Viral Childhood Exanthems

  • Viral rashes are often caused by immune reactions to the virus and cell damage caused by the virus.
  • A key bacterial cause of rash is Streptococcus pyogenes, which causes Scarlet Fever.

Helpful distinguishers between the viral exanthems:

  • We can categorize them by the initial location and pattern of the rash.
    – Three viral exanthems tend to initiate on the face:
    Measles, rubella, and erythema infectiosum.
    – Chickenpox arises on the face/scalp and trunk.
    – Roseola infantum typically first appears on the trunk
    – Hand, Foot, and Mouth disease produces rash on the hands and feet, in the mouth.

Be aware that these are meant to be helpful generalizations, and may not always hold true; for example, hand, foot, and mouth disease can also produce rash on the buttocks.

  • Rash types:
    – Multiple rash types can exist at once.
    – Macules are flat, colored spots on the skin.
    – Papules are solid, raised areas; larger papules are called nodules.
    – Vesicular rashes comprise raised “pockets” of fluid in the skin.
  • The timing of the rash and presence of other symptoms can also help distinguish among the exanthems.
    – For example, some infections are associated with fever, malaise, and respiratory symptoms.
    – Knowing the time lapse between virus introduction and symptom appearance can also help, although the incubation periods of the various viruses often overlap and may include a wide range.


Hand, foot, and mouth disease:

  • Usually caused by Coxsackievirus A.
  • Average incubation period of 3-6 days.
  • Most common in children younger than 5.
  • As its name suggests, hand, foot, and mouth disease is characterized by a rash that can be macular, maculopapular, or vesicular on the hands, feet, and in and around the mouth.

Erythema infectiousum, aka, Fifth Disease

  • Caused by Parvovirus B19.
  • Average incubation period of 7 days
  • Tends to affect children 5-15 years old.
  • Initial symptoms can include fever, runny nose, headache; diarrhea is also possible.
  • These flu-like symtpoms are followed by a malar facial rash that spreads to the trunk and extremities.
    – Facial rash takes on a characteristic “slapped cheeks” pattern, whereas the rash on the extremities often comprises maculopapular rash in a “lacy” pattern.

Roseola infantum, aka, exanthema subitum

  • Most commonly caused by Human Herpes Virus 6, and sometimes Human Herpes Virus 7.
  • Roseola infantum is also sometimes called “6th disease”, because it was the 6th exanthema identified (erythema infectiosum was the fifth).
  • Average incubation period is 9 days.
  • Although disease can occur in a wide range of ages, it most commonly affects children younger than 2 years old.
  • Initial symptoms include a very high fever (exceeding 104 degrees Fahrenheit/40 degrees Celsius).
    – The fever lasts approximately 3 days, which is why Roseola infantum is sometimes called “3-Day Fever”.
  • Macular or maculopapular “blanching rash” arises first on the trunk.
    – “Blanching rash” means that when the skin is pressed upon, often with a clear glass, the rash fades from red to pale.
  • Another common finding are red uvulopalatoglossal spots, aka, Nagayama spots,.
  • A range of other symptoms, including gastrointestinal, respiratory, ocular, and auditory problems, can occur.
  • Febrile seizures are a common complication in roseola infantum.


  • Caused by Varicella-Zoster virus (aka, Human Herpes Virus-3)
  • Average incubation period is 16 days.
  • Often affects children younger than 5.
  • Prior to rash, patients may experience fever, malaise, sore throat, and low appetite.
  • Rash is characterized by crops of lesions that pass through macular, vesicular, and crusted phases.
    – Lesions usually first appear on the head/neck, and spread to the rest of the body.
  • Clinical correlation: Shingles is an illness that occurs in adults upon reactivation of the Varicella-Zoster Virus; the reactivated virus is called Herpes-Zoster Virus.
    – Whereas the chickenpox rash is often itchy, the shingles rash can be very painful. Vaccination against Varicella-Zoster virus also prevents shingles.

Measles (aka, rubeola)

  • Caused by the Measles virus.
  • Average incubation period is 14 days.
  • Prior to rash, patients often experience Fever and the “Three C’s”Cough, Coryza (runny nose), and Conjunctivitis.
  • These symptoms are followed by a *maculopapular rash that begins on the face and neck and spreads.
  • Before the body rash, many patients also develop Koplik spots, which are spots along the palate and internal buccal surfaces (these spots are sometimes calked Koplik’s sign).
  • Serious complications from measles virus infection include potentially fatal pneumonia and encephalitis; vaccination helps to prevent these and other complications.

Rubella (aka, German measles)

  • Caused by Rubella virus.
  • Average incubation period is 14 days.
  • Rubella is characterized by the acute onset of a pink maculopapular rash that begins on the face and spreads.
    – The rash lasts about 3 days, so Rubella is sometimes called “3-Day measles” – careful not to confuse this with Roseola infantum, which is sometimes called “3-Day Fever.”
  • Some patients also have swollen lymph nodes in the neck area; systemic symptoms, such as headache, are mild if present.
  • Congenital rubella, which is contracted during fetal development, is associated with severe birth defects; this form of rubella can also be prevented by the rubella vaccine.

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