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Cutaneous manifestations of the Zika virus

Benjamin Farahnik, BA,a Kourosh Beroukhim, BS,b Collin M. Blattner, DO,c and John Young III, MDd
Burlington, Vermont; Los Angeles, California; and Corvallis and Salem, Oregon
Key words: disease prevention and control; microcephaly; public health concerns; viral exanthem; Zika

he Zika virus outbreak in Africa, Asia, the

Americas, and the Pacific has drawn attention
to the virus in the media and medical
community. As of February 10, 2016, 52 travelrelated cases of Zika virus have been reported in
the United States.1 The Zika virus was initially
isolated in 1947 in a rhesus monkey in the Zika forest
of Uganda. The first documented human outbreak
occurred in 2007 in the Federated States of
Micronesia and was followed by another outbreak
in 2013 through 2014 in the nearby Pacific Island
nations.2 In May 2015, the Zika virus was confirmed
in the Americas and active transmission has since
been reported in 33 countries and territories.1 The
following editorial addresses a practice knowledge
gap by discussing what dermatologists should know
about the Zika virus to ensure the safety of providers,
patients, and the community.
The Zika virus is an arbovirus within the
Flaviviridae family, which also includes the dengue,
West Nile, yellow fever, and Japanese encephalitis
viruses.2 The Zika virus is an icosahedral, singlestranded, positive-sense RNA virus. The virus is
transmitted primarily through the bite of the infected
mosquito species Aedes aegypti and Aedes albopictus. These mosquitos, which are aggressive daytime
biters, become infected when they bite a person who
has already contracted the virus. The virus has also
been reported to be transmitted through blood
transfusions and sexual contact, and from mother
to fetus during pregnancy.1 In utero infection with
Zika virus is particularly concerning given the
theorized association with microcephaly among
affected fetuses. This potential link has led the
World Health Organization (WHO) to classify the
Zika virus as a global health threat that has prompted

From the University of Vermont College of Medicinea; David

Geffen School of Medicine at the University of California, Los
Angelesb; Good Samaritan Regional Medical Center, Corvallisc;
and Silver Falls Dermatology, Salem.d
Funding sources: None.
Conflicts of interest: None declared.

Fig 1. Zika viruseassociated skin exanthem in a 51-year-old

woman with a diffuse maculopapular eruption on her trunk.
(Photograph courtesy of A. Neumayr, Swiss Tropical and
Public Health Institute, Basel.)

the Centers for Disease Control and Prevention

(CDC) to issue its highest level of alert.1
For decades after the virus was isolated, it
primarily affected monkeys along the equatorial
belt, across Africa and Asia, and sporadically affected
human beings but only caused mild disease. Zika
does not appear to have a gender or age
predilection. After an incubation period of 3 to
12 days, 1 in 5 people infected with the Zika virus
may present with mild symptoms lasting from several
days to a week.3 In adults, common symptoms
include transient fever, rash, myalgia, arthralgia,
headache, and conjunctivitis.1,3 Health officials are
also investigating a potential association between
Zika virus infection and Guillain-Barre syndrome.
The most common dermatologic finding of the
Zika virus, as described by the WHO and CDC, is a
nonspecific, diffuse eruption consisting of macules
and papules that appear 3 to 12 days after initial

Reprint requests: John Young III, MD, Silver Falls Dermatology,

1793 13th Street SE, Salem, OR 97302. E-mail: jyoung@
J Am Acad Dermatol 2016;jj:j-j.
2016 by the American Academy of Dermatology, Inc.

2 Farahnik et al


n 2016

Fig 2. Zika viruseassociated skin exanthem. Peripheral edema of bilateral hands (A) and feet
(B). Generalized lymphadenopathy was also present. (Photograph courtesy of A. Neumayr,
Swiss Tropical and Public Health Institute, Basel.)

infection (Fig 1).1,3 Although the eruption typically

spares the palms and soles, case reports have
described various presentations, including involvement of the palms and soles.4,5 The morbilliform or
scarlatiniform eruption begins on the face and
subsequently extends to the trunk and extremities
(Fig 2, A and B).4,5 Mild hemorrhagic manifestations,
including petechiae and bleeding gums, may be
observed with Zika virus infection. The eruption may
be pruritic and heals with desquamation.6 The
eruption begins to subside within 2 to 3 days and
complete resolution usually occurs within 1 week.1
Unfortunately, there do not appear to be any unique
features to differentiate the eruption from other
insect-derived viral infections, and thus dengue and
chikungunya virus infection should be considered in
the differential diagnosis.
Diagnosis is made with reverse transcription
polymerase chain reaction and enzyme-linked
immunosorbent assay during the first 7 days of
illness, or Zika-specific IgM antibodies and plaquereduction neutralization tests 4 or more days after
disease onset.3 There is currently no vaccine for the
Zika virus and no specific treatments are necessary
for relatively mild disease. Patients should be
counseled to rest, maintain adequate hydration,
and use acetaminophen for pain and fever
as necessary.1 To protect against disease, patients

should be advised to wear long-sleeved shirts and

long pants to avoid mosquito bites, stay in cooler
locations with rooms that have window or door
screens while in endemic areas, and use
Environmental Protection Agencyeregistered insect
Because preventive measures and protocols
continue to evolve, all providers should be aware
of current CDC and WHO recommendations that can
be found at These measures will hopefully assist in preventing disease
spread through patient education and early
1. World Health Organization. Zika virus fact sheet. 2016. Available at:
Accessed February 17, 2016.
2. Samarasekera U, Triunfol M. Concern over Zika virus grips the
world. Lancet. 2016;387:521-524.
3. CDC Division of Vector-Borne Diseases. Revised diagnostic
testing for Zika, chikungunya, and dengue viruses in US Public
Health Laboratories. Atlanta: Centers for Disease Control and
Prevention. 2016.
4. Keighley CL, Saunderson RB, Kok J, Dwyer DE. Viral exanthems.
Curr Opin Infect Dis. 2015;28(2):139-150.
5. Hayes EB. Zika virus outside Africa. Emerg Infect Dis. 2009;15(9):
6. Mann D. Concern About Zika virus in US set to escalate. Pract
Dermatol. 2016;13(1):10.