Characteristic viral exanthems Fever with skin rash

1. Official reprint from UpToDate
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Author
Antonio A T Chuh, MD, FRCP,
FRCPCH
Section Editors
Moise L Levy, MD
Morven S Edwards, MD
Deputy Editor
Abena O Ofori, MD
Gianotti-Crosti syndrome (papular acrodermatitis)
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2014. | This topic last updated: May 22, 2014.
INTRODUCTION — Gianotti-Crosti syndrome (GCS), also known as papular acrodermatitis, papular acrodermatitis
of childhood, and infantile papular acrodermatitis, is a symmetric papular eruption with an acral distribution (cheeks,
buttocks, and extensor surfaces of the forearms and legs) (picture 1A-F). It was first described by Gianotti in 1955,
and by Crosti and Gianotti in 1957 [1,2], and was initially believed to occur only in infants and children [3-5]. It has
since been reported in adults [6-8].
TERMINOLOGY — In the original descriptions, Gianotti-Crosti syndrome (GCS) had three cardinal manifestations
[1-5]:
Gianotti referred to papular or papulovesicular acral eruptions, with or without itching, associated with reactive
lymphadenitis, but not hepatitis, as "papulovesicular acrolocated syndrome" [4]. However, it is not possible to
distinguish between GCS and papulovesicular acrolocated syndrome solely on the basis of cutaneous findings [9].
With current terminology, neither lymphadenopathy nor hepatitis is mandatory for the diagnosis of GCS. The term
"Gianotti-Crosti disease" is sometimes reserved for patients with GCS that is documented to be related to hepatitis B
virus (HBV) infection [10].
EPIDEMIOLOGY — The incidence and prevalence of Gianotti-Crosti syndrome (GCS) are unknown. Because many
children with GCS may be diagnosed with a "viral rash" or "nonspecific viral exanthem," GCS is probably
underdiagnosed [11]. (See 'Differential diagnosis' below.)
GCS primarily affects children younger than five years of age. During childhood, boys and girls are equally affected
[12,13]. However, in adulthood, females may be more prone than males to develop GCS [10].
Most reports of GCS describe isolated cases. However, several outbreaks have been described [14-18]. Three
outbreaks in Japan were associated with HBV and involved 153, 54, and 14 patients [14-16]. The remaining two
outbreaks were associated with Epstein-Barr virus (EBV) infection, and each involved five patients [17,18]. A mini-
epidemic with four patients was reported, but the underlying virological cause was not found [19].
ETIOLOGY — Gianotti-Crosti syndrome (GCS) usually occurs in association with a viral illness. HBV and EBV are
the most common causes. In a review of 308 cases, 22 percent were caused by HBV and 78 percent by other
viruses [9].
Hepatitis B virus — The association of GCS with HBV infection is well known [9,14-16,20-23]. However, HBV is an
uncommon cause of GCS in the United States and in other countries where universal hepatitis B vaccination during
infancy is routine [10]. In infants and young children with acute HBV infection, GCS may be the only clinical
manifestation. The clinical manifestations, treatment, and prevention of hepatitis B virus are discussed separately.
(See "Overview of hepatitis B virus infection in children" and "Epidemiology, transmission, and prevention of hepatitis
B virus infection" and 'Complications' below.)
Epstein-Barr virus — Epstein-Barr virus is another common cause of GCS, accounting for approximately one-half
®
®
Nonrelapsing erythemato-papular dermatitis localized to the face and limbs, lasting about three weeks●
Paracortical hyperplasia of lymph nodes●
Acute hepatitis, usually anicteric, which could last for months and progress to chronic liver disease●

