How to spot Henoch-Schönlein purpura in children and act on it
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How to spot Henoch-Schönlein purpura in children and act on it

Pavan Amara Nurse, midwife and health journalist

Advice for nurses on how to identify this disease affecting a child’s small blood vessels, and also rule out other possibilities such as sepsis and meningitis

Henoch-Schönlein purpura (HSP) is a disease that mainly affects children’s small blood vessels. A raised rash on the lower limbs is the main symptom. It tends to be a mild and self-limiting condition, but can result in serious complications, including kidney failure and bowel blockage.

Emergency Nurse. 31, 3, 6-7. doi: 10.7748/en.31.3.6.s2

Published: 02 May 2023

The rash, or purpura, is non-blanching and non-pruritic. It is distinctive due to its red and purple colours, and small spots called petechiae. It occurs when the capillaries within the skin become inflamed. Similarly, abdominal pain and joint swelling can also be symptoms, as blood vessels in other parts of the body can become inflamed.

In around half of cases the small blood vessels of the kidney are affected, causing blood or protein to leak into the urine and sometimes resulting in reduced urine output.

An HSP rash is similar to those associated with meningitis, sepsis, immune thrombocytopenic purpura, or thrombotic thrombocytopenic purpura.

Advanced nurse practitioner Nicholas Wetherill, says: ‘You can’t differentiate easily between the rashes, it’s the symptoms that allow you to differentiate between the conditions.

‘Children with HSP will be generally well and not have a high temperature, vomiting, headaches or low platelets.’

Assessment tips for nurses

  • 1. Quick assessment is crucial: rule out time-critical emergencies such as meningitis and sepsis, then consider Henoch-Schönlein purpura (HSP)

  • 2. Look at the bloods: blood results can rule out other conditions. For example, immune thrombocytopenic purpura (ITP) and HSP both present with a rash and can be otherwise asymptomatic, but a low platelet count indicates ITP

  • 3. Be familiar with different skin types: the rash can be harder to see on black and brown skin, but you can palpate, and ask parents what is normal for their child

  • 4. Work with other healthcare professionals: health visitors, school nurses and GPs will know if there are risk factors in a child’s family, making it easier to differentiate between an HSP rash and child abuse

Rash formation clues

With its bruise-like colouring, an HSP rash can also be difficult to distinguish from child abuse.

‘You’d want to look at the formation of the rash for clues,’ says Mr Wetherill, who works at Sheffield Children’s NHS Foundation Trust. ‘Child abuse bruises might be scattered. Taking a thorough history will enable you to check that symptoms and test results match what is being said.’

The condition predominately affects children aged between two and 11 years, and a slightly higher number of boys than girls.

Evidence shows that people from a South Asian background are more likely than those from a white British background to develop HSP, and people from an African Caribbean background are the least likely.

The cause of HSP has not been confirmed, but research suggests that genetic, immune and environmental factors are likely to be involved. Many cases develop after an upper respiratory tract infection.

Evelina London Children’s Hospital paediatric renal nurse specialist Emma Rigby says: ‘There is a theory that some people have a gene that gives you a dispensation to getting a certain condition, but you would need a viral trigger to make it happen for an individual person. Most children present after they’ve had a viral infection.’

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Henoch-Schönlein purpura: raised rash on a child’s foot

Picture credit: Alamy

Mr Wetherill says a build-up of the antibody immunoglobulin A (IgA) could also contribute to the development of HSP. ‘It builds in the blood vessels, and they become inflamed.’

Institute of Health Visiting policy and quality lead Georgina Mayes, who is also a children’s nurse and health visitor, says that although emergency department (ED) nurses may triage the condition, community children’s nurses are as likely to deal with HSP patients.

‘Health visitors and school nurses in particular will be helping parents manage this at home,’ she says.

‘They will also be monitoring children at home to identify any red flags like abnormalities in urine, escalating symptoms, high blood pressure or reduced urine output. That’s important so urgent help can be sought quickly if needed, because this can result in acute renal failure.

‘Community-based nurses could also be contacts for the ED nurses who are seeing bruise-like marks on a child, and want good intelligence on what is happening at home to rule out abuse.’

Symptoms should last a few weeks and can be managed at home, according to NHS advice.

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Picture credit: iStock

Differing Henoch-Schönlein purpura ibuprofen guidelines are confusing

Emma Higgins is a community nurse from Cardiff. Her son Charlie is nine years old and was diagnosed with Henoch-Schönlein purpura (HSP) in late January.

‘I spotted two small, red, non-blanching spots on one of his legs and assumed it was an insect bite,’ she explains. The following night he was covered with a red and purple non-blanching rash on his legs. My first thought was meningitis, but he was too clinically well for that.

‘We went to a children’s assessment unit at the hospital, and they diagnosed HSP. They did a urine dip, took blood pressure and bloods, and no abnormality was detected. We were discharged home, and an advanced nurse practitioner has seen him for follow-up appointments since.

‘The differing guidelines on ibuprofen are confusing. In Charlie’s case we were told it was fine to give because his kidney function was normal, and ibuprofen did reduce his pain far more than paracetamol. But I noticed that every time I gave it the rash would exacerbate. I don’t know if there is a link there, but some clarification in the official advice would be useful.’

Monitor for kidney damage

If blood or protein is found in urine, then follow-up appointments will be needed for at least six months to monitor for signs of permanent kidney damage, according to guidance from Chelsea and Westminster Hospital NHS Foundation Trust.

Most trusts arrange the initial appointment two weeks after presentation.

Initial tests check blood pressure and urine for blood or protein, to indicate renal involvement. Blood tests can also be taken – blood cultures to rule out bacterial or fungal infections, a liver function test to check albumin levels, and urea and electrolytes to monitor kidney function, according to online resource InfoKID, a partnership project of the Royal College of Paediatrics and Child Health, the British Association for Paediatric Nephrology and the charity Kidney Care UK.

If necessary, imaging scans and a kidney biopsy can also be ordered, it says. Treatment is focused on managing symptoms and complications.

Guidelines from the Great Ormond Street Hospital for Children NHS Foundation Trust state that ibuprofen can be given. But the NHS advises that ibuprofen should not be given to children with HSP before speaking to a doctor, due to the effect on the kidneys.

At the Sheffield Children’s NHS Foundation Trust, Mr Wetherill says ibuprofen is a ‘bone of contention’. He says: ‘If you know renal function is fine and the child is in hospital, then ibuprofen is okay. But if the child is going home, how do you know it won’t impact them until the next follow-up?’

This is an abridged version of an article at rcni.com/henoch-purpura

Find out more

NHS (2022) Henoch-Schönlein Purpura (HSP).

Norfolk and Norwich University Hospitals NHS Foundation Trust (2022) Immune Thrombocytopenia.

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