What Is A Viral Exanthem?

  • Samreen Noman Master's degree, Biomedical Sciences, General, Bonn-Rhein-Sieg University of Applied Sciences, Germany

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A viral exanthem is a skin rash or eruption occurring as a result of a viral infection and usually occurring in children. An exanthem can also be caused by toxins, drugs, or microorganisms or can result from autoimmune diseases. These rashes are often characterized by distinctive patterns, appearance, and distribution on the skin, which can help healthcare professionals identify the underlying viral cause.

A viral exanthem can represent a diverse group of skin eruptions resulting from various viral infections. These rashes have distinctive appearances, ranging from maculopapular lesions to vesicular or erythematous patterns. They serve as visual markers of the body's immune response to the invading virus, characterized by their varying colours, textures, and distribution patterns. Viral exanthem rashes can be accompanied by a spectrum of systemic symptoms, such as fever, sore throat, and malaise, providing valuable diagnostic clues. The diagnosis typically relies on clinical evaluation, with treatment primarily aimed at symptom management, as most viral exanthems are self-limiting.1

Why is it important to understand viral exanthems?

  1. Accurate Diagnosis: Knowledge of viral exanthems allows healthcare professionals to accurately diagnose the underlying viral infections based on the distinct characteristics of the rash. This ensures that appropriate treatment and management strategies are employed.
  2. Differential Diagnosis: Many viral exanthems present with similar symptoms initially, but their unique rash patterns and associated symptoms can help differentiate one viral infection from another. This aids in selecting the most suitable course of action and prevents misdiagnosis.
  3. Public Health and Infection Control: Recognizing viral exanthems is crucial for public health efforts. Identifying outbreaks of contagious diseases like measles or chickenpox promptly allows for containment measures and prevention of further transmission.
  4. Patient Care: Understanding viral exanthems is essential for providing optimal care to patients. It helps healthcare providers manage the symptoms, educate patients and their families about the condition, and provide appropriate guidance on isolation and hygiene practices to prevent spreading the infection.
  5. Vaccination and Prevention: Knowledge of specific viral exanthems underscores the importance of vaccination. Vaccination programs have been instrumental in reducing the prevalence of many viral exanthems, leading to better public health outcomes.
  6. Research and Treatment Development: A deeper understanding of viral exanthems contributes to ongoing research on viral infections. It helps in the development of antiviral medications, vaccines, and treatment protocols, ultimately improving patient outcomes.
  7. Pediatric and Family Medicine: Pediatricians, family physicians, and healthcare providers who treat children regularly encounter viral exanthems. Understanding these conditions is essential for providing comprehensive care to young patients and offering reassurance to concerned parents.
  8. Epidemiology: Knowledge of viral exanthems aids epidemiologists in tracking the spread and prevalence of specific viruses. This information is invaluable for public health planning and response during outbreaks.

Types of viral exanthem rashes

DiseaseCausative infectionClinical featuresExanthem image
Common Viral Exanthems
MeaslesMeasles virus (paramyxovirus)- High fever, cough, coryza (runny nose)
- Characteristic red, blotchy rash that starts on the face and spreads downward.
Measles - NHS
ChickenpoxVaricella-zoster virus (herpesvirus)- Itchy, vesicular (fluid-filled) rash that begins on the face, scalp, and trunk, then spreads to other areas.
- Fever and malaise.
Chickenpox - NHS
Rubella (German Measles)Rubella virus (togavirus)- Mild fever, swollen lymph nodes
- Pinkish-red rash that starts on the face and spreads to the body (may be less severe than measles).
Rubella (german measles) - NHS
Roseola InfantumHuman herpesvirus 6 (HHV-6) or 7 (HHV-7)- High fever.
- Rash consisting of small, pink, raised spots that often starts on the trunk.
Roseola - NHS
Fifth Disease (Erythema Infectiosum)Parvovirus B19- A slapped-cheek appearance on the face was followed by a lacy, red rash on the trunk and limbs.
- Mild fever and joint pain.
Slapped cheek syndrome - NHS
Less Common Viral Exanthems
Hand, Foot, and Mouth DiseaseEnteroviruses, commonly coxsackievirus A16- Painful sores or blisters in the mouth, on the palms of the hands, and the soles of the feet.
- Rashes on the buttocks and limbs.
Hand, foot and mouth disease - NHS
Herpes Simplex Virus (HSV) InfectionsHerpes simplex virus (HSV-1 and HSV-2)- Cold sores caused by HSV-1.
- HSV-2 cause genital lesions.
Genital herpes - NHS
ShinglesVaricella-zoster virus (herpesvirus)- Itchy, painful, blistering rash that can break open.
- Flu-like symptoms.
Shingles - NHS
Cytomegalovirus (CMV)Human herpesvirus 5 (HHV-5)- Fever, fatigue, muscle aches.
- Swollen lymph nodes.
- Small, flat, red spots or raised, reddish bumps on the skin.
Cytomegalovirus (CMV) Infection Treatment and Diagnosis
Eczema herpeticumHerpes simplex virus 1 (HSV-1)- Presents as vesiculopustules on the trunk
- Fever and lymphadenopathy
NHS 111 Wales - Health A-Z : Eczema (atopic)
EBVUbiquitous herpesvirusSkin lesions with acute infectious mononucleosis.Epstein-Barr virus infection - Stock Image - C025/9595 - Science Photo  Library

