Fifth Disease (Slapped Cheek Syndrome) in Children

If your child's cheeks suddenly turned bright red and a lace-like rash appeared on the arms, legs or trunk a few days later, the cause may be fifth disease.

Fifth disease, known medically as erythema infectiosum, is a contagious infectious illness caused by a virus called Parvovirus B19.

It is seen especially in school-age children, and in the great majority of healthy children it runs a mild course and clears on its own.

The most characteristic finding of the illness is the marked redness that appears on the cheeks and is described as a "slapped cheek" appearance.

But there is an important detail to know about fifth disease:

By the time the characteristic rash appears in a child, the most contagious period of the illness is usually already over.

What Is Fifth Disease?

Fifth disease is an illness caused by a virus called Parvovirus B19, which causes infection only in humans.

In children in particular, it leads to a characteristic picture of illness with a rash.

The name "fifth disease" comes from the way childhood illnesses with fever and a rash were numbered in the past.

The illness should not be confused with the parvovirus infections seen in pets.

Human Parvovirus B19 infection is not caught from dogs or cats.

Who Gets Fifth Disease?

Although fifth disease is seen most often in school-age children, it can occur at any age.

The virus is quite widespread in the community, and a large share of adults have come across Parvovirus B19 at some point in their lives.

While the rash may be more characteristic in children, joint pain may be more prominent in adults.

How Does Fifth Disease Begin?

Parvovirus B19 infection does not run the same course in every child.

In some children the infection can pass without causing any symptoms at all.

When symptoms do develop, cold-like symptoms may be seen in the first stage of the illness, such as:

• Mild fever
• Headache
• Runny nose
• Sore throat
• Fatigue
• Muscle aches

A few days after this first stage has passed, the characteristic rash may appear.

What Does the Rash of Fifth Disease Look Like?

The most widely known finding of fifth disease is the bright red rash on the cheeks.

This appearance is often described as a "slapped cheek" look.

The area around the mouth looking paler can make the redness on the cheeks stand out even more.

After the rash on the cheeks, a second rash may appear on:

• The arms
• The legs
• The trunk
• The buttock area

Over time, this rash may begin to fade in the middle and take on a net-like or lace-like appearance.

How Many Days Does the Rash of Fifth Disease Last?

The rash usually fades noticeably within 7 to 10 days.

However, one of the interesting features of fifth disease is that the rash can become more apparent again from time to time over a period of weeks after it has gone.

In particular:

• A hot bath
• Exercise
• Sunlight
• A warm environment
• Other situations that cause the skin to warm up

can make the rash temporarily show up again.

This usually does not mean that the illness has started again or that the child has become contagious again.

Does Fifth Disease Cause Itching?

The rash can be itchy in some children, but itching is not seen in every child.

If the itching is marked, the child should be kept from irritating their skin and, if needed, appropriate symptomatic treatment should be discussed with the pediatrician.

How Does Fifth Disease Spread?

Parvovirus B19 spreads mainly from person to person through respiratory secretions.

Coughing, sneezing and close contact can play a role in transmission.

The virus can also pass:

• Through blood and blood products
• From mother to fetus during pregnancy

Transmission can be seen particularly in settings with close contact, such as school and the home.

When Is Fifth Disease Contagious?

This is one of the points families most often get confused about with this illness.

A child is more contagious before the rash appears, during the period when there is a mild fever, a runny nose or other cold-like symptoms.

By the time the characteristic "slapped cheek" rash appears, contagiousness in healthy children with a typical course has usually largely come to an end.

For this reason, by the moment you see your child's rash, the most important period of the illness in terms of transmission is generally already over.

However, in special situations such as aplastic crisis accompanied by severe anemia or chronic Parvovirus B19 infection, contagiousness is assessed differently.

How Long Is the Incubation Period of Fifth Disease?

There can be a period of up to several weeks between coming across the virus and the appearance of symptoms.

For this reason, it is often not possible for families to pin down exactly from whom and when the child caught the illness.

Is Fifth Disease Dangerous?

In the great majority of healthy children, no.

Fifth disease is mostly an infection that runs a mild course and clears on its own.

However, Parvovirus B19 is not just a "rash virus."

Because the virus can affect the precursor cells involved in producing red blood cells, it can cause serious problems in certain special patient groups.

For this reason, the following should be evaluated more carefully when they come across Parvovirus B19:

• Sickle cell disease
• Thalassemia
• Children with chronic hemolytic conditions such as hereditary spherocytosis
• Children whose immune system is suppressed

Does Fifth Disease Cause Anemia?

In healthy children, Parvovirus B19 infection mostly does not lead to serious anemia.

However, the virus can temporarily suppress the production of red blood cells.

