erythematous; vesicular; history of contact
2. Viral exanthems: Accurate history would reveal elevated temperature and other prodromal signs or symptoms.
3. Candidiasis: Shiny, intensely inflamed, sharply defined border with satellite lesions
4. Erythema toxicum neonatorum: Develops on day 2 or 3 of life and resolves in 7–14 days.
VI. Plan
A. Treatment is symptomatic.
1. Keep environment cool and dry; use air conditioner, fan, or dehumidifier if possible.
2. Tepid to cool baths tid; may use baking soda in bath
3. Apply Caldesene powder frequently.
4. Clothing
a. Light, absorbent cotton clothing
b. Do not overdress baby.
c. Use a cotton shirt to keep body folds separated.
d. Avoid use of plastic (bibs) and synthetic fabrics.
5. Use cotton mattress pad over plastic covered mattress.
6. Calamine lotion can be used on toddlers or older children.
B. Severely inflamed miliaria: 1% hydrocortisone cream tid
VII. Education
A. Prevention is of prime importance.
B. Powder
1. Do not allow child or baby to play with powder.
2. Use powder with caution near face to avoid inhalation.
3. Shake into hand to apply. Do not shake from can directly onto infant or child.
4. Do not let powder accumulate in creases.
5. Do not use cornstarch: It encourages bacterial and fungal overgrowth.
C. Use hydrocortisone cream sparingly.
D. Use mild or hypoallergenic soap (Neutrogena or Lowila).
E. Laundry: Avoid harsh detergents, bleach, and fabric softeners.
F. Keep baby’s fingernails short.
G. If rash is on the back of the neck, advise mother not to wear irritating fabrics (wool, nylon, synthetics) when feeding baby.
H. Do not put baby to sleep in the sun, particularly in a closed carriage.
VIII. Follow-up
A. Telephone follow-up in 4 to 6 days
B. If no improvement is noted by parents, try calamine lotion 4 times a day for soothing and drying effect.
C. Return for reevaluation if above treatment measures are unsuccessful.
IX. Consultation/referral: No improvement with treatment or exacerbation of rash.