Clinical presentation

Characteristics of viral exanthem rashes

  • Maculopapular Rash: Many viral exanthem rashes present as maculopapular rashes, which consist of flat, red spots (macules) and raised, reddish bumps (papules). These may evolve into other forms during the course of the illness.
  • Vesicular Rash: Some viral exanthems, like chickenpox, display a vesicular rash with small, fluid-filled blisters (vesicles) on a pink or red base. These vesicles can be intensely itchy.
  • Distribution: The distribution of the rash can vary. It may be localized to specific areas or generalized, affecting large areas of the body. The pattern of distribution can provide clues for diagnosis.
  • Centripetal Spread: In certain exanthems like measles, the rash spreads from the face and head to the trunk and extremities in a centripetal manner.
  • Fading Lesions: As the rash progresses, some lesions may fade while new ones appear, leading to a changing appearance over time.

Symptoms associated with viral exanthems

  • Fever ranges from mild to high-grade.
  • Malaise.
  • Sore Throat.
  • Conjunctivitis.
  • Respiratory symptoms.
  • Swollen Lymph Nodes.

Diagnosis and Evaluation

Clinical assessment

  • Medical History

Obtaining a detailed medical history includes information about the patient's symptoms, recent illnesses, travel history, and vaccination status.

  • Physical examination

A thorough physical examination is conducted, paying close attention to the characteristics of the rash. A diagnostic framework approaching viral exanthems based on patient age, followed by the pattern of distribution and morphology of the rash, is currently used for clinical diagnosis. Further laboratory tests can be used as a confirmatory tool for challenging cases.

Differential diagnosis

Exanthems could be caused either by viral infections or due to other factors like bacterial infections, drug reactions, autoimmune conditions, and other dermatological disorders. Overlapping features may pose diagnostic challenges. Hence, observation of histopathological features can help differentiate in case of clinical overlaps.3

Laboratory tests

  1. Virus-specific serology:4
    • Virus-specific serology is used for laboratory confirmation of viral exanthems. This technique is non-invasive and also accounts for minimal sample degradation if handled and stored correctly. The presence of pathogen-specific immunoglobulin M (IgM) antibodies is used to indicate an ongoing infection.
    • Confirmation of infection is typically achieved through immunoglobulin G (IgG) seroconversion or a rise in antibody titers between acute and convalescent sera.
    • Measuring IgG avidity to assess the maturity of the IgG response can help differentiate between acute and past infections.

Limitations of Virus-specific serology:

  • False-positive results in serology testing can occur due to cross-reactivity with other viruses.
  • The time-consuming process of confirming infection.
  • Collecting convalescent sera is not always feasible.
  • Although high IgG avidity indicates a previous infection, low IgG avidity doesn't necessarily confirm an acute infection, as the development of high avidity antibodies can take several years.
  1. Nucleic acid testing (NAT)5

NAT on blood, fluid and tissue specimen is a highly sensitive and specific technique to help identify the specific virus responsible for the exanthem. This is particularly useful when clinical presentation alone is not definitive or when differential diagnosis (multiple viruses with similar clinical features are circulating) occurs. This technique is also beneficial in early identification of the genetic material, often before the onset of symptoms or appearance of the rash.

Limitations of NAT:

  1. Specimen quality, storage and transport can affect the resulting specificity.
  2. NAT may not detect the viral genetic material during early stages of infection if the viral load is low.
  3. While NAT is highly specific, it may occasionally cross-react with similar genetic sequences from non-target organisms or closely related viruses, potentially leading to false-positive results.
  4. Viral mutations leading to genetic variability can result in false negatives as the test may be unable to detect the variant.
  5. Preparing samples for NAT can be expensive, complex and time-consuming, requiring specialized equipment and trained personnel. Errors in sample preparation can impact the accuracy of the test.
  1. Immunofluorescence antigen detection

This method involves the use of fluorescently labeled antibodies to detect specific viral antigens within patient samples. The presence of viral antigens can be interpreted by analyzing the pattern and intensity of fluorescence. It also allows for direct visualization of viral antigens, aiding in the identification of the virus causing the exanthem.

