Journal of Pakistan Association of Dermatologists 2013;23 (3):253-255.
Editorial
Skin and measles
Shehla Shaukat, Shahbaz Aman, Atif Hasnain Kazmi
Department of Dermatology, King Edward Medical University/ Mayo Hospital, Lahore
Measles is an acute infectious disease of
children, also known as rubeola, caused by
paramyxovirus which is a single stranded
enveloped RNA virus.1 According to WHO, it
remains one of the leading causes of death
among children globally, approximately 158000
people mostly children under the age of five
died from measles in 2011.2 Recently, Pakistan
witnessed measles epidemic particularly in the
province of Sindh from January 2012 to
February 2013, 19,048 suspected measles cases
with 463 deaths of children were reported
throughout the country. Most of these cases
were reported during the last quarter of 2012. 3
The total number of cases of measles reported
from Punjab was 19,192 with 239 deaths during
the last six months.4,5 Compared to previous
years these are alarming figures which compels
us as dermatologists to know more about the
disease and its common and uncommon
cutaneous presentations.
The virus resides in the upper respiratory tract of
an infected person. It can spread by droplet
infection or by fomites which are infected by the
secretions. Incubation period of measles is 7-14
days.6
In classical dermatological measles syndrome,
the symptoms are initially nonspecific including
Address for correspondence
Dr. Shehla Shaukat
Department of Dermatology, Unit I,
King Edward Medical University/Mayo Hospital,
Lahore
E-mail: shehla786@hotmail.com
fever, sore throat, cough, rhinorrhea,
conjunctivitis and photophobia.6 During the
initial two to three days the pathognomonic
Koplik’s spots are also seen in the buccal
mucosa.6 The typical maculopapular rash starts
from behind the ears and along the hairline. It
spreads in cephalocaudal pattern to involve the
face, trunk and limbs over the next few days. 6
The fever becomes high grade with temperature
rising to 104ºF or 105ºF. The patients remain
infectious from four days before the rash
appears till the four days after the rash is there.
The rash after a few days starts to fade away
starting from the face sometimes leaving behind
a staining pattern or hyperpigmentation.7
There can be an atypical or modified
presentation of the disease. People who received
killed measles vaccine or are exposed to wild-
type virus can develop an atypical measles
syndrome.8 The rash can be urticarial, purpuric
or even vesicular. It starts from palms and soles
then spreads to the trunk before fading. Koplik’s
spots in these cases are absent. 8 Atypical measles
syndrome may also present with congested
macules and papules starting on the extremities
and back.9 The systemic features include fever,
pleural effusions, pneumonia and swelling of
extremities.9 In HIV positive patients there can
be an atypical rash or no rash at all. 9 Skin
necrosis or even minute skin coloured papules
can also be seen.9
In modified form of measles the symptoms are
mild and last for a very short time. 9 It develops
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Journal of Pakistan Association of Dermatologists 2013;23 (3):253-255.
in those persons who received immunoglobulins
after exposure to measles or the those infants
who were either non-immunized or had low
immunity from their mothers.8
The complications of measles are more common
in children under the age of five, or adults over
the age of twenty. Complications include
diarrhea, otitis media, bronchitis, pneumonia,
corneal ulcerations and scarring, encephalitis,
subacute sclerosing panencephalitis,
thrombocytopenia or even death. 10 The mortality
rate reported by WHO is 10% in underdeveloped
nations where there are high rates of
malnutrition and poor health care. In
immunocompromised patients the fatality rate is
approximately 30%.2 Women infected while
pregnant may end up with miscarriage or
preterm delivery. Risk factors for severe measles
and its complications include malnutrition,
underlying immunodeficiency, pregnancy and
vitamin A deficiency.10
Diagnosis is made clinically, as well as, by
laboratory investigations including detection of
IgM antibodies or culture of virus. IgA
antibodies can be tested from the saliva of the
patients in whom phlebotomy is difficult. 11 The
differential diagnoses are numerous including
dengue fever, drug eruptions, enteroviral
infections, fifth disease, rubella, Kawasaki
disease, Rocky Mountain spotted fever, roseola
and toxic shock syndrome.11
There is no specific antiviral treatment for
measles. Nonimmunized people, including
infants, may be given measles vaccination
within 72 hours of exposure to the measles
virus, to provide protection against the disease.
The symptoms are usually milder and transient
even if the person develops measles. Pregnant
women, infants and immunodeficient people
should receive immunoglobulins within six days
of exposure to the virus.7 The complications are
treated by supportive care which includes
antipyretics, treatment of dehydration, adequate
nutrition and antibiotics for eye, ear infections
and pneumonia. Two doses of vitamin A
supplements are given to children in developing
countries for prevention of eye damage and
blindness.11 Vitamin A supplements have been
shown to reduce the number of deaths from
measles by 50%.11
Prevention of measles is possible by
vaccination. First dose of measles vaccine is
given at nine months of age while second dose
with triple combination vaccine called MMR
(measles, mumps and rubella) at fifteen months
and booster dose at four to five years in
developing countries. In developed countries
two doses at fifteen to eighteen months and then
at four to six years of age are given. 11 Side
effects of the vaccine are rare, with fever and
pain at the injection site being the most
common. The vaccine is less effective in HIV-
infected infants than in general population.
People who recover from measles remain
immune from this disease for the rest of their
lives.
It is time for us to play our role in creating
awareness about cutaneous manifestations of
this viral infection among general public and
practitioners for early referral to tertiary care
hospitals for its management.
References
1. Tod B, Carrara H, Levin M, Todd G.
Dermatological manifestations of measles
infection in hospitalized paediatric patients
observed in the 2009-2011 Western Cape
epidemic. S Afr Med J. 2012;102;356-9.
2. World Health Organization. Measles. Fact
sheet No. 286. Available from: URL:
www.who.int/mediacentre/factsheets/fs286/
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3. Report on measles outbreak in Pakistan (vol-
1) wafaqi mohtasib (ombudsman)’s
secretariat Islamabad. Available at: URL:
202.83.164.28/wafaqimoh/userfiles1/file/Me
asles%20Report.pdf
4. 89 new cases of measles reported in a day.
Available at:
URL: www.dailytimes.com.pk/24-6-2013-
pg13-6
5. Galpin R. Fighting Pakistan's measles epidemic.
Available at: URL: www.bbcnews.com/30-5-
2013.
6. Morrison LK, Ahmed A, Madkan V et al.
Exanthematous viral diseases. In: Goldsmith
LA, Katz SI, Gilchrest BA et al. editors.
Dermatology in General Medicine, 8th edn.
New York: McGraw-Hill; 2012. P. 2337-67.
7. Centers for disease control and prevention.
www.cdc.gov/vaccines/pubs/pinkbook/meas
.html
8. Pang M, Xu JY, Li P et al. Clinical analysis
of 51 cases of atypical measles syndrome
characterized by fever and multiple lung
lesions. Zhonghua Jie He He Hu Xi Za Zhi
(Chinese). 2008;31:731-5.
9. Permar SR, Griffin DE, Letvin NL. Immune
containment and consequences of measles
virus infection in healthy and
immunocompromised individuals. Clin
Vaccine Immunol. 2006;13:437-43.
10. URL: en.wikipedia.org/wiki/Measles
11. Mancini AJ, Shani-Adir A. Other viral
diseases. In: Bolognia JL, Jorrizo JL, Rapini
R eds. Dermatology, 3rd edn. UK: Elsevier
Saunders; 2012. p. 1345-62.
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