Roseola Infantum

What is roseola infantum?

Roseola infantum – also called roseola, three-day rash or three-day fever, exanthem subitum, pseudo-rubella or sixth disease – is a typically mild, self-limiting viral infection that mainly affects infants and toddlers. It causes a high fever, which is often followed by a rash on the trunk (torso) that may spread to the face, arms and legs.[1][2]

The rash is typically characterized by small, painless pink or red spots that turn white when pressed firmly. The spots may be flat or raised and may be surrounded by a white ring. The rash can fade quickly (within a few hours of appearing), or remain for a couple of days.[1][3]

Roseola is most common in children between six months and two years of age. Most children have been exposed to roseola before they are five years old and develop the antibodies to avoid repeat infection. However, roseola is occasionally contracted by older children, or adults who have not previously encountered it. If adults contract roseola, the symptoms are usually very mild.[4][5] It is possible to have roseola more than once, but this is unusual unless the person has a compromised immune system.[2][6]

Roseola is caused by two viruses in the herpes family: HHV, or human herpes virus, most often type 6 or occasionally type 7.[2] The virus is spread via droplet infection when an infected person coughs or sneezes, or through direct contact with an infected person or item that was, for example, sneezed on by an infected person.[5] This kind of herpes infection does not lead to lip (herpes labialis) or genital sores.[7]

Most children make a full, fast recovery from roseola without any specific treatment other than rest and adequate hydration.[8][2][9] Over-the-counter medicine, such as ibuprofen or acetaminophen (Paracetamol or Tylenol), may be recommended to help with symptoms like the fever.[1]

Roseola infantum symptoms

Following exposure to and infection with one of the two viruses causing roseola infantum, symptoms typically appear after an incubation period of approximately nine days (though this can be 5-15 days)[2].[1] The incubation period is the time between catching an infection and symptoms appearing.

The first symptom is rapidly occurring high fever (above 100.4 F or 38 C). The fever can last from three to seven days, and a rash typically develops after the fever passes.[4][5]

Common initial signs of roseola infantum may include:[1][5][8][10][2]

  • Sudden development of high fever (up to 104 F or 40 C)
  • Irritability
  • Tiredness
  • Pink or red spots (called Nagayama spots) at the back of the throat and on the uvula[3][2]
  • Runny nose
  • Loss of appetite
  • Swollen glands in the neck

Less common signs may include:[2]

  • Irritated eyes and swollen eyelids
  • Inflamed tympanic (ear drum) membranes
  • Vomiting
  • Diarrhea
  • Sore throat
  • Cough

Some people experience practically no symptoms of roseola.[4] However, they may still be contagious (able to transmit the virus to others). Practising good hygiene can help prevent the spread of roseola and many other diseases.[11]

Roseola infantum rash

When the fever passes, a distinct rash will often appear on the chest, back and stomach, sometimes spreading to the arms and legs and occasionally the face too. The rash is usually characterized by small pink or red spots that turn white when pressed. Some of the spots may have a white ring around them.[1][3]

The rash may have a raised appearance or remain flat, and it does not itch or hurt. It can fade within a few hours, or persist for a couple of days.[1][3][8][2]

The infection is usually over by the time the rash develops, and most children feel well again. As the fever and early symptoms can mimic other conditions, roseola is sometimes hard to diagnose. The fever appears before the characteristic rash, and high fevers can have quite a few other causes in infants and toddlers. This is why doctors usually diagnose roseola based on the appearance of the rash.[4]

Causes of roseola infantum

Roseola is most commonly caused by human herpes virus 6 (HHV-6), though it can also be caused by human herpes virus 7 (HHV-7). These types of herpes are different to the strains that cause cold sores and genital herpes.[5][9]

The virus is spread through droplets of fluid from the mouth, throat and nose, for example when a person coughs or sneezes. Contact with a person who has roseola, or items that have been contaminated with infected droplets, can result in the virus being transmitted.[5][9]

Diagnosis of roseola infantum

A doctor will typically diagnose roseola after taking the child’s (or adult’s) medical history and performing a physical examination. They will consider the signs and symptoms and rule out other common illnesses that cause a rash, such as measles or rubella (German measles). Laboratory blood tests may be ordered to confirm the diagnosis of roseola, but these are only rarely used, e.g. for very unclear presentations, or people with a compromised immune system.[5][2][9]

Prevention of roseola infantum

While it may not always be possible to prevent roseola, steps can be taken to reduce the risk of developing the condition. These include:[8][10]

  • Washing the hands thoroughly and often, with warm (not too hot) water and soap
  • Teaching children to sneeze and cough into tissues and to dispose of them in a sanitary manner
  • Avoiding the sharing of cups, plates and cutlery
  • Regularly disinfecting surfaces around the home

There is no vaccination to prevent roseola.

