Cutaneous Conditions in Febrile Patients

Aka: Cutaneous Conditions in Febrile Patients, Dermatologic Manifestations in Patients with Fever, Rash in the Febrile Patient, Febrile Patient with Rash, Fever and Rash, Febrile Eruption, Viral Exanthem, Diffuse Erythema and Desquamation in the Febrile Patient, Vesiculobullous Eruptions in the Febrile Patient, Petechial Eruptions in the Febrile Patient, Nodular Eruptions in the Febrile Patient, Centripetal Rash, Blanching, Maculopapular Rashes in Febrile Children

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II. History

  1. Contagious Contacts
  2. Vaccination history
  3. Medication allergies
  4. Travel History
    1. See Cutaneous Conditions in Febrile Returning Traveler
    2. International travel
    3. Outdoor exposures (e.g. Tick Borne Illness)
  5. Timing
    1. Fever onset in relation to the rash
  6. Medications
    1. See Drug Eruption
    2. See Fixed Drug Eruption
    3. See Drug-Induced Fever
    4. See Life-Threatening Drug-Induced Rashes
  7. Associated symptoms
    1. Upper respiratory symptoms (cough, congestion, Rhinorrhea)
  8. Past Medical History
    1. Immunocompromised State (e.g. Chemotherapy, immunomodulators, status post transplant)

III. Causes: Classic Exanthems (historical order of first identified)

  1. First: Rubeola (Measles)
  2. Second: Scarlet Fever (Streptococcus Pyogenes)
  3. Third: Rubella (German Measles)
  4. Fourth: Dukes' Disease (Coxsackievirus or Echovirus)
  5. Fifth: Fifth Disease (Erythema Infectiosum, Parvovirus)
  6. Sixth: Exanthem Subitum (Roseola Infantum, HH6, HH7)

IV. Causes: Distribution of Febrile Eruption

  1. Central Eruptions (starts with head and neck, trunk)
    1. Viral Exanthem
      1. Papular Acrodermatitis
      2. Rubeola (Measles)
      3. Rubella
      4. Parvovirus B19 (Erythema Infectiosum)
      5. Roseola Infantum (HH6)
    2. Drug Eruption
    3. Typhoid Fever
  2. Peripheral Eruptions (Centripetal Rash - starts on distal extremities)
    1. Erythema Multiforme
    2. Secondary Syphilis
    3. Meningococcemia
    4. Rocky Mountain Spotted Fever
    5. Dengue Fever
    6. Coxsackievirus

V. Causes: Petechial Eruptions in the Febrile Patient

  1. See Purpura (or Petechiae)
  2. Common and Urgent Causes
    1. Toxic Appearing Patient
      1. Rocky Mountain Spotted Fever
      2. Meningococcemia
        1. Rash may first appear blanching, maculopapular before becoming petechial
    2. Well-Appearing Patient
      1. Henoch-Schonlein Purpura
        1. Afebrile, well appearing child with preceding viral syndrome in prior 1-3 weeks
        2. Symmetric lower extremity Petechiae and Purpura
  3. Viral Causes
    1. Coxsackievirus A9
    2. Echovirus 9
    3. Epstein-Barr Virus
    4. Cytomegalovirus
    5. Atypical Measles
    6. Viral Hemorrhagic Fever
      1. Arbovirus Infection
      2. Arenavirus Infection
  4. Other Causes
    1. Disseminated Gonococcus
    2. Staphylococcal Sepsis
    3. Thrombotic Thrombocytopenic Purpura

VI. Causes: Diffuse Erythema and Desquamation in the Febrile Patient

  1. See Desquamation
  2. Most Common
    1. Kawasaki Disease
    2. Scarlet Fever
      1. Fever, Pharyngitis and diffuse, fine red papular rash (sandpaper) on trunk, caused by Group A Streptococcus
      2. Distinguish from Kawasaki Disease
    3. Toxic Shock Syndrome
      1. Diffuse Erythroderma with fever, Hypotension and multi-system organ dysfunction due to Strep or Staph
    4. Scalded Skin Syndrome
      1. Burn-like rash in toxic appearing infants and toddlers, starting on the face and genitalia
  3. Less Common
    1. Ehrlichiosis
    2. Streptococcus viridans bacteremia
    3. Enteroviral infection
    4. Toxic Epidermal Necrolysis
    5. Graft-versus-host reaction
    6. Erythroderma
    7. Generalized Pustular Psoriasis (von Zumbusch)