2. to three-quarters of cases in some series [12,24-28]. The clinical manifestations and treatment of EBV infection are
discussed separately. (See "Clinical manifestations and treatment of Epstein-Barr virus infection" and 'Complications'
below.)
Other infections — GCS is less commonly reported in association with other pathogens, including enteroviruses
[29,30], cytomegalovirus [31-33], parvovirus [34,35], parainfluenza virus [36,37], hepatitis A virus [38,39], rotavirus
[40,41], molluscum contagiosum [34,42], respiratory syncytial virus [30], human immunodeficiency virus [43], human
herpesvirus 6 (mainly 6B) [44,45], Mycoplasma pneumoniae [46,47], beta-hemolytic streptococci [30], Bartonella
henselae [48], and Borrelia burgdorferi [49]. (See appropriate topic reviews).
Vaccines — GCS has been reported to occur after the administration of various vaccines, including influenza virus
vaccine [50], measles-mumps-rubella vaccines [51], hepatitis B and measles vaccines [52,53], oral polio vaccine
[54], hepatitis A vaccine [55], and Japanese encephalitis vaccine [56]. However, many children receive vaccinations
before any disease event; such temporal associations may be purely coincidental and cannot be taken as definitive
evidence for a causal association.
PATHOGENESIS — The pathogenesis of Gianotti-Crosti syndrome (GCS), including the mechanism for the acral
distribution of lesions, is unknown. Lesional histopathologic changes are nonspecific, and include focal spongiosis
(collections of fluid in the epidermis) and parakeratosis with perivascular lymphocytic infiltrates in the upper dermis
[57].
The clinical manifestations of GCS may represent a final common pathway for infections caused by several viruses.
One hypothesis suggests that the clinical manifestations result from a delayed hypersensitivity reaction to viral illness
[58].
The significance of IgE-mediated immunity in the pathogenesis of GCS and other viral exanthems is another area of
investigation. A case-control study noted that children with GCS were significantly more likely to have had atopic
dermatitis and to have a family history of atopy than control children who were being evaluated for recurrent
infections (24 versus 7 percent for atopic dermatitis and 52 versus 31 percent for family history of atopy) [59].
CLINICAL FEATURES — Gianotti-Crosti syndrome (GCS) usually occurs in children younger than five years, but
older children, adolescents, and adults also may be affected. Most patients have an upper respiratory or
gastrointestinal illness in the week before the onset of the rash [10]; the initial illness may have resolved by the time
the child presents with the rash.
Dermatologic findings — GCS presents as a sudden symmetric eruption of multiple small papular or
papulovesicular lesions. The lesions are monomorphous, flat-topped, pink-brown papules or papulovesicles, 1 to 10
mm in diameter; they may coalesce into plaques (picture 1A-F) [10,60].
The face, buttocks, extensor aspects of forearms and legs, and feet are predominantly affected. Truncal lesions are
commonly present, although more transient and fewer in number than acrally distributed lesions. The presence of
truncal lesions does not exclude a diagnosis of GCS [61]. The mucosal surfaces and nails are not involved [62,63].
The appearance of lesions at sites of trauma (ie, the Koebner phenomenon) may be seen during the early phase
[12,63]. Pruritus usually is of mild to moderate severity; however, the spectrum ranges from absent to severe.
Hemorrhagic changes occasionally occur, particularly in areas subject to trauma [10,60,63]. It has been suggested
that patients with petechial lesions are more likely to have HBV [64]. However, the cutaneous findings of GCS are
not helpful in determining whether GCS is caused by HBV, EBV, or another etiologic agent [9]. (See "Overview of
hepatitis B virus infection in children".)
Other findings — Affected patients may have concurrent malaise, low-grade fever, or diarrhea [10].
Lymphadenopathy is present in 25 to 35 percent of patients, usually in the cervical, axillary, or inguinal regions
[12,65]. The frequency of hepatic involvement is not known [10]. When hepatitis is present, it usually is anicteric
(without clinically recognized jaundice) [5,66]. Splenomegaly may occur, but is uncommon [10].
Neither lymphadenopathy nor hepatomegaly is necessary to make a diagnosis of GCS. (See 'Diagnosis' below.)
Laboratory findings — There are no laboratory features characteristic of GCS. Patients with GCS may have
modest lymphocytosis or lymphopenia [10]. Liver enzymes may be elevated in patients with EBV, CMV, or hepatitis-

