Pink macules and small papules that later coalesce and often desquamate. Purpura can be seen. Pink macules begin on the face. Within one day, the rash fades from the face and spreads centrifugally to the trunk and extremities. The pink macules coalesce on the trunk but remain discrete on the extremities. The rash may be absent in as many as 25% of cases.
Pinpoint petechiae of the soft palate may be observed (Forchheimer spots), typically at the end of the prodrome or start of the cutaneous eruption.
Impact of skin color on clinical presentation: The red color of macules and papules is more readily appreciated in lighter skin colors. Their appearance may be subtle in darker skin colors, and the textural change of fine papules may be the sole clinical finding. A faint pink, deep red, or violaceous hue may be seen. Applying brief gentle pressure with a fingertip or microscope slide to blanch involved skin may accentuate subtle erythema as the pressure is withdrawn. Use of a bright light may further illuminate any subtle color changes present. Postinflammatory hyperpigmentation is more prominent and lasts longer in darker skin colors.
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