VII. Causes: Vesiculobullous Eruptions in the Febrile Patient

  1. See Vesiculobullous Rash
  2. Common
    1. Varicella Zoster Virus (Chicken Pox)
      1. Initial prodrome (fever, upper respiratory symptoms, malaise)
      2. Rash after 12-24 hours with oval, teardrop Vesicles on an erythematous base (dew-drop on rose petal)
      3. Rash starts on face and scalp and spreads to trunk and back (minimal extremity involvement)
      4. Lesions heal over 7-10 days
      5. In vaccinated children, breakthrough varicella causes central eruption, <50 lesions
    2. Herpes Zoster (Shingles)
      1. Unilateral Dermatomal Distribution of vessicles on an erythematous base
    3. Hand Foot and Mouth Disease (Coxsackievirus A)
      1. High fever and variably painful, maculopapular or vesicular lesions on hands, feet as well as Oral Mucosa
      2. May also affect buttocks and genitalia, and spread by fecal-oral route
    4. Bullous Impetigo
      1. Staphylococcal Skin Infection typically on the extremities or face; some lesions may have honey-colored crust
    5. Eczema Herpeticum
      1. HSV1 superinfection in 3% of Atopic Dermatitis typically on face, neck, chest and upper back
      2. Sudden onset grouped, dome-shaped Vesicles that rupture leaving erosions, and then crust, and resolve after 6 weeks
      3. Often with systemic symptoms (fever, malaise, Lymphadenopathy), and may be superinfected with Bacteria
  3. Less common
    1. Staphylococcal Bacteremia
    2. Gonococcemia
  4. Immunocompromised Patient Causes
    1. Disseminated Herpes Simplex Virus
    2. Vibrio vulnificus (seafood exposure)
    3. Rickettsia Akari

VIII. Causes: Nodular Eruptions in the Febrile Patient

  1. See Nodular Lymphangitis
  2. See Subcutaneous Nodule
  3. Erythema Nodosum
  4. Disseminated Fungal Infection (Immunocompromised)
    1. Disseminated Candidiasis
    2. Cryptococcosis
    3. Blastomycosis
    4. Histoplasmosis
    5. Coccidioidomycosis
    6. Sporotrichosis
  5. Other rare causes
    1. Nocardia
    2. Pseudomonas
    3. Mycobacterium species

IX. Causes: Important Blanching, Maculopapular Rashes in Febrile Children

  1. Measles
    1. Rash preceded by cough, Coryza and Conjunctivitis and high fever (>39 C); Buccal mucosaKoplik Spots
    2. Rash starts on day 2-4 of symptoms, scalp and face first, then spreads to body (see Central Eruptions above)
  2. Parvovirus B19
    1. Starts with cough, congestion, followed in 1 week by slapped cheek on face
    2. Later, develops lacy reticular rash on extremities (but spares palms and soles)
    3. Causes edematous, pupuric socks and gloves syndrome (other causes HH6-7, EBV, CMV, Measles, Rubella, Covid)
    4. Complications include severe Anemia, Hydrops fetalis (due to congenital infection during pregnancy)
  3. Roseola (sixth disease, HH6-7)
    1. Three days of high fever, Conjunctivitis, Rhinorrhea, irritability, followed by development of central erupting rash
    2. Diffuse, blanching maculopapular rash (first on trunk, then extremities)
    3. Nagayama spots may develop on Soft Palate and uvula in 66% of Roseola cases
  4. Acute Rheumatic Fever
    1. Erythema Marginatum (pink rash, pale center, serpiginous margin)
    2. Associated with Jones Criteria (Migratory Arthritis, carditis, Nodules, Sydenham's Chorea)
  5. Kawasaki Disease (Mucocutaneous Lymph Node Syndrome)
    1. Variable, polymorphous non-vesicular rash
    2. Associated with 5 days fever, Conjunctivitis, adenopathy, strawberry Tongue and distal extremity edema
    3. Vasculitis with Coronary Artery complication risk

