SAEM Clinical Images Series: Face and Chest Rash

chicken pox

A 23-year-old female with a past medical history of asthma presented with a rash that began five days ago on her face and spread to her chest. The lesions are painful and pruritic, spreading slightly to her extremities. She noted a slight sore throat and nasal congestion. She denied any known fever and had no known vaginal or oral lesions. She has a 5-year-old daughter at home with no known symptoms. She is sexually active with one male partner who has no rash or illness. She is vaccinated for COVID-19. She is unsure of childhood illnesses and believes she was never properly immunized as a child in Central America.

Vitals: BP 110/55; Temperature 37°C; pulse ox 97%

Skin: Face, thorax, and extremity papules are noted with an erythematous base, some vesicular, others with occasional crust or scabs. No dermatomal distribution. There is relative sparing of extremities with more lesions noted on the trunk and face. Negative Nikolsky sign. Otherwise, no other findings on physical examination.


Herpes varicella-zoster, or chickenpox, is a viral infection transmitted by airborne droplets and direct contact. Before immunization, 90% of cases occurred in children. While primary infection in children is generally benign, adult and infant infections can have severe complications including encephalitis and pneumonia. Erythematous vesicular lesions appear in successive crops typically starting on the face and spreading to the trunk. Extremities usually have more minor involvement with sparing of palms and soles. Vesicles progress quickly to crusted erosions in 8-to-12-hour periods. Treatment should focus on symptomatic care.

Antivirals can slow the severity of the course if given within 24 hours of the onset. Severely immunocompromised patients should receive acyclovir 10 mg/kg IV every 8 hours for 7 to 10 days.

Take-Home Points

  • Chickenpox presents with several “crops” of lesions: papules, vesicles, and scabs.
  • Adult primary disease is not common and is more severe than pediatric illness.
  • Antivirals are not indicated after the first day of illness in immunocompetent adults with mild to moderate disease.

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