How nurses can tell if children have Henoch-Schönlein purpura
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How nurses can tell if children have Henoch-Schönlein purpura

Pavan Amara Nurse, midwife and health journalist

Advice for nurses on managing a disease that affects a child’s small blood vessels and on ruling out conditions 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.

Nursing Children and Young People. 35, 3, 9-10. doi: 10.7748/ncyp.35.3.9.s3

Published: 04 May 2023

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Picture credit: iStock

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 in 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 about 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. If these types of symptoms occur, that is your sign that this is another condition, and not HSP.’

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 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 with a child’s family, making it easier to differentiate between an HSP rash and child abuse

Source: Nurses interviewed for this article

Rash formation

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.

There is limited research on which ethnic groups are most at risk. But the evidence that does exist 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.

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.’

HSP tends to present during winter, autumn and spring.

Children’s emergency department matron Caroline McKenna says this could be because respiratory viruses are most likely to occur then.

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.

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.’

Home monitoring

‘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.’

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

NHS trusts’ guidelines vary on when follow-up appointments should take place within that period, but most arrange the initial appointment two weeks after presentation. In up to one third of cases symptoms can recur within four to six months.

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.

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Henoch-Schönlein purpura: areas of bleeding in the lower limbs

Picture credit: iStock

Prescribing ibuprofen

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.

Even in the same NHS trust opinions may vary according to department. Ms McKenna says: ‘In our ED, we would say if a child is well with HSP and there is no renal involvement then give ibuprofen.’

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?’

Early recognition and treatment of Henoch-Schönlein purpura in children rcni.com/hsp-children

Further information

Brogan P, Eleftheriou D (2017) Vasculitis update: pathogenesis and biomarkers. Pediatric Nephrology. 33, 187–198. doi.org/10.1007/s00467-017-3597-4

Chelsea and Westminsiter Hospital NHS Foundation Trust (2023) Henoch-Schonlein Purpura (HSP).

Great Ormond Street Hospital for Childern NHS Foundation Trust (2023) Henoch Schönlein Purpura (HSP).

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

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

Patient (2022) Thrombotic Thrombocytopenic Purpura.

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