By Gary M. White, MD

Viral exanthem A pink, symmetric, fine, maculopapular or urticarial eruption is typical.

A viral exanthem is a diffuse maculopapular rash that develops as an immune response to a viral infection.

Viral Exanthem vs. Drug Eruption (from JAAD 2017;76;538]

Feature Viral Drug
Season Spring, Summer Fall, Winter
Location Buttocks, hands and feet, and face Proximal trunk and extremities
Morphology (beyond Maculopapular) +-Petechiae or vesicles Dusky +- petechiae
Symptoms Conjunctivitis, cough, diarrhea, fatigue, headache, insomnia, irriability, sore throat, and vomiting. Diarrhea, sore throat.
Signs Fever, hepatomegaly and lymphadenopathy Can have low-grade fever
Enanthem (changes in the mouth) Yes No
Pruritus No Yes

Differentiating from a drug hypersensitivity may be difficult. The presence of petechiae and vesicles are highly suggestive of infection. Papules and pustules are more typically drug-related. The presence of enanthem points strongly toward infection.


The clinical appearance can be quite variable. The classic appearance is a non-specific diffuse maculopapular exanthem. However and perhaps because so many viruses can be causative, other presentations are seen. For example, the rash may localize just on the hands and feet and mouth (e.g. Hand, foot, and mouth disease). Or it may localize to the knees and axilla. In some, the rash may involve the face, in others not. Occasionally, the rash is vesicular (e.g. chickenpox). Most are truncal, but some are acral (e.g. Gianotti-Crosti syndrome). An unusual type localized to the hands and feet is called Gloves and Socks Syndrome.

Potential Viruses

Virus Special features
CMV Asymptomatic or Infectious mononucleosis
Adenovirus URI
Influenza virus Flu
Epstein Barr Virus Infectious mononucleosis, Gianotti-Crosti Syndrome
Human herpesvirus-6 and -7 Pityriasis rosea, Infectious mononucleosis
Parvovirus B19 Erythema infectiousum (slapped cheeks), Gloves and Socks Syndrome, arthralgia, purpura
Chikungunya, Dengue and Zika
Measles, Rubella
Enterovirus, Coxsackie virus, Echovirus Hand, foot and mouth


Only supportive therapy is needed, e.g. rest and acetominephin. Other family members could be affected. Advise the patient to contact you if blisters, vesicles or oral lesions appear. If the patient is in significant discomfort, e.g. itch, systemic steroids may be given, e.g. 1 mg/kg and tapered over 10-14 days.

Additional Photos

Viral exanthem Viral exanthem Viral exanthem Viral exanthem Viral exanthem Viral exanthem

Oral ulcerations accompanying a viral exanthem.
Oral ulcerations accompanying a viral exanthem


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