Apple Disease: Red Rash in a 3-Year-Old Without Fever

A three-year-old female child presents with generalized erythematous patches, without fever, and mild localized pruritus?

Dear Dr.
Liang,
I apologize for taking up your valuable time.
My child experienced mild symptoms on September 26.
On the evening of September 22, she had abdominal pain and was seen by a doctor, who diagnosed it as general colic.
After taking the prescribed medication, she had a bowel movement within one or two hours.
From September 22 to the evening of September 26, she did not complain of abdominal pain.

On the morning of September 27, she woke up complaining of abdominal pain again.
I assessed it to be similar to the colic on September 22 (she tends to squat down when in pain but can walk normally after a while).
However, that day, her skin appeared as described in the subject, with redness on her cheeks, itching behind her ears, localized itching on her hands and feet, but no itching on her body.
Therefore, I thought it would be best to observe her for another day.

However, by the afternoon of September 28, there was still no improvement, so I took her back to the doctor.
The doctor examined her mouth and tongue and found no abnormalities.
The diagnosis was "Apple Disease" (her face was indeed as red as an apple, and her overall condition was good).
The symptoms included a rash followed by a fever, and the doctor advised me to monitor her condition closely.
The doctor also prescribed medication for her abdominal pain and an antipyretic for emergency use, but did not prescribe anything specifically for the rash.

After returning home, I suddenly realized I had not asked the doctor about the causative agent of "Apple Disease," so I searched online for related information but found nothing (I checked www.openfind.com.tw).
Therefore, I am reaching out to you, Dr.
Liang, for clarification.
I would greatly appreciate your response.
Sincerely,
Fuliu, Kaohsiung City

richlinx, 30~39 year old female. Ask Date: 2002/09/28

Dr. Liang Hongjian reply Pediatrics

The term "apple heat" you mentioned is not commonly found in standard textbooks, but many physicians simplify this term for better public understanding.
"Apple heat" refers to a condition where many children experience flushing of the face or body due to fever (an increase in body temperature, which may be caused by infectious or non-infectious factors) leading to peripheral vasodilation.
The flushing associated with infections is well-known, but non-infectious causes may often be overlooked by the general public.
Common non-infectious triggers include vigorous exercise, excessive wrapping of infants in blankets, overheating, or poor air circulation.
Additionally, endocrine factors and medications can also lead to flushing.
Based on your description, it may initially seem like an allergic reaction; however, upon closer examination, the issue appears to be related to abdominal pain after taking medication (on September 22), lasting about 6 to 7 days until around September 28, during which there was no mention of fever.
Generally, viral rashes last about 4 to 6 days, with a characteristic progression where the rash starts mildly and peaks around the third to fourth day before gradually fading.
Furthermore, certain medications for abdominal pain can also cause peripheral vasodilation, leading to flushing, which should also be considered as a possible explanation.

Reply Date: 2002/09/28

More Info

The symptoms you've described regarding your three-year-old daughter, particularly the red rash and mild itching, raise several considerations. The term "apple disease" or "apple heat" seems to be a colloquial expression used to describe a condition where children exhibit facial flushing or rashes, often associated with fever. However, it’s important to clarify that this term is not widely recognized in medical literature and may be used informally to help parents understand certain symptoms.

From your description, it appears that your daughter experienced abdominal pain initially, which was diagnosed as general colic. Following treatment, she had a period without significant symptoms until the onset of the rash and facial flushing. The fact that she had no fever at the time of the rash is noteworthy. Typically, rashes in children can arise from various causes, including viral infections, allergic reactions, or even non-infectious factors such as environmental triggers.

In the context of your daughter's symptoms, the rash and flushing could be attributed to several potential causes:
1. Viral Exanthems: Many viral infections in children can cause rashes. These rashes often appear after the fever has subsided. However, since your daughter did not exhibit a fever at the time of the rash, this may be less likely.

2. Allergic Reactions: Allergies to food, medications, or environmental factors can lead to rashes and localized itching. Given that your daughter was recently treated with medication for her abdominal pain, it’s possible that she could be experiencing an allergic reaction to that medication.

3. Heat Rash: If your daughter was dressed warmly or was in a hot environment, she could develop a heat rash, which is characterized by red, itchy bumps on the skin.

4. Dermatological Conditions: Conditions such as eczema or contact dermatitis could also present with similar symptoms, particularly if there was exposure to an irritant or allergen.

5. Other Infections: While less common, certain infections can cause rashes without fever, such as roseola, which typically presents with a high fever followed by a rash, but this may not apply if the fever was absent.

Given that your daughter’s condition did not improve after a day of observation, it was prudent to seek further medical evaluation. The physician's examination, which included checking her oral cavity and tongue, was appropriate to rule out other conditions. The absence of significant findings may suggest that the rash is not due to a systemic infection.

In terms of management, it is essential to monitor her symptoms closely. If the rash persists, worsens, or if new symptoms arise (such as fever, increased pain, or changes in behavior), it would be advisable to return to the physician for further evaluation. Additionally, if there are concerns about allergic reactions, discussing this with a pediatric allergist may provide insights into potential triggers and management strategies.

In conclusion, while "apple heat" may describe the appearance of your daughter’s symptoms, it is crucial to consider a broader differential diagnosis. Ongoing observation and communication with healthcare providers will be key in ensuring her health and well-being. If you have further questions or if her condition changes, do not hesitate to reach out to her healthcare provider for guidance.

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