Limitations of Immunofluorescence antigen detection:

  1. The success of immunofluorescence depends on the availability of specific antibodies that recognize the viral antigen of interest.
  2. The quality of the clinical specimen is crucial for accurate results.
  3. Interpretation of immunofluorescence results can be subjective and may require experienced laboratory personnel.
  1. Viral cultures and skin-biopsies

Although time-consuming and labor-intensive, viral cultures remain the gold standard for viral diagnosis. They can help identify the specific virus causing the exanthem. In rare cases where the diagnosis is unclear or when a drug-induced exanthem is suspected, a skin biopsy may be performed. Histological examination and immunohistochemistry can provide insights into the presence of specific viral infections.

Diagnostic challenges

Diagnosing viral exanthems can sometimes be challenging due to several factors:

  1. Variable Presentations: Viral exanthems can manifest in a variety of ways, leading to a wide range of skin rash appearances. This variability can make it difficult to differentiate between different viral exanthems and other skin conditions based solely on clinical presentation.
  2. Similar Clinical Features: Some viral exanthems may have clinical features that overlap with other skin conditions or infections. For example, the early stages of chickenpox may resemble insect bites or contact dermatitis.
  3. Atypical Cases: Viral exanthems do not always follow the classic patterns. In some cases, the rash may have unusual characteristics or distribution, making diagnosis more challenging.
  4. Coinfections: Patients can have more than one viral infection simultaneously, leading to complex clinical presentations that require careful evaluation and diagnostic testing.
  5. Timing of Testing: The timing of diagnostic tests can impact accuracy. For example, serological tests may not detect antibodies in the early stages of infection.
  6. Cross-Reactivity: Serological tests can sometimes produce false-positive results due to cross-reactivity with antibodies from other infections.
  7. Limited Availability of Diagnostic Tests: In some settings, access to specialized diagnostic tests like NAT or serological assays may be limited, making it challenging to confirm the viral etiology.
  8. Emerging or Uncommon Viruses: In the case of emerging or less common viruses, healthcare providers may be less familiar with their clinical presentations, leading to diagnostic delays.
  9. Patient Factors: Individual variations in immune response and underlying health conditions can affect the timing and accuracy of diagnostic tests.
  10. Epidemiological Factors: Seasonal variations in the prevalence of certain viral infections and regional differences can influence the likelihood of encountering specific viral exanthems.

Treatment and management

The primary approach to treating viral exanthems involves providing supportive care and focuses on alleviating symptoms and providing comfort, as specific antiviral treatments are not available. Using topical treatments like steroid creams does not alter the natural course of the condition.  It is essential to implement infection control measures to prevent the further spread of the infection4.

Supportive care

  • The goal of supportive care is to alleviate symptoms, provide comfort, and promote the body's natural healing processes.
  • Some key elements include symptom management like the use of over-the-counter antipyretic medications to help reduce fever and relieve associated discomfort and pain relief administered through systemic methods or applied topically for painful mouth sores and smaller rash areas.
  • Hydration, rest, comfortable clothing, avoiding irritants, isolation and hygiene are some other factors to be considered to support the immune system and also to prevent further spreading of the virus.

Antiviral medications

Antiviral medications are not typically used to treat viral exanthems. It is generally reserved for individuals with severe illness, immunocompromised individuals, or certain high-risk populations. This is determined by a healthcare provider based on a thorough evaluation of the patient's medical history and clinical condition.

  1. Varicella-Zoster Virus (Chickenpox): Antiviral medications like acyclovir or valacyclovir may be prescribed for individuals at higher risk of severe chickenpox complications, such as immunocompromised individuals, adults, or pregnant women6.
  2. Roseola Infantum: Ganciclovir or foscarnet antivirals can be used in more severe cases7.
  3. Erythema Multiforme and Herpes Simplex Virus (HSV): Antiviral medications like acyclovir, valacyclovir, or famciclovir are commonly used to treat primary and recurrent herpes simplex outbreaks8 and also reduces the duration of symptomatic erythema multiforme lesions9.
  4. Epstein-Barr Virus (EBV): Antivirals (including acyclovir, ganciclovir and vidarabine)  used in combination with immunomodulatory drugs are proposed to a possible inhibitor of EBV replication10.
  5. Cytomegalovirus (CMV): Antiviral medications like ganciclovir or valganciclovir11 may be used to treat severe CMV infections in immunocompromised individuals.
  6. Herpes Zoster (Shingles): Antiviral medications such as acyclovir, valacyclovir, or famciclovir can help reduce the severity of symptoms, particularly when treatment is initiated within 72 hours of symptom onset.

