Common Exanthems

Adam Goldstein, MDAdam Goldstein, MDAssociate ProfessorAssociate Professor

UNC Department of Family MedicineUNC Department of Family MedicineChapel Hill, NCChapel Hill, NC

aog@med.unc.eduaog@med.unc.edu

Objectives Understand nomenclature for Understand nomenclature for

common exanthemscommon exanthems Know an appropriate Know an appropriate

differential dx for most differential dx for most exanthemsexanthems

Improved ability to diagnose:Improved ability to diagnose: Measles (rubeola)Measles (rubeola) German Measles (Rubella)German Measles (Rubella) Chicken Pox (Varicella)Chicken Pox (Varicella) Fifth Disease (Erythema Fifth Disease (Erythema

infectiosum)infectiosum)

Roseola (exanthem subitum) Roseola (exanthem subitum) Hand, foot & mouth disease Hand, foot & mouth disease Pityriasis rosea Pityriasis rosea Asymmetric periflexural Asymmetric periflexural

exanthem of childhood (APEC)exanthem of childhood (APEC) Kawasaki diseaseKawasaki disease SmallpoxSmallpox Scarlet feverScarlet fever Drug eruptionsDrug eruptions Unknown exanthemsUnknown exanthems

Exanthems Anyone of a number of systemic processes Anyone of a number of systemic processes

giving generalized eruptiongiving generalized eruption Usually not isolatedUsually not isolated Caused by:Caused by:

VirusesViruses BacteriaBacteria Fungal Fungal DrugsDrugs IdiopathicIdiopathic

Exanthems (Historical)

1 1 MeaslesMeasles 22 Scarlet feverScarlet fever 33 RubellaRubella 44 "Dukes' disease”- ? measles, rubella, "Dukes' disease”- ? measles, rubella,

scarlet fever, Staph infection, or one of several scarlet fever, Staph infection, or one of several unspecified enteroviral infections;unspecified enteroviral infections;

55 Erythema InfectiosumErythema Infectiosum 66 Roseola. Roseola.

Measles (Rubeola)

Diff DxDiff Dx S/S’s: Fever, conjunctivitis, coughS/S’s: Fever, conjunctivitis, cough

Characteristic Koplik spots 24-48 Characteristic Koplik spots 24-48 hours before rash hours before rash

Rash:Rash: Days 4-5, red & blotchyDays 4-5, red & blotchy begins on face & behind ears begins on face & behind ears usually with onset high feverusually with onset high fever spreads to bodyspreads to body Usually spares palms/solesUsually spares palms/soles Rash coalesces on trunk/faceRash coalesces on trunk/face

Rubella (German measles)

"little red”; 3rd Disease"little red”; 3rd Disease Schoolchildren highest infectivity in Schoolchildren highest infectivity in

unvaccinated populationsunvaccinated populations Congenital Rubella SyndromeCongenital Rubella Syndrome

deafness, eye lesions, heart deafness, eye lesions, heart malformations & mrmalformations & mr

24 cases 1997-1999, mostly 24 cases 1997-1999, mostly immigrantimmigrant

25-50,000 cases Mexico 199825-50,000 cases Mexico 1998 Higher suspicion cases in patients Higher suspicion cases in patients

immigrating from countries with higher immigrating from countries with higher ratesrates

Vaccination contraindicated pregnancyVaccination contraindicated pregnancy

(MMWR, 2001)

Rubella Diffuse rash, LN enlargement, h/a, Diffuse rash, LN enlargement, h/a,

malaise, mild cough and malaise, mild cough and conjunctivitisconjunctivitis

Pink rash appears on face and Pink rash appears on face and spreads to bodyspreads to body

www.info.gov.hk/dh/diseases/ CD/rubella.htm

Chicken Pox- Varicella caused by varicella-zoster viruscaused by varicella-zoster virus blister-like rash, itching, fatigue & blister-like rash, itching, fatigue &

feverfever 250-500 itchy blisters, 3 stages at 250-500 itchy blisters, 3 stages at

same time (papule, vesicle, scab)same time (papule, vesicle, scab) 1 in 10 complications: bacterial, 1 in 10 complications: bacterial,

pneumonia, encephalitispneumonia, encephalitis

Chicken Pox- Varicella

Fifth Disease (Erythema infectiosum) Parvovirus B19Parvovirus B19 S/S’s: low fever, cold, mildly ill S/S’s: low fever, cold, mildly ill Skin:Skin:

"slapped-cheek" rash on face"slapped-cheek" rash on face lacy red rash trunk & limbslacy red rash trunk & limbs

infected adults may develop joint infected adults may develop joint pains hands, wrists, kneespains hands, wrists, knees

kids may return to school- no longer kids may return to school- no longer infectiousinfectious

pregnant women exposed- refer to pregnant women exposed- refer to guidelinesguidelines

(Crane J, J Obstet Gynaecol Can, 2002)

Roseola/Exanthem Subitum Human Herpes Virus 6>7Human Herpes Virus 6>7 spread via salivaspread via saliva 72-95% sero + in US early 72-95% sero + in US early

ageage S/S’s: irritable, diarrhea, S/S’s: irritable, diarrhea,

cough, fever 102-105F, for 3-cough, fever 102-105F, for 3-7 days; 10% seizure7 days; 10% seizure

Skin:Skin: As fever resolves, faint macules As fever resolves, faint macules

develop on trunk and extremities develop on trunk and extremities that blanch upon pressurethat blanch upon pressure

Rash resolves 1-2 daysRash resolves 1-2 days

Roseola/Exanthem Subitum Skin:Skin:

As fever resolves, faint As fever resolves, faint macules develop on macules develop on trunk and extremities trunk and extremities that blanch upon that blanch upon pressurepressure

Rash resolves 1-2 daysRash resolves 1-2 days

Hand Foot and Mouth Disease Common acute febrile Common acute febrile

illness of childrenillness of children Group A coxsackie Group A coxsackie

virusesviruses 2-7 days resolves2-7 days resolves Hand washingHand washing Rare complicationsRare complications

HFM Disease

handhand

foot foot

mouth mouth

Pityriasis rosea

Unknown causeUnknown cause Lasts 6-12 weeksLasts 6-12 weeks Herpes viruses 6 & 7 associatedHerpes viruses 6 & 7 associated Herald patch 1-20 days before rashHerald patch 1-20 days before rash Sometimes confused with T. Corporis or psoriasisSometimes confused with T. Corporis or psoriasis

Pityriasis rosea

Oval patches follow Oval patches follow line of ribs like fir treeline of ribs like fir tree

Erythromycin may be Erythromycin may be effective txeffective tx

(Sharma, JAAD, 2000)

Asymmetric periflexural exanthem of childhood (APEC)

Laterothoracic exanthemLaterothoracic exanthem Uncommon, G > BUncommon, G > B Viral symptoms can occurViral symptoms can occur Often mistaken for eczema, fungal Often mistaken for eczema, fungal Skin:Skin:

Usually starts in armpit or groin and Usually starts in armpit or groin and extends outwards, on one side of bodyextends outwards, on one side of body

May spread to face, genitalia, hands or May spread to face, genitalia, hands or feetfeet

Patches are net-like or in ringsPatches are net-like or in rings PruriticPruritic Resolves within 3 monthsResolves within 3 months

Kawasaki disease

80% in children < 4 years80% in children < 4 years Self-limiting & resolves spontaneously without Self-limiting & resolves spontaneously without

treatment 4-8 weekstreatment 4-8 weeks 15-20% have damage to coronary arteries and 2% 15-20% have damage to coronary arteries and 2%

of patients die from heart attackof patients die from heart attack

(Brogan PA, Arch Dis Child, 2002)

Kawasaki disease

Kawasaki disease

Kawasaki disease

http://www.dermnetnz.org/index.html

Smallpox

Classic generalized Classic generalized exanthemexanthem

Latin word for “spotted” Latin word for “spotted” referring to the raised referring to the raised bumps on the face and bodybumps on the face and body

Rash, high fever & mortality Rash, high fever & mortality rate 30%rate 30%

Last natural case Somalia in Last natural case Somalia in 19771977

http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp

Smallpox

Exanthem from vaccinationExanthem from vaccination 1/100,0001/100,000

Vaccinia rash or outbreak Vaccinia rash or outbreak of soresof sores

Generalized vacciniaGeneralized vaccinia Erythema multiformeErythema multiforme

http://www.bt.cdc.gov/agent/smallpox/

Smallpox

From VaccinationFrom Vaccination 1/50,0001/50,000

Eczema vaccinatumEczema vaccinatum Progressive vacciniaProgressive vaccinia

Postvaccinal encephalitisPostvaccinal encephalitis

Scarlet fever Group A streptococcus toxinGroup A streptococcus toxin children aged 4-8children aged 4-8 contagious by contagious by

coughing/sneezing or coughing/sneezing or touching the infected skintouching the infected skin

sudden fever with sore throat, sudden fever with sore throat, swollen LN’s, h/a, n, v, loss swollen LN’s, h/a, n, v, loss of appetite, swollen and red of appetite, swollen and red strawberry tongue, abdominal strawberry tongue, abdominal pain, body aches, and malaisepain, body aches, and malaise