3. associated disease. Skin biopsy may be useful in cases that are clinically confusing.
Course — Most children with GCS have an excellent prognosis, although the course may be prolonged [10].
Spontaneous remission of the rash without active intervention is the rule. The rash usually lasts from 10 days to 6
months; however, durations ranging from 5 days to 12 months have been reported [65]. Pruritus may last for weeks.
In the initial two to three weeks, new papules and papulovesicles continue to occur, and the areas of involvement
expand. The distribution of eruption is most classic in the middle phase of the disease. Near the end of the course,
slow resolution of the lesions occurs. There may be mild postinflammatory hyperpigmentation or hypopigmentation.
However, scarring and/or pigment changes usually are not permanent. Recurrences are possible, but rare [67].
Lymphadenopathy and hepatomegaly (or hepatosplenomegaly) usually take longer to resolve than the cutaneous
lesions [21,63].
Complications — Postinflammatory hypopigmentation or hyperpigmentation occurs frequently in children with
darker skin types and can persist for months after resolution of the rash, but eventually resolves [10,68]. Permanent
scarring is infrequent, even for children with facial involvement.
Other potential complications are related to the underlying etiology. Complications related to EBV infection, including
splenic rupture, or lymphoproliferative disorders, are theoretically possible. (See "Clinical manifestations and
treatment of Epstein-Barr virus infection", section on 'Complications'.)
Children with acute HBV infection may progress to chronic infection [14]. The age at the time of acute infection is the
main determinant of the risk of progression: more than 90 percent of infants infected perinatally, and 25 to 50 percent
of children infected between one and five years of age, develop chronic HBV infection [69]. The natural history of
chronic HBV infection in children is variable, depending upon age, mode of acquisition, and ethnicity. (See "Overview
of hepatitis B virus infection in children", section on 'Natural history'.)
DIAGNOSIS — Gianotti-Crosti syndrome (GCS) is a clinical diagnosis. Laboratory investigations are not helpful in
establishing the diagnosis in young children, but may be necessary to determine the etiology or to exclude other
conditions in the differential diagnosis, particularly if the eruption or course is atypical for GCS. (See 'Differential
diagnosis' below.)
Clinical diagnosis — A diagnosis of GCS is strongly suggested by the sudden onset of a symmetrically distributed
papular or papulovesicular eruption in a young child that primarily involves the face, buttocks, and/or extensor
surfaces of the extremities and does not have another identifiable cause (picture 1A-F). The presence of
extracutaneous signs and symptoms (eg, malaise, fever, diarrhea, lymphadenopathy) is variable.
The establishment of diagnostic criteria would help to facilitate the clinical diagnosis of GCS and future studies of the
disease. It remains to be determined whether diagnostic criteria proposed by the author and others are the ideal
criteria for the diagnosis of this disease [70].
Skin biopsy — Lesional histopathologic changes are nonspecific and cannot confirm the diagnosis. However,
lesional skin biopsy may be necessary to exclude other considerations in the differential diagnosis if the rash is
atypical (eg, more prominent truncal than acral distribution or lack of spontaneous resolution in six months). (See
'Differential diagnosis' below.)
Etiologic diagnosis
HBV — Whether HBV serology and liver function tests are indicated for children with a diagnosis of GCS is
controversial. On the one hand, HBV is an uncommon cause of GCS in countries where universal hepatitis B
vaccination during infancy is routine [10]; HBV also appears to be an uncommon cause of GCS in some developing
countries, such as India [71].
On the other hand, GCS may be the only clinical manifestation of acute HBV in infants and young children. The
presence of jaundice cannot be used to indicate the need for HBV testing, since the hepatitis associated with GCS is
usually anicteric. (See "Overview of hepatitis B virus infection in children", section on 'Acute HBV infection' and
'Other findings' above.)
The ethnic origin, HBV carrier status of parents and family members (if known), physical status of the child,