Roseola infantum treatment and medication

Roseola and the rash typically go away on their own, without any special treatment. A child (or adult) with roseola can usually recover at home.

The fever can be managed using techniques including:

  • Drinking lots of fluids
  • Getting plenty of rest
  • Dressing in cool clothing
  • Applying a cool cloth to the head

As roseola is a viral infection, antibiotics are not prescribed. Over-the-counter drugs such as ibuprofen or acetaminophen can be given in appropriate doses to reduce fever and pain.

Aspirin should never be given to treat a fever in children or young adults under 19 years of age, as it increases their risk of developing Reye’s syndrome, a life-threatening condition.[12]

The roseola virus remains in the body for life, making reactivation or reinfection possible at a later stage. This is more likely to occur if the person becomes immunocompromised, for example while undergoing treatment for cancer or receiving a bone marrow transplant.[2][13] If a child has a severely weakened immune system, the doctor may prescribe the antiviral drug ganciclovir to help treat the roseola and avoid complications.[4]

Complications of roseola infantum

Roseola typically does not cause any complications. However, in some children (up to 15 percent of cases), the high fever can cause febrile seizures (fever seizures).[1][2][5]

In very rare cases, roseola can lead to other complications like encephalitis (an inflammation of brain structures). The risk of this occurring is higher in children and adults with weakened immune systems.[5]

Febrile seizures

Febrile seizures are convulsions and periods of unresponsiveness that typically last for a few minutes. They can be alarming, but are seldom harmful.[1][14][15]

If a child has no history of febrile seizures but seems to be experiencing one, to be safe, an ambulance should be called without delay, or the child taken to a hospital or urgent care treatment center to receive a proper workup of the condition.[16][15]

In children with a history of febrile seizures, it is recommended that caregivers note the start time of a seizure and, should it continue for more than five minutes, call an ambulance immediately. Similarly, if the seizure ends within five minutes, but the child does not recover quickly and return to normal, an ambulance should be called.[15]

During a febrile seizure, the child should not be restrained, but placed on the ground or another appropriate, safe surface, and positioned on their side or stomach. If there is anything in the child’s mouth, this should be gently removed, if it is possible to do so without causing harm to the child or caregiver. Nothing should ever be placed in a child's or any person’s mouth during a convulsion.[15]

When to see a doctor

Most children recover from roseola within a week of the onset of the fever.[9] However, a doctor should be contacted if the rash lasts longer than one week, or if the fever, rash or other symptoms worsen instead of getting better. A doctor should be called immediately if the symptoms become so severe at any point that the child or caregiver cannot cope with them.

Roseola infantum FAQs

Q: How can one tell the difference between roseola and measles?
A: The rashes associated with roseola and measles are frequently confused, but they have different appearances. The roseola rash is pinkish-red and typically begins on the trunk (belly and back), then spreads to the extremities and sometimes the face. The spots are distinct and may be surrounded by a white ring. The roseola rash develops when the fever disappears and typically clears within a couple of days. The measles rash, on the other hand, is brownish-red and usually spreads from the face down to the rest of the body, with the spots running into each other and creating a blotchy or bumpy appearance. When the rash appears, a person may develop a high fever and feel very unwell. The rash typically persists for 5-6 days.[4][17][18][19]

Q: When can a child with roseola return to school?
A: A child with roseola can usually return to school and other activities after their temperature has returned to normal[10] and they feel well again.[8] A healthcare practitioner can advise on the best time of return for each child.

Q: Is a pregnant person at risk of passing roseola on to her fetus?
A: Most adults are immune to roseola infection due to previous exposure. Even if a pregnant person does contract roseola, the risk that they will pass it on to their unborn baby, or that it will cause complications for the fetus, appears to be very low.[20][21]

Other names for roseola infantum

  • Roseola
  • Three-day rash
  • Exanthem subitum
  • Pseudo-rubella
  • Sixth disease

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  15. Febrile Seizures Fact Sheet.” National Institute of Neurological Disorders and Stroke. May 10, 2017. Accessed February 10, 2018.

  16. Febrile seizures.” NHS Choices. October 10, 2016. Accessed: February 8, 2018.

  17. Differential Diagnosis of Viral Exanthemas.” Open Vaccine Journal. 2010. Accessed: February 15, 2018.

  18. Measles (Rubeola): Signs and Symptoms.” Centers for Disease Control and Prevention. February 5, 2018. Accessed: February 15, 2018.

  19. Measles - Symptoms.” NHS Choices. September 11, 2015. Accessed: February 15, 2018.

  20. Roseola in pregnancy.” babyMed. Accessed: August 3, 2017.

  21. Outcomes of infants whose mothers are positive for human herpesvirus‐6 DNA within the genital tract in early gestation.” Pediatrics International. January 19, 2011. Accessed: March 27, 2018.