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nonspecific viral exanthem in a child in whom other diagnoses have been
excluded and who may have signs of associated illness or systemic features such
as fever. If specific diagnosis is required, it can be determined by viral isolation
and/or a rise in diagnostic titer.

Generalized Eruptions Without Fever
Many generalized eruptions are not associated with fever. Many are fairly easily
recognizable, such as psoriasis, contact dermatitis, pityriasis rosea.
Guttate Psoriasis and Pityriasis Rosea
Please see Chapter 70 Rash: Papulosquamous Eruptions and Viral Exanthems for
full discussion of papulosquamous skin rashes.
Rubella
Rubella is rarely seen in the postvaccine era in the United States. In a classic case
of rubella, the rash, similar to measles, begins on the head and spreads caudally.
The progression occurs over 2 to 3 days, and typically, the rash is entirely gone
by the fourth day. The rash always remains macular and never becomes confluent,
which is an important distinguishing characteristic from measles. One-third of all
rubella virus infections is clinically silent (i.e., they have no exanthem). The rash
of rubella may show extensive variation in location, progression, and duration, at
times disappearing within 12 hours or being localized to one part of an extremity
without any progression.
Unlike measles, in which systemic toxicity and fever are the rule, fever is
uncommon. Associated symptoms and complaints in rubella include joint pain
and adenopathy (most commonly suboccipital, postauricular, and cervical).
Arthralgia that occurs with a viral exanthem is highly characteristic for rubella.
Diagnosis is based on clinical presentation, and treatment is supportive.

Vesicles/Bullae
Enterovirus Infections
Enterovirus infection can not only cause morbilliform exanthems but can also
cause vesicles and blisters. The classic exanthem of coxsackievirus A16 infection,

also appropriately called hand–foot–mouth disease , is common and easily
recognized. Infections may occur in epidemics, most commonly in the late
summer or early fall. Multiple infected members within a household are common.
Coxsackievirus A16 infection begins with a prodrome of low-grade fever,
anorexia, mouth pain, and malaise, followed within 1 to 2 days by an oral