4. immunization status of the child, and local prevalence of HBV infection are factors to consider in making a decision
about testing for HBV. (See "Epidemiology, transmission, and prevention of hepatitis B virus infection".)
We suggest the following tests for patients who are at increased risk for hepatitis B virus or who have hepatomegaly
[10]:
Other viruses — Investigations for EBV such as polymerase chain reaction for EBV DNA in peripheral blood
mononuclear cells and serologic testing are generally unnecessary, since they do not affect clinical management.
However, identification of an etiologic agent may be indicated in immunocompromised patients and/or patients with
close contact with immunocompromised patients or pregnant women [72]. (See 'Other infections' above.)
DIFFERENTIAL DIAGNOSIS — The constellation of clinical features in Gianotti-Crosti syndrome (GCS) is usually
so characteristic that the diagnosis can be made relatively easily [10]. However, early in the course, during
resolution, or in atypical cases, a number of other conditions may warrant consideration.
Common conditions in the differential diagnosis of GCS include erythema infectiosum or other viral exanthems,
erythema multiforme (early in the course), hand-foot-mouth disease, papular urticaria, scabies, diffuse lichen planus,
and cutaneous drug eruptions. Less common, but important, conditions to consider in the differential diagnosis of
GCS (because of the different implications for treatment, prognosis, and spread of infection) include papular purpuric
gloves and socks syndrome, acrodermatitis enteropathica, Henoch-Schönlein purpura (IgA vasculitis), and Kawasaki
disease.
Clinical features that may help to differentiate these conditions from GCS include the onset, duration, distribution,
and color of the rash; the presence and intensity of pruritus; and the involvement of the mucosa or nails [63].
Liver function tests — Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline
phosphatase, and gammaglutamyl transpeptidase (GGT).
●
Hepatitis B serology — Hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), and
hepatitis B core antibody (HBcAb). (See "Diagnosis of hepatitis B virus infection".)
●
Erythema infectiosum − Erythema infectiosum (EI, also known as "fifth disease") is a common childhood
exanthem caused by parvovirus B19. Like GCS, EI begins with nonspecific prodromal illness and acral
eruption. However, the rash of EI, which begins on the cheeks (picture 2) and spreads to the extremities
(picture 3), is usually macular rather than papular. By the time the rash develops, the child is no longer
contagious. (See "Clinical manifestations and pathogenesis of human parvovirus B19 infection", section on
'Erythema infectiosum'.)
●
Erythema multiforme − Erythema multiforme (EM) typically affects adolescents and young adults, but 20
percent of cases occur in children [60]. EM is often caused by herpes simplex virus or Mycoplasma infection.
Although target lesions are characteristic of EM (picture 4), the lesions may be papular early in the course.
Mucosal lesions are present in 25 to 50 percent of children with EM [60] and may help to distinguish it from
GCS.
●
Hand, foot, and mouth disease − Hand, foot, and mouth disease (HFM) is a common childhood illness that is
usually caused by the group A coxsackieviruses. HFM is characterized by fever; oral vesicles on the buccal
mucosa and tongue; and peripherally distributed small, tender cutaneous lesions on the hands, feet, buttocks,
and (less commonly) genitalia (picture 5A-C). It usually resolves in around seven to ten days. The mucosal
lesions and clinical course of HFM distinguish it from GCS. (See "Clinical manifestations and diagnosis of
enterovirus and parechovirus infections", section on 'Hand, foot, and mouth syndrome'.)
●
Scabies − Scabies is an infestation of the skin by the mite Sarcoptes scabiei that results in an intensely pruritic
eruption (picture 6). The degree of pruritus distinguishes scabies from GCS: GCS never itches as severely as
virtually every case of scabies does. (See "Scabies".)
●
Papular urticaria − Papular urticaria (also known as insect bite-induced hypersensitivity reaction) is defined by
chronic or recurrent eruptions of papules, vesicles, target lesions, or wheals caused by hypersensitivity to
insect bites (eg, fleas, mosquitoes, bedbugs, mites) in children between 2 and 10 years of age. The lesions are
symmetric and usually grouped in crops or clusters on exposed areas; they may take weeks to years to
●

