Pediatric Rubella and Staphylococcal Scalded Skin Disease

Third Disease and Fourth Disease

While rashes are common in pediatric populations and can be limited only to the skin, some rashes are caused by infections experienced throughout the body. Many of these viruses and bacteria can cause children to experience characteristic dermatologic symptoms that aid diagnosis and treatment.

Skin allergy covering a child's back
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As early as the 19th century, doctors understood this connection and, in 1905, Dr. Cheinisse in France classified six diseases based on their clinical appearance and linked them to population-based disease studies. Doctors today still occasionally use his terminology when classifying these rashes and treating patients. This article discusses “Third Disease” and “Fourth Disease.”

Rubella Virus: “Third Disease” or German Measles

Like measles, rubella is caused by an RNA-based virus spread through airborne droplets or direct contact. In the past, some in the medical community called rubella “the German measles,” but this term is no longer widely used in the United States.

Rubella is generally mild for adults and older children with up to half of all infected people not displaying any symptoms. Rubella can be a particularly serious infection for unborn children, however, with around 90% transmission from mother to baby. Due to incomplete worldwide vaccination for mothers, 110,000 infants are born with rubella infection annually. Many babies suffer serious birth defects, deafness among them, and risk stillbirth.


The rubella rash starts on the face and quickly involves the chest, back, and limbs. It begins two to three weeks following exposure and disappears within a few days. The rash, like measles, has pink to red spots, almost always flat, which often combine to give off a uniform red patchy appearance.


Doctors diagnose rubella in pediatric and adult patients with history and physical exam. Rubella, unlike measles, characteristically causes swelling of the lymph nodes behind the neck and ears in addition to lymph node swelling in the front of the neck. The rubella rash is also critical to diagnosis, as well as an exposure history. Children may have low-grade fevers, with some experiencing nausea and eye redness. Pregnant women receive simple blood testing for rubella immunity as infection while pregnant can be deforming and life-threatening to the unborn child. Occasionally patients receive gene sequence testing for the virus itself in unclear cases.


Treatment of rubella infections in adults, children, and babies is supportive care, primarily fluids, and rest. For those infected, including new babies, limiting contact with the non-immune is advised for one week. The best treatment, however, is prevention. Rubella immunization occurs in the combination of measles, mumps, and rubella vaccine. One dose gives 95% of patients lifelong immunity to rubella infection.  


Adults and non-infant children infected with rubella usually have a mild illness and typically recover less than a week after the rash appears. Unborn babies in their first trimester of growth are at serious risk, however, and can suffer from congenital rubella syndrome, which includes hearing impairments—deafness in many cases—heart defects, and thyroid disorders. Before the vaccine was developed in the 1960s, around 0.5% of babies born worldwide had some degree of congenital rubella syndrome. These birth defects are usually irreversible.

Staphylococcal Scalded Skin Disease or “Fourth Disease”

Most medical textbooks of today do not mention Duke’s disease or other references to Fourth Disease. It is a condition that is brought up in medical trivia and has largely been supplanted, but it is included here for reference. It may represent staphylococcal scalded skin syndrome, which is caused by staphylococcal bacteria infection and the release of a toxin into the human bloodstream.


The rash is usually seen in infants and starts with the appearance of redness around the mouth which then covers much of the body within 2 days and can be tender. Applying slight pressure with side to side movement of a finger to the skin lesions results in the displacement of the skin layers, the epidermis from the dermis, known by doctors as a positive Nikolsky's sign. Often the lesions become fluid-filled blisters. The blisters will break and then lead to peeling. Within 7-10 days, the skin improves and heals without long-term scarring. Secondary bacterial infections of the lesions can result in scarring. The rash is never present on the mucous membranes.


Doctors clinically diagnose staphylococcal infections of the skin, usually with a history and physical exam. If necessary, blood cultures and skin biopsy of affected areas can confirm the diagnosis.


Pediatric patients require supportive care and eradication of the primary infection. Supportive measures include rehydration and anti-fever medications including acetaminophen (Tylenol). Antibiotic treatment with intravenous medication includes nafcillin, oxacillin, or vancomycin. Clindamycin is also occasionally used because of its inhibition of staphylococcal toxins, the primary driver of scalded skin syndrome.


Children recover well with supportive care and antibiotics. Most children will be completely better within 10 days.

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Article Sources
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  • Belazarian et al. “Exanthematous Viral Diseases.” Fitzpatrick’s Dermatology in General Medicine; 2012: 2337-2366.
  • Cheinisse L: Une cinquie`me maladie eruptive: Le maladie eruptive: Le megalerytheme epidemique. Sem Med 1905;25:205-207.
  • “About Rubella.”  Centers for Disease Control and Prevention. 2014.
  • “Rubella.”  World Health Organization. 2015.