Pediatric Exanthems
Continuity Clinic
Objectives
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Be familiar with the terminology to
describe rashes accurately to other
providers
Be able to identify the rashes of Measles,
Rubella, Scarlet Fever, Erythema
Infectiousum, and Roseola Infantum
Know the general clinical features of
each of the above rashes
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Review of Terminology of
Skin Lesions
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The Basics of Rashes
• Distribution
– Localized vs. Systemic
– Sun exposed areas?
• Configuration
– Round
– Serpiginous
– Coalesce
• Description
– Macular, Papular, Petechial
• Evolution
– Where it began and where it ended
• Associated Findings
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Description of Rashes
• Macule – circumscribed color change in the skin that is
flat
• Papule – solid, elevated area < 1 cm in diameter
• Plaque – solid, circumscribed area >1 cm in diameter
• Vesicle – circumscribed, elevated < 1 cm with serous
fluid
• Bulla – circumscribed, elevated > 1 cm with serous
fluid
• Pustule – vesicle with purulent material
• Nodule – mass with indistinct borders, elevates over
epidermis
• Wheal – circumscribed, flat topped, firm elevation of
skin resulting from tense edema of papillary dermis
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Description of Rashes
MACULE
VESICLE
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PUSTULE
NODULE
Definitions
• Exanthem – a skin eruption occurring as a
symptom of a general disease
• Enanthem – eruptive lesions on the
mucous membranes
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Classic Childhood Exanthems
1.
2.
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4.
5.
6.
Measles (Rubeola)
Scarlet Fever
Rubella (German Measles)
Filatow-Dukes Disease
Erythem Infectiousum
Roseola Infantum
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“1st Disease” - Measles
• Paramyxovirus
• At risk:
– Preschool age children unvaccinated
– School age children in whom vaccine failed
• Season: late winter/spring
• Incubation: 8-12 days
• Infectious: 1-2 days before prodrome to 4
days after onset of rash
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Measles – clinical features
• Prodrome
– Day 7-11 after exposure
– Fever, cough, coryza, conjunctivitis
• Enanthem
– Koplik’s spots appear 2 days before rash and
lasts 2 days into rash
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Koplik’s Spots
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Koplik’s Spots
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Exanthem of Measles
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Exanthem of Measles
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Complications of Measles
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Otitis Media
Bronchopneumonia
Encephalitis
Pericarditis
Subacute sclerosing panencephalitis – late
sequellae due to persistent infection of the
CNS
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“2nd Disease” - Scarlet Fever
• Due to erythrogenic exotoxin-producing group A
beta-hemolytic streptococci
• At risk:
– <10 years old
– Peak 4-8 years old
• Season:
– late fall, winter, spring
– Likely due to close contact indoors in school
• Incubation period: 2-4 days
• Infectious period: during acute infection,
gradually diminishes over weeks
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Scarlet Fever – Clinical Features
• Abrupt onset fever, headache, vomiting,
malaise, sore throat
• Enanthem
– Bright red oral mucosa
– Palatal petechiae
– Tongue changes
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Strawberry Tongues
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Scarlet Fever - Exanthem
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Scarlet Fever - Exanthem
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Scarlet Fever - Complications
• Purulent
– Otitis media
– Sinusitis
– Peritonsillar/retropharyngeal abscesses
– Cervical adenitis
• Nonsuppurative sequalae
– Rheumatic Fever
– Acute glomerulonephritis
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“3rd Disease” - Rubella
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Togavirus
At risk: Unvaccinated adolescents
Season: late winter/early spring
Incubation: 14-21 days
Infectious period: 5-7 days before rash to
3 to 5 days after rash
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Rubella – Clinical Features
• Asymptomatic infection in up to 50%
• Prodrome
– Children: absent to mild
– Adolescent & adult: fever, malaise, sore
throat, nausea, anorexia, painful occipital LAD
• Enanthem
– Forschheimer’s spots  petechiae on the
hard palate
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Rubella - Exanthem
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Rubella - Exanthem
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Rubella - Complications
• Arthralgias/arthritis in older patients
• Peripheral neuritis, encephalitis,
thrombocytopenic purpura (rare)
• Congenital rubella syndrome
– Infection during first trimester
– IUGR, eye findings, deafness, cardiac
defects, anemia, thrombcytopenia, skin
nodules
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“4th Disease” – Filatow Dukes
Disease
• Obsolete
• Probably now better defined as another
clinical entity
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“5th Disease” – Erythema
Infectiosum
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Human Parvovirus B19
At risk: school age children
Season: sporadic
Incubation period: 4-14 days
Infectious period: up until onset of the
rash
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Erythema Infectiosum Clinical
Features
• Over 50% of infections are asymptomatic
• Prodrome:
– Mild fever (15-30%)
– Sore throat
– Malaise
• Adults: flu like symptoms,
arthralgias/arthritis, rash in up to 40%
• Hematological changes: proerythrocyte
tropic virus – drop in RBC count
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EI: Slapped Cheek
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EI: Exanthem
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EI: Exanthem
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EI: Complications
• Immunocompromised:
– Chronic infection with severe, persistent,
relapsing and remitting anemia, prolonged
viral shedding
• Patients with decreased RBC survival time
– Hemoglobinopathies, hemolytic disease
– Aplastic crises
– Prolonged viral shedding
• Fetal infection – hydrops fetalis (1-9% risk
of death)
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“6th Disease” – Roseola Infantum
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Human Herpes Virus 6 (and 7)
At risk: 6-36 months (peak 6-7 months)
Season: sporadic
Incubation: 9 days
Infectious period:
– Virus is intermittently shed into saliva
throughout life; asymptomatic persistent
infection
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Roseola – Clinical Features
• High fever for 3-4 days
• Abrupt defervescence with appearance of
rash
• Associated seizures likely due to infection
of the meninges by the virus
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Roseola - Exanthem
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Roseola - Exanthem
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