5. TREATMENT — The treatment of Gianotti-Crosti syndrome (GCS) is supportive, consisting of symptomatic
treatment of pruritus and education of the parents regarding the typically benign clinical course.
Supportive care
Pruritus — Symptomatic relief for pruritus is the only necessary treatment for most children with GCS. Various
treatments for pruritus in GCS have been described in observational studies; none has been studied in a randomized
controlled trial.
In our experience, topical emollients provide adequate relief for most children. We suggest topical calamine lotion for
children with pruritus of moderate severity. We suggest a nocturnal dose of a systemic sedating antihistamine (eg,
diphenhydramine) for children with severe pruritus.
resolve. Management is reviewed separately. (See "Insect bites", section on 'Papular urticaria'.)
Lichen planus − Diffuse lichen planus might mimic GCS in adults. Distinguishing features of lichen planus
include intense pruritus, pale violet color (picture 7), frequent involvement of the mucosal surfaces, and
tendency to occur on the volar surface of the wrists (picture 8) [10]. (See "Lichen planus".)
●
Cutaneous drug eruption − Cutaneous drug eruptions begin in dependent areas and generalize, often with
associated mucus membrane erythema. Pruritus is the most common symptom. Blood eosinophilia may be
present but is not a reliable finding. The most commonly prescribed medications (eg, antibiotics) are implicated
most often.
The clinical course distinguishes drug eruption from GCS. The onset of drug eruptions is almost always within
two weeks of beginning a new drug, and within days of reexposure to a drug to which an individual is
sensitized; chemically related compounds can cause cross reactions. Discontinuing the offending drug leads to
resolution of the rash. (See "Drug eruptions", section on 'Drug-induced exanthems'.)
●
Papular purpuric gloves and socks syndrome − Papular purpuric gloves and socks syndrome (PPGSS)
typically occurs in young adults, but may occur in children [60,73,74]. It may be caused by several viruses
including parvovirus B19, EBV, and CMV [75,76]. It is characterized by rapidly progressive symmetric painful
swelling and erythema of hands and feet, often with a petechial or purpuric component [60]. There is a sharp
demarcation at the wrists and ankles (picture 9).
Systemic features may include anorexia, fever, and arthralgias [72]. Mucosal lesions, which do not occur in
GCS, are a characteristic feature of PPGSS. In contrast to patients with EI, patients with parvovirus B19-
related PPGSS may remain viremic, and therefore contagious, during the exanthem [60]. (See "Clinical
manifestations and pathogenesis of human parvovirus B19 infection", section on 'Erythema infectiosum'.)
●
Acrodermatitis enteropathica − Acrodermatitis enteropathica is a recessively inherited partial defect in
intestinal zinc absorption. The clinical features include hyperpigmented skin lesions on the acral surfaces of the
upper and the lower extremities, as well as the face and buttocks (picture 10). Acrodermatitis enteropathica is
usually associated with other clinical manifestations (eg, alopecia, night blindness, diarrhea, impaired taste,
growth retardation, and immune dysfunction) and has a different clinical course from GCS. (See "Zinc
deficiency and supplementation in children and adolescents", section on 'Acrodermatitis enteropathica'.)
●
Henoch-Schönlein purpura (IgA vasculitis) − Henoch-Schönlein purpura (HSP, IgA vasculitis [IgAV]) is the
most common form of systemic vasculitis in children. It is characterized by palpable purpura in patients with
neither thrombocytopenia nor coagulopathy (picture 11A-B), arthritis/arthralgia, abdominal pain, and renal
disease. The clinical manifestations may develop over the course of days to weeks and may vary in their order
of presentation. When present, the noncutaneous manifestations of HSP (IgAV) distinguish it from GCS. (See
"Henoch-Schönlein purpura (IgA vasculitis): Clinical manifestations and diagnosis".)
●
Kawasaki disease − Kawasaki disease is another common vasculitis of childhood. It is characterized by
systemic inflammation manifested by fever, bilateral nonexudative conjunctivitis, erythema of the lips and oral
mucosa, rash, extremity changes, and lymphadenopathy. The mucosal lesions of Kawasaki disease help to
distinguish it from GCS. (See "Kawasaki disease: Clinical features and diagnosis".)
●

6. Topical corticosteroids have been tried in GCS but there is no evidence that the disease course is modified by such
therapy [36]. Nonetheless, they may be helpful in controlling pruritus.
Education — Parents of children with GCS should be provided with information about the etiology, prognosis,
complications, and potential spread of the eruption to other children. As a general rule, complications of GCS are
rare, the course is benign, and the prognosis is good. (See 'Etiology' above and 'Course' above and 'Control
measures' below.)
Monitoring — Children with GCS due to HBV infection should be followed-up regularly. In patients who recover
from acute hepatitis B infection without progression to chronic infection, normalization of serum aminotransferases
usually occurs within one to four months. Persistent elevation of serum ALT for more than six months indicates
chronic hepatitis. (See "Clinical manifestations and natural history of hepatitis B virus infection", section on 'Acute
hepatitis'.)
Children with chronic hepatitis B infection should be referred to a pediatric gastroenterologist or hepatologist. (See
'Referral indications' below.)
Control measures — The likelihood that the eruption will spread to other children depends to some extent upon the
underlying etiology. However, for most of the causative infections, children are no longer contagious once the rash
appears.
Exclusion from child-care or school is unnecessary for most children with typical GCS. Children who are hepatitis B
surface antigen positive can be admitted to child-care without restrictions provided that they have no behavioral or
medical risk factors (eg, aggressive behavior, biting, bleeding disorder) [69]. (See "Overview of hepatitis B virus
infection in children", section on 'Counseling and prevention'.)
Referral indications — Referral to a pediatric dermatologist may be indicated if the diagnosis is uncertain or the
disease course is exceptionally prolonged (eg, longer than six months).
Referral to a pediatric gastroenterologist or hepatologist is indicated for children with persistently elevated liver
enzymes or chronic hepatitis B infection. (See "Overview of hepatitis B virus infection in children".)
SUMMARY AND RECOMMENDATIONS
Gianotti-Crosti syndrome (GCS) is a symmetric papular eruption with an acral distribution (cheeks, buttocks,
and extensor surfaces of the forearms and legs). (See 'Introduction' above.)
●
GCS primarily affects children younger than five years, but can occur in adolescents and adults. (See
'Epidemiology' above.)
●
GCS usually occurs in association with a viral illness. Hepatitis B virus (HBV) and Epstein-Barr virus are the
most common causes. HBV is an uncommon cause of GCS in the countries where immunization of infants
against HBV is routine. (See 'Etiology' above.)
●
Although GCS has been reported to occur after the administration of various vaccines, a causal association
has not been established. (See 'Vaccines' above.)
●
The diagnosis of GCS is clinical. The characteristic rash of GCS consists of symmetric monomorphous, flat-
topped, pink-brown papules or papulovesicles, 1 to 10 mm in diameter, that occur on the face, buttocks, feet,
and extensor aspects of forearms and legs (picture 1A-F). (See 'Clinical features' above.)
●
Noncutaneous findings include malaise, low-grade fever, and diarrhea. Lymphadenopathy is present in 25 to 35
percent of patients, typically in the cervical, axillary, or inguinal regions. Hepatitis, when present, is usually
anicteric. (See 'Other findings' above.)
●
An etiologic diagnosis for GCS should be pursued in patients with increased risk for hepatitis B virus infection,
immunocompromised patients, and patients who have close contact with immunocompromised individuals or
pregnant women. (See 'Etiologic diagnosis' above.)
●
The constellation of clinical features in GCS is usually characteristic. However, a number of other conditions
may warrant consideration early in the course, during resolution, or in atypical cases. These include erythema
●

