Characterizing Viral Exanthems

Joseph M Lam

Pediatr Health. 2010;4(6):623-635.

Conclusion & Future Perspective

Our understanding of certain viral exanthems has expanded significantly since the original description of the classic exanthems of childhood. Many viral diseases, such as measles, rubella and varicella, are now preventable with vaccination. However, our understanding and recognition of new viral-associated exanthems continues to expand. In the case of papular acrodermatitis of childhood, what was once thought to be a manifestation of hepatitis B is now recognized to be a manifestation of a number of infectious agents, including viruses. In the case of acute generalized exanthematous pustulosis, what was once thought to be a drug-induced exanthem is now recognized to have viral triggers. In the case of parvovirus B19, the ability to detect the virus in seronegative patients using PCR has been useful in linking the virus to erythema infectiousum, as well as other manifestations, such as PPGSS and generalized petechiae.

There are still cases of exanthematous disease where the roles of viruses have yet to be fully elucidated. These include the association of HHV-6 and -7 reactivation in drug hypersensitivity syndrome, the role of viral triggers in Kawasaki syndrome and the role of viruses in dermatological conditions with seasonal clustering, such as lichen striatus. Improving laboratory testing in combination with continual clinical sleuthing may provide clues to the role of viruses in these and other exathematous disease in childhood.

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Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.

Cite this: Characterizing Viral Exanthems - Medscape - Dec 01, 2010.

Box 1. Proposed diagnostic criteria for papular acrodermatitis of childhood.
*Positive clinical features* Monomorphous, flat-topped, pink-brown papules or papulovesicles 1–10 mm in diameter on at least three of the following four sites: cheeks, buttocks, extensor surfaces of the forearms, and extensor surfaces of the legs Symmetrical distribution Duration of at least 10 days
*Negative clinical features* Extensive truncal lesions Scaly lesions

Data taken from [52].

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Executive Summary

Macular & maculopapular exanthems

Measles, rubella, erythema infectiousum and roseola infantum are part of the six classic childhood exanthems, and have very distinct and recognizable features.
The eruption when aminopenicillins are administered to patients with Epstein–Barr virus is a bright-red morbilliform eruption that does not preclude future use of aminopenicillins.

Vesicular & pustular exanthems

Varicella infection is benign and self-limiting, but has the potential to cause life- and limb-threatening complications in immunocompetent and immunocompromised hosts. The varicella vaccine is now available in combination with the measles–mumps–rubella vaccine.
Eczema herpeticum is a severe form of disseminated cutaneous herpes simplex virus infection that morphologically presents as monomorphic umbilicated vesiclulopustules, which progress to form punched-out erosions.
Hand–foot–mouth disease is a distinct monomorphous exanthem that is most commonly caused by the Coxsackie A16 virus and human enterovirus 71. Meningoencephalitis and myocarditis are rare complications, which occur more commonly with human enterovirus 71.
Although acute generalized exanthematous pustulosis usually occurs following drug ingestion, cases in children may be caused by viral infections.

Papular exanthems

Papular acrodermatitis of childhood is characterized by the abrupt onset of erythematous papules over the extremities, buttocks and face, with relative sparing of the abdomen and chest. It appears to occur as a response to a number of infectious stimuli.
Therapy for molluscum contagiosum ranges from destructive techniques to observation, as lesions will eventually resolve spontaneously.

Other viral exanthems

Parovovirus B19 has been linked recently to several petechial and purpuric exanthems, which may be localized to particular areas of the body. Recently, it has also been implicated in outbreaks of generalized petechiae.
Pityriasis rosea in children may present atypically by involving the face and extremities.
Erythema multiforme is often triggered by herpes simplex virus in children.
Unilateral laterothoracic exanthem is a distinct exanthem, which preferentially affects one side of the body, with a prolonged clinical course.

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Characterizing Viral Exanthems

Conclusion & Future Perspective

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