There is no specific antiviral therapy for measles, rubella infection, dengue, Zika and HFMD infections.

Complication management

Complication management in viral exanthems involves addressing any potential complications or adverse outcomes that may arise during the course of the illness. Some of the commonly observed secondary complications include:

  1. Secondary Bacterial Infections like impetigo or cellulitis caused in skin breaks. Use of appropriate antibiotics can help treat infections.
  2. Dehydration caused by fever, decreased fluid intake, and sweating, especially in children. Use of oral rehydration solutions and constant monitoring for signs of dehydration is essential.
  3. Pneumonia or Respiratory Complications induced by certain viral infections like measles or varicella-zoster virus (chickenpox). Oxygen therapy and vaccination against preventable respiratory viruses are essential management techniques.
  4. Neurological Complication like encephalitis or neuralgia occur in case of viral infections like mumps or herpes zoster (shingles). Prompt medical evaluation and appropriate treatments for pain management can help ease discomfort.
  5. Pregnancy Complications such as congenital abnormalities in the developing fetus are observed in rubella cases. Preventive measures, including vaccination, are crucial in such cases.
  6. Prolonged viral exanthems in immunocompromised individuals. Close monitoring, early antiviral therapy (if appropriate), and supportive care tailored to the individual's immune status may be necessary to manage complications.
  7. Eye complications like conjunctivitis or keratitis are observed in measles patients, which can be treated using ophthalmic medications.
  8. Antiviral medications or other treatments may lead to adverse reactions or side effects, in rare cases.
  9. Psychological and Emotional distress induced by the discomfort and appearance of the rash, particularly in adolescents and adults.

Prevention strategies

Major prevention strategy against viral infections is vaccination. Some of the commonly available vaccines include:

  • Measles - MMR or MMRV vaccine
  • Chickenpox - Varicella vaccine, shingles vaccine or MMRV vaccine
  • Rubella - Rubella vaccine, MMR or MMRV vaccine
  • Dengue Fever - Dengue vaccine
  • Zika Virus - currently under research
  • Epstein-Barr Virus (EBV) - currently under research
  • Cytomegalovirus (CMV) - currently under research
  • Shingles - Varicella vaccine, shingles vaccine or MMRV vaccine

Other secondary prevention strategies may include:

  • Hand hygiene
  • Respiratory hygiene
  • Isolation and quarantine
  • Avoiding close contact
  • Travel precautions
  • Public health awareness

Real-life cases of viral exanthem rashes

  • Measles Outbreak: In 2019, several countries experienced measles outbreaks due to declining vaccination rates. Around 310,000 suspected cases had been reported owing to poor health infrastructure and awareness of vaccination.
  • Chickenpox in Schools: Varicella-zoster virus, which causes chickenpox, can spread rapidly in school settings. Regular outbreaks of chickenpox in schools could be managed by regular vaccinations.
  • Rubella during Pregnancy: Rubella infection during pregnancy can have serious consequences for the developing fetus. Real-life cases have highlighted the importance of rubella vaccination in preventing congenital rubella syndrome.

Conclusion

In conclusion, understanding viral exanthems is crucial for accurate diagnosis, effective patient care, and public health efforts.  

The importance of understanding viral exanthems extends to various aspects, including accurate diagnosis, differential diagnosis, public health and infection control, patient care, vaccination and prevention, research and treatment development, pediatric and family medicine, and epidemiology. Knowledge of specific viral exanthems, their clinical presentations, and associated complications guides healthcare providers in providing optimal care to patients and prevents the further spread of these contagious diseases.

FAQs

  1. What is a viral exanthem?

A viral exanthem is a skin rash that occurs as a result of a viral infection. It's often characterized by distinct patterns and appearances on the skin.

  1. What causes viral exanthems?

Various viruses can cause viral exanthems, including measles, chickenpox, rubella, and more.

  1. What are the common symptoms of viral exanthems?

Symptoms can include fever, sore throat, malaise (general discomfort), and a rash with varying colors and textures.

  1. How are viral exanthems diagnosed?

Diagnosis usually involves a clinical evaluation by a healthcare professional based on the appearance of the rash and associated symptoms. Lab tests like serology or nucleic acid testing may also be used in some cases.