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infectiosum, erythema multiforme, hand-foot-mouth disease, scabies, papular urticaria, lichen planus, papular
purpuric gloves and socks syndrome, acrodermatitis enteropathica, Henoch-Schönlein purpura (IgA vasculitis),
and Kawasaki disease. (See 'Differential diagnosis' above.)
The treatment of GCS is supportive. We suggest the following supportive measures (Grade 2C):●
Topical emollients for mild pruritus•
Topical calamine lotion for moderate pruritus•
A nighttime dose of sedating antihistamine (eg, diphenhydramine) for severe pruritus•
Children with GCS due to HBV infection should be followed-up regularly. (See 'Monitoring' above.)●
Referral to a pediatric gastroenterologist or hepatologist is indicated for children with persistently elevated liver
enzymes or chronic hepatitis B infection. (See 'Referral indications' above.)
●

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10. 76. Grilli R, Izquierdo MJ, Fariña MC, et al. Papular-purpuric "gloves and socks" syndrome: polymerase chain
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41:793.
Topic 4040 Version 9.0

11. GRAPHICS
Characteristic eruption of Gianotti-Crosti syndrome
(papular acrodermatitis)
The characteristic rash of Gianotti-Crosti syndrome consists of symmetric pink-
brown papular or papulovesicular lesions that are flat-topped and range from 1
to 10 mm in diameter. The face, buttocks, extensor aspects of forearms and
legs, and feet are predominantly affected.
Courtesy of Moise L Levy, MD.
Graphic 67780 Version 2.0

12. Gianotti-Crosti syndrome
Multiple papules and papulovesicles on the extremities of a child.
Reproduced with permission from: www.visualdx.com. Copyright © 2014 Logical Images, Inc.
Graphic 95217 Version 1.0

13. Gianotti-Crosti syndrome
Multiple papules and papulovesicles on the face of a child with Gianotti-Crosti syndrome.
Reproduced with permission from: www.visualdx.com. Copyright © 2014 Logical Images, Inc.
Graphic 95218 Version 1.0

14. Gianotti-Crosti syndrome
Papular and papulovesicular eruption with a predilection for the face
and extremities in a child with Gianotti-Crosti syndrome.
Reproduced with permission from: www.visualdx.com. Copyright © 2014
Logical Images, Inc.
Graphic 95219 Version 1.0

15. Gianotti-Crosti syndrome
Papules and papulovesicles in Gianotti-Crosti syndrome.
Reproduced with permission from: www.visualdx.com. Copyright © 2014 Logical Images, Inc.
Graphic 95220 Version 1.0