Scarlet fever Skin:Skin:

rash 12-48 hours after feverrash 12-48 hours after fever ears, neck, chest, armpits, groin, ears, neck, chest, armpits, groin,

then rest of body over 24 hours then rest of body over 24 hours scarlet spots or blotches, often scarlet spots or blotches, often

the first sign the first sign starts to look like sunburn with starts to look like sunburn with

goose pimplesgoose pimples skin may have a rough skin may have a rough

sandpaper-like feelsandpaper-like feel as rash fades, it peels similar to as rash fades, it peels similar to

that of sunburned skinthat of sunburned skin

Drug eruptions

Almost all drugsAlmost all drugs

Drug eruptions

DilantinDilantin

Drug eruptions

MinocyclineMinocycline

Drug eruptions

Fixed drug eruptionFixed drug eruption

Unknowns 1

Unknowns 2

Unknowns 3

Unknowns 4

Unknowns 5

Unknowns 6

Unknowns 7

Unknowns 8

Unknowns 9

Unknowns 10

BONUS

BONUS

BONUS

References Trizna Z. Viral diseases of the skin: diagnosis and antiviral treatment. Trizna Z. Viral diseases of the skin: diagnosis and antiviral treatment.

Pediatr Drugs 2002;4:9-19.Pediatr Drugs 2002;4:9-19. http://home.mdconsult.com/das/guideline/view/26827010/N/11196820?http://home.mdconsult.com/das/guideline/view/26827010/N/11196820?

sid=166362089&source=MIsid=166362089&source=MI Crane J. Parvovirus B19 infection in pregnancy. J Obstet Gynaecol Can Crane J. Parvovirus B19 infection in pregnancy. J Obstet Gynaecol Can

2002; 24: 727-43.2002; 24: 727-43. Glatman-Freedman A. Rubella vaccine. Pediatr Rev 2002; 23(3): 106-7.Glatman-Freedman A. Rubella vaccine. Pediatr Rev 2002; 23(3): 106-7. Smallpox Vaccine. Pediatrics 2002. American Academy of Pediatrics, Smallpox Vaccine. Pediatrics 2002. American Academy of Pediatrics,

Committee on Infectious Diseases; 110: 4.Committee on Infectious Diseases; 110: 4. Bromberg K. Group A beta-hemolytic streptococcal pharyngitis. Am Bromberg K. Group A beta-hemolytic streptococcal pharyngitis. Am

Fam Physician 2001; 63(8): 1486-7.Fam Physician 2001; 63(8): 1486-7. Bisno AL. Practice guidelines for the diagnosis and management of Bisno AL. Practice guidelines for the diagnosis and management of

group A streptococcal pharyngitis. Infectious Diseases Society of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis 2002; 35(2): 113-25.America. Clin Infect Dis 2002; 35(2): 113-25.

References Gable EK. Pediatric exanthems. Prim Care 2000; 27: 353-69.Gable EK. Pediatric exanthems. Prim Care 2000; 27: 353-69. Brogan PA. Kawasaki disease: an evidence based approach to Brogan PA. Kawasaki disease: an evidence based approach to

diagnosis, treatment, and proposals for future research. Arch Dis diagnosis, treatment, and proposals for future research. Arch Dis Child 2002; 86: 286-90.Child 2002; 86: 286-90.

Hairston BR. Viral diseases of the oral mucosa. Dermatol Clin 2003; Hairston BR. Viral diseases of the oral mucosa. Dermatol Clin 2003; 21(1): 17-32.21(1): 17-32.

De Araujo T. Human herpesviruses 6 and 7. Dermatol Clin 2002; De Araujo T. Human herpesviruses 6 and 7. Dermatol Clin 2002; 20(2): 301-6.20(2): 301-6.

Sharma PK. Erythromycin in pityriasis rosea: A double-blind, Sharma PK. Erythromycin in pityriasis rosea: A double-blind, placebo-controlled clinical trial. J Am Acad Dermatol 2000; 42: 241-placebo-controlled clinical trial. J Am Acad Dermatol 2000; 42: 241-4. 4.

MMWR. Control and prevention of rubella: evaluation and MMWR. Control and prevention of rubella: evaluation and management of suspected outbreaks, rubella in pregnant women, and management of suspected outbreaks, rubella in pregnant women, and surveillance for congenital rubella syndrome. July 13, 2001; 50: 1-23.surveillance for congenital rubella syndrome. July 13, 2001; 50: 1-23.

Thank you.