In children with chronic hemolytic anemia, in whom red blood cells are already broken down faster than normal, this can lead to a transient aplastic crisis and serious anemia.

If a child has a known blood disorder, the physician following the child should be contacted in case of contact with Parvovirus B19 or suspected infection.

Is Fifth Disease Risky for Pregnant Women?

This point is especially important with fifth disease.

Parvovirus B19 infection during pregnancy can pass from the mother to the fetus.

The great majority of infections during pregnancy do not lead to a serious problem for the fetus. However, an infection during the first half of pregnancy in particular can in some cases cause serious anemia in the fetus, non-immune hydrops fetalis related to it and, more rarely, pregnancy loss.

For this reason, if a pregnant person learns that they have been in close contact with a child who has fifth disease, they should speak with their obstetrician rather than panicking.

Blood tests can show whether the person has previously had Parvovirus B19 and gained immunity, or whether they have had a recent infection.

When necessary, the pregnancy is followed more closely.

How Is Fifth Disease Diagnosed?

In a healthy child, the typical "slapped cheek" appearance and the lace-like rash that follows are often characteristic enough for the diagnosis.

For this reason, a blood test is not needed in every child.

However, laboratory investigations may be needed:

• In cases of contact or suspected infection during pregnancy
• In those with chronic hemolytic anemia
• In people whose immune system is suppressed
• In situations that are atypical or run a severe course

When necessary, tests that assess the antibodies formed against Parvovirus B19 or the viral DNA can be used.

What Illnesses Can Fifth Disease Be Confused With?

Fever and a rash in children can appear for many different reasons.

Fifth disease can be confused with different conditions such as:

• Measles
• Rubella
• Sixth disease
• Scarlet fever
• Enterovirus infections
• Drug rashes
• Allergic rashes

For this reason, it is not correct to diagnose fifth disease simply because "the child's cheek turned red."

The appearance of the rash, how it spreads, when it appears and the other accompanying symptoms should be evaluated together.

How Is Fifth Disease Treated?

In the great majority of healthy children, no specific antiviral treatment is needed for fifth disease.

The illness mostly clears on its own.

Treatment is aimed at easing the child's complaints.

If there is fever or pain, medicines appropriate for the child's age and weight can be used in line with the physician's advice.

Taking in enough fluid and resting should be supported.

In children with chronic hemolytic anemia or a condition involving the immune system, treatment and follow-up can be different.

Are Antibiotics Used in Fifth Disease?

No.

Because fifth disease is caused by a virus, antibiotics do not treat the illness.

An antibiotic should be used only if a bacterial infection is separately identified.

Does the Rash of Fifth Disease Need a Cream?

The rash mostly fades on its own without needing any specific treatment.

If there is no itching, applying a cream or medication routinely is not necessary.

The rash becoming more apparent again after heat, sunlight or exercise is also usually not a situation that requires treatment.

Does Fifth Disease Cause Joint Pain?

Yes.

Parvovirus B19 infection can cause joint pain and sometimes swelling in the joints.

Although this can be seen in children, it occurs more often in adults, and especially in women.

In most people, joint complaints improve over time.

Can a Child with Fifth Disease Go to School or Daycare?

In typical fifth disease, by the time the characteristic rash appears the child is usually no longer contagious.

For this reason, the presence of the rash alone does not mean the child needs to be kept away from school or daycare for days.

If the child has no fever, is in good general condition and is able to take part in daily activities, a return to school can be considered.

If there is a specific practice related to an outbreak at the school or daycare, the recommendations of the institution and the health authorities should also be taken into account.

Does Fifth Disease Happen Again?

Immunity is expected to develop after a Parvovirus B19 infection.

For this reason, having classic fifth disease over and over again is not an expected situation.

Because similar rashes appearing later on can have other causes, not every rash should be assumed to be fifth disease again.

How Can Fifth Disease Be Prevented?

There is no vaccine in routine use against Parvovirus B19.

To reduce the risk of transmission, the following can be helpful:

• Washing hands regularly with soap and water
• Covering the mouth and nose when coughing and sneezing
• Not sharing personal items such as cups and forks
• Cleaning frequently touched surfaces
• Reducing close contact with people who have symptoms of a respiratory tract infection

However, because the most contagious period of the illness comes before the characteristic rash appears, it is not always possible to prevent transmission completely.

When Should You See a Doctor for Fifth Disease?

Although the illness mostly runs a mild course in healthy children, a physician's evaluation is needed if:

• The child's general condition is clearly declining
• There is difficulty breathing
• Marked paleness is developing
• There is unusual fatigue or weakness
• The child has a known chronic blood disorder
• The immune system is suppressed
• There is uncertainty about the cause of the rash

In addition, if there is a pregnant person in close contact with the child, it is important for that person to speak with their own obstetrician.