16. Gianotti-Crosti syndrome
Papules and papulovesicles on the buttocks of a child with Gianotti-Crosti syndrome.
Reproduced with permission from: www.visualdx.com. Copyright © 2014 Logical Images, Inc.
Graphic 95221 Version 1.0

17. Slapped cheek rash of parvovirus B19
A child with the characteristic malar ("slapped cheek") rash associated
with parvovirus B19 (erythema infectiousum, fifth disease).
Courtesy of Moise L Levy, MD.
Graphic 71737 Version 1.0

18. Erythema infectiosum
Reticulating pattern of an erythematous eruption on the extremities
due to parvorvirus B19. Rash is more common in children. The
presence of intense erythema (a slapped cheek appearance) on the
face is highly characteristic.
Courtesy of Lee T Nesbitt, Jr. The Skin and Infection: A Color Atlas and Text,
Sanders CV, Nesbitt LT Jr (Eds), Williams & Wilkins, Baltimore, 1995.
http://www.lww.com
Graphic 75125 Version 5.0

19. Erythema multiforme
Characteristic target lesions of the palm in erythema multiforme begin
with a central vesicle.
Courtesy of Lee T Nesbitt, Jr. The Skin and Infection: A Color Atlas and Text,
Sanders CV, Nesbitt LT Jr (Eds), Williams & Wilkins, Baltimore 1995.
http://www.lww.com
Graphic 74095 Version 5.0

20. Hand-foot-and-mouth disease - buccal mucosa
Small ulcers are present on the oral mucosa.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
Graphic 58566 Version 4.0

21. Hand-foot-and-mouth disease - tongue
Multiple small ulcers are present on the tongue.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
Graphic 71314 Version 3.0

22. Hand-foot-and-mouth disease - foot
Multiple vesicular lesions on an erythematous base are present on the
foot.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
Graphic 53423 Version 4.0

23. Interdigital lesions of scabies
The essential lesion is a small, erythematous, nondescript papule.
Courtesy of John T Crissey, MD.
Graphic 51161 Version 1.0

24. Lichen planus
Lichen planus is characterized by flat-topped, violaceous papules.
Courtesy of Andrew Samel, MD.
Graphic 59807 Version 1.0

25. Lichen planus
Note discrete polygonal scaling erythematous papules on the wrist.
Courtesy of Beth G Goldstein, MD and Adam O Goldstein, MD.
Graphic 50579 Version 1.0

26. Gloves and socks syndrome secondary to
parvovirus B19 infection
Papular-purpuric rash on the hands and feet of a patient with acute
parvovirus B19 infection.
Reproduced with permission from: Anderson DJ, Fangman W, Fowler VG, et
al. A returning traveler with fever and rash. Clin Infect Dis 2005; 41:1453.
Copyright © 2005 University of Chicago Press.
Graphic 51856 Version 2.0

27. Acrodermatitis enteropathica
Acrodermatitis enteropathica in an infant. Moist erythematous plaques are
present on the cheeks and buttocks. The buttock lesions are typically symmetric.
(Panel A) Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
(Panel B) Courtesy of Robert Sidbury, MD.
Graphic 71329 Version 6.0

28. Skin manifestations of Henoch-Schönlein purpura (IgA
vasculitis)
This picture shows the classic skin manifestations of Henoch-Schönlein purpura
(IgA vasculitis), with clusters of typical ecchymoses, petechiae, and palpable
lesions on the legs in a typical distribution (gravity/pressure-dependent areas).
IgA: immunoglobulin A.
Courtesy of Susan Kim, MD.
Graphic 63367 Version 5.0

29. Skin manifestations of Henoch-Schönlein purpura (IgA
vasculitis)
Courtesy of Susan Kim, MD.
Graphic 72094 Version 4.0

30. Disclosures: Antonio A T Chuh, MD, FRCP, FRCPCH Nothing to disclose. Moise L Levy, MD Grant/Research/Clinical Trial Support:
GSK [psoriasis (calcipotriene)]; Anacor [atopic dermatitis (investigational drug)]. Consultant/Advisory Boards: Galderma [acne (epiduo)].
Patent Holder: Incontinentia pigmenti (NEMO gene mutations). Morven S Edwards, MD Grant/Research/Clinical Trial Support: Novartis
Vaccines [Group B Streptococcus]. Consultant/Advisory Boards: Novartis Vaccines [Group B streptococcal vaccine development]. Abena
O Ofori, MD Employee of UpToDate, Inc.
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