X. Causes: Important Bacterial and Life Threatening Febrile Rashes

  1. See Life-Threatening Drug-Induced Rashes
  2. Erysipelas (and Cellulitis)
    1. Erysipelas is bright red, well demarcated raised dermal infection, that spreads rapidly (faster than Cellulitis)
    2. Typically due to Group A Streptococcus (but Staphylococcus Aureus can present similarly, esp. on face)
  3. Rocky Mountain Spotted Fever (Dermacentor tick borne)
    1. High mortality illness, developing 4-10 days after Tick Bite, esp. in summer months
    2. Starts with petechial rash at ankles and wrists, spreading centrally toward Abdomen
    3. Associated with fever, Headache and Fatigue; high mortality (20-30%) with delayed treatment
  4. Lyme Disease (Deer Tick borne)
    1. Fever, Headache, malaise and Fatigue starting within days of Tick Bite
    2. Erythema Migrans target-like erythematous rash develops in 70% of cases between 3 and 30 days
    3. Rash gradually increases >5 cm to often 20-30 cm over days
  5. Septic Arthritis
    1. Fever, severe Joint Pain and swelling (unable to bear weight) with erythematous rash over affected joint
  6. Scarlet Fever
    1. Group A Streptococcal infection presents with Strep Pharyngitis, strawberry Tongue, fever and chills
    2. Diffuse sandpaper-like, reticular rash (esp. trunk)
  7. Disseminated Gonococcal Infection
    1. Sexually active patient or congenital exposure with fever, malaise, Arthralgias
    2. Skin lesions (Macules, Papules, Pustules, Vesicles, micro-abscesses) affect the trunk, hands and feet
    3. May also affect oropharynx and Rectum
  8. Staphylococcal Scalded Skin Syndrome
    1. Primarily affects children age <5 years (esp. <3 years); infection with Exotoxin A/B producing Staph Aureus
    2. Onset with fever, malaise, irritability, followed by rash after 24 to 48 hours
    3. Rash is rapidly progressive, erythematous, desquamating with Blistering of the face and flexor surfaces
  9. Toxic Shock Syndrome
    1. Superantigen producing Group A Strep and staph infecting retained foreign bodies, burns, Skin Infections
    2. Prodrome of fever, Nausea, Vomiting, URI followed by rash, Hypotension/shock (mortality 50%)
    3. Rash is diffuse, erythematous, blanching with later Desquamation after days-weeks
    4. May involve mucous membranes (oropharynx, vagina)
  10. Meningococcemia (Neisseria Meningitidis)
    1. Prodrome with malaise, fever, Headache, Vomiting progressing to meningeal signs, Altered Mental Status
    2. Dark purple, purpuric, non-blanching rash occurs later, and may involve mucous membranes, hands, feet
  11. Necrotizing Fasciitis
    1. Toxin producing group A strep, staph aureus (and others) spread rapidly along fascial planes
    2. Associated fever, severe pain exacerbated by involved extremity flexion/extension (esp. Immunocompromised)
    3. Pain out of proportion to initially mild skin findings (later erythema, edema, induration, and late bullae, Purpura)
  12. Stevens Johnson Syndrome and Toxic Epidermal Necrolysis
    1. Immune triggered (80% due to medications) Cytokine Storm with secondary diffuse tissue necrosis
    2. Prodrome of Nausea, Vomiting, fever, malaise, URI symptom followed by rash after 3-4 days
    3. Painful rash, Erythroderma, Blisters (with Nikolsky Sign) and mucosal involvement

XI. References

  1. Behar and Claudius in Herbert (2020) EM:Rap 20(6): 6-8
  2. Grimm (2026) Crit Dec Emerg Med 40(3): 28-41
  3. Cunha (1998) Crit Care Clin 14:35-53 [PubMed]
  4. McKinnon (2000) Am Fam Physician 62(4):804-16 [PubMed]
  5. Schlossberg (1996) Infect Dis Clin North Am 10:101-10 [PubMed]

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