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Taking the Fifth

Expert Advance From NADNP

One of the "joys" of being a healthcare provider is that family members and friends view you as a mini walk-in clinic. My specialty of dermatology means that my cell phone has become a scaled down teledermatology tool. I save many of the photos sent to me because they may come in handy when writing articles; some of the cases have been quite interesting.

A caveat to this version of home healthcare is that I strongly recommend against it. Unless your family and friends are your established patients, it is best for you to direct them to their usual provider. This is wise for legal and ethical reasons. However, at times I don't follow my own advice.

The following case discusses a common pediatric exanthema. The proper diagnosis is erythema infectiosum, but it is most commonly referred to by its original name, Fifth disease, or by its most obvious symptom: "slapped face syndrome." Although this condition is self-limited and has a relatively innocuous course, it has some important implications and precautions that must be communicated to the parents of a child affected by it.

Subjective Report

My older sister, who lives with her family in another state, sent me a text message one day last summer. She reported concern about a rash that my 6-year-old nephew had developed overnight. The rash was primarily on the arms, legs and face. She stated that his cheeks were red and hot. Although he had a slight fever, it wasn't high enough to cause this appearance. I asked her to send me a picture of this presentation (see photo).

On further inquiry, I learned that my nephew had been sick for a few days with cold symptoms. My sister said he had experienced a slight fever, cough, mild headache and general malaise. She had managed his symptoms with acetaminophen and he appeared to be improving - until the rash appeared. He complained that it itched a little, but otherwise the rash was asymptomatic. My sister's concern was about a possible allergic reaction: Should she take him to the emergency room or should she just give him diphenhydramine  to stop the reaction? I told her that neither action was necessary.

Objective Report

Obviously I could not physically examine the pseudopatient first hand, but over the last 11 years of unofficial family teledermatology, my family members have gotten better at taking pictures and knowing what information I need. And, I have gotten better at using words they understand.

This otherwise healthy 6-year-old boy was presented to me via text message and photograph with an acute erythematous eruption of the upper and lower extremities, face and torso. The photo of the torso and extremities was not helpful and therefore not included in this case study.

The exanthem on the extremities and torso appeared to have many discrete annular macules and the mother described their appearance as "little rings." The extremity rash was mildly pruritic and different from the appearance of the "slapped face" look of the cheeks. This portion of the exanthem was bright red, fiery in appearance and covered both cheeks as well as the chin, extending mostly along the mandibular angle. The forehead and neck were spared.

As mentioned previously, the patient had a 2- to 3-day history of flu-like symptoms, including cough, fever, headache and runny nose. He was taking no new medications. There had been no recent travel, and no changes in soaps, detergents or diet. The child was in no apparent distress and exhibited no shortness of breath. Although the exanthem covered much of his body, no signs of edema were present, nor were any indications that this was an allergic reaction or urticaria.


Based on the parent's report of history and the photographic appearance, I diagnosed erythema infectiosum was reached. This condition is commonly referred to as Fifth disease, and it was named more than 100 years ago as a group of characteristic pediatric eruptions. Also included in this list were measles, scarlet fever, rubella, roseola infantum and varicella (chicken pox). Erythema infectiosum is caused by parvovirus B19 (erythrovirus) and it is the only parvovirus known to infect humans.¹

There are several manifestations of erythema infectiosum, but the most common is that of the pediatric case described above. This highly contagious respiratory virus has an average age of onset between 3 and 12, and it occurs equally in boys and girls. Erythema infectiosum is characterized by the fiery-red flushing of the cheeks and lacy erythema on the torso, arms and legs. This rash coincides with a release of IgG antibodies about 2 to 3 days after infection occurs. Unfortunately, the rash that is the hallmark sign of this virus in children marks the end of the contagious stage, thus likely leading to the rampant spread of the virus within school environments.²

Although this infection is considered an inconvenience rather than a serious illness, several populations must be wary of this easily transmitted disease. The virus can cause a reduction in the production of red blood cells, which can lead to the development of transient aplastic anemia, chronic red cell aplasia, hydrops fetalis or congenital anemia.3 People with disorders that affect red blood cell development or life span should avoid contact with people known to be infected. Special precautions should be taken for people with HIV, sickle cell disease, thalassemia and sprocyosis. They may require transfusions or intravenous immunoglobulin therapy if infected by erythema infectiosum.¹ Pregnant women should avoid contact with sick people because maternal-to-infant transmission has been linked to high fetal loss rates.³


Symptom management is all that is required for erythema infectiosum: acetaminophen for fever and ingestion of plenty of fluids. Over-the-counter hydrocortisone creams can be used to alleviate itching.

Parents should be instructed to avoid the above mentioned at-risk populations. In the case of my nephew, the rash resolved within a few days and he had no lasting effects.


A multitude of exanthems are associated with bacterial and viral diseases in children. Providers should be comfortable in discerning them and able to educate patients - or in this case, family members - about what they are and how to treat them. Unless you are comfortable doing this, avoid teledermatology consults requested by others. Refer them to their regular healthcare provider or insist on seeing them personally.


1. Lam JM. Characterizing viral exanthems. Pediatr Health. 2010;4(6):623-635.

2. Burkhart CN. Erythematous facial rash followed by reticulated eruption. Clinical Advisor. 2007;10(1):84.

3. Beigi RH, et al. High rate of severe fetal outcomes associated with maternal parvovirus B19 infection in pregnancy. Infect Dis Obstet Gynecol.


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