  1. Are viral exanthems contagious?

Yes, many viral exanthems are contagious. It's important to take precautions to prevent the spread of the virus to others.

  1. Is there a specific treatment for viral exanthems?

Typically, treatment focuses on managing symptoms, as most viral exanthems are self-limiting. Antiviral medications may be considered in severe cases or for certain viruses.

  1. How long do viral exanthems last?

The duration can vary, but these rashes often resolve on their own within a week or two.

  1. Can adults get viral exanthems, or are they primarily a childhood condition?

Adults can also get viral exanthems, although they are more common in children.

  1. What complications can be associated with viral exanthems?

Complications can include secondary bacterial infections, dehydration, pneumonia, neurological issues, and more.

  1. Is there a vaccine to prevent viral exanthems?

Vaccines are available for some viruses that cause exanthems, like the measles, mumps, and rubella (MMR) vaccine or the varicella (chickenpox) vaccine.

  1. When should I seek medical attention for a viral exanthem?

If you experience severe symptoms or complications or are unsure about the cause of your rash, it's advisable to consult a healthcare provider.

  1. How can I differentiate viral exanthems from other skin conditions?

A healthcare provider can help differentiate viral exanthems from other skin conditions through clinical evaluation and, if necessary, diagnostic tests.

References

  1. ‘Viral Exanthem Rash: Symptoms, Causes & Treatment’. Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/22510-viral-exanthem-rash. Accessed 25 Sept. 2023.
  2. Korman, Abraham M., et al. ‘Viral Exanthems: An Update on Laboratory Testing of the Adult Patient’. Journal of the American Academy of Dermatology, vol. 76, no. 3, Mar. 2017, pp. 538–50. DOI.org (Crossref), https://doi.org/10.1016/j.jaad.2016.08.034.
  3. Singh, Sanjay, et al. ‘Assessment of Histopathological Features of Maculopapular Viral Exanthem and Drug‐induced Exanthem’. Journal of Cutaneous Pathology, vol. 44, no. 12, Dec. 2017, pp. 1038–48. DOI.org (Crossref), https://doi.org/10.1111/cup.13047.
  4. Keighley, Caitlin L., et al. ‘Viral Exanthems’. Current Opinion in Infectious Diseases, vol. 28, no. 2, Apr. 2015, p. 139. journals.lww.com, https://doi.org/10.1097/QCO.0000000000000145.
  5. Sciuto, Emanuele Luigi, et al. ‘Nucleic Acids Analytical Methods for Viral Infection Diagnosis: State-of-the-Art and Future Perspectives’. Biomolecules, vol. 11, no. 11, Oct. 2021, p. 1585. PubMed Central, https://doi.org/10.3390/biom11111585.
  6. Sauerbrei, Andreas. ‘Varicella-Zoster Virus Infections – Antiviral Therapy and Diagnosis’. GMS Infectious Diseases, vol. 4, Feb. 2016, p. Doc01. PubMed Central, https://doi.org/10.3205/id000019.
  7. Mullins, Tessa B., and Karthik Krishnamurthy. ‘Roseola Infantum’. StatPearls, StatPearls Publishing, 2023. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK448190/.
  8. Kimberlin, David W., and Richard J. Whitley. ‘Antiviral Therapy of HSV-1 and -2’. Human Herpesviruses: Biology, Therapy, and Immunoprophylaxis, edited by Ann Arvin et al., Cambridge University Press, 2007. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK47444/.
  9. Soares, Alexa, and Olayemi Sokumbi. ‘Recent Updates in the Treatment of Erythema Multiforme’. Medicina, vol. 57, no. 9, Sept. 2021, p. 921. PubMed Central, https://doi.org/10.3390/medicina57090921.
  10. Andrei, Graciela, et al. ‘Novel Therapeutics for Epstein–Barr Virus’. Molecules, vol. 24, no. 5, Mar. 2019, p. 997. PubMed Central, https://doi.org/10.3390/molecules24050997.
  11. Chen, Shiu-Jau, et al. ‘Antiviral Agents as Therapeutic Strategies Against Cytomegalovirus Infections’. Viruses, vol. 12, no. 1, Dec. 2019, p. 21. PubMed Central, https://doi.org/10.3390/v12010021.

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Pooja Padmakumar

MRes in Molecular Medicine, Bangor University, Wales

Pooja is a doctoral scholar at Bangor University, currently researching antimicrobial resistance in wastewater and marine environment. She previously worked as a laboratory technician with the wastewater monitoring program for COVID surveillance at Bangor University. Prior to this, she has several years of experience in clinical trial database design and data management. Alongside her research work, she contributes to writing articles that help raise awareness among the general public.

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