Identification and Approaches to Common Viral Rashes
- Victoria Wermers, RN,MSN,FNP, PMHNP
- Sep 24, 2024
- 15 min read
Updated: Jul 1
MEASLES - SHINGLES - HERPES 1&2 - MONO
These rashes—which are viral skin conditions—can vary in appearance based on the illness. This guide explores Identification and Approaches to Common Viral Rashes, including those caused by chickenpox (and other pox viruses), mononucleosis (mono), herpes, shingles, rubeola (measles), shingles and herpes (genital and oral).
There are vaccinations to prevent some viral illnesses, and only a few of them respond to antiviral medicines. Still others seem to respond to herbal remedies, as noted below. But, because they are viruses, our "magic antibiotics" will not work to eliminate them.
The ones that we often see in adults, like shingles, herpes simplex (HSV), and mononucleosis (primarily in adolescents), will be addressed in some detail below.
When people hear the diagnosis of "herpes," they get all sorts of ideas. They are all related viruses but very different problems. Three well-known (and relentless) types of herpes viruses cause skin rashes. 1) Shingles (herpes zoster), 2) Cold sores (herpes simplex and 3) Genital herpes (herpes simplex. The problem with these viruses is that while symptoms may improve, the virus stays in your system forever.
These three viruses are all very similar in their progression. They start with some discomfort at sight (burning, tingling) and progress to a red raised rash that breaks into blisters and then scabs over. THE SOONER THESE ARE TREATED, THE SOONER THEY WILL GO AWAY! THE MOST EFFICIENT TREATMENT IS STARTED WITHIN 24-48 HOURS OF THE ONSET. Each will be discussed below.
Identification and Approaches to Common Viral Rashes: MEASLES (RUBEOLA) -
(Not to be confused with the German Measles"- Rubella)
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Before 2025, I was not intending to include the rash caused by the measles virus. However, because there has been a recent uptick, primarily in unvaccinated people, it is something people should know more about.
What is Measles?
According to Sloan Kettering citations, the measles has been around for centuries: It presumably came from bovine/hoofed animals back in 400th century BC; only occasionally infecting people. However, by 1100 - 1200 AD, it had evolved into a very contagious human virus. According to the CDC website, in the early 1900s, there were approximately 6,000 deaths every year from measles. By the 1960s, prior to the vaccine, it was estimated that 3-4 million people contracted measles; 400 to 500 people died, 48,000 were hospitalized, and 1,000 people developed encephalitis (brain swelling). In 1963, a measles vaccination was developed (MMR-combination measles, mumps, and rubella) and was routinely given to children. Measles cases were drastically reduced, and in 2000, measles was essentially eliminated in the US due to widespread vaccination. According to Statista, a Health, Pharma, and Medtech Site, as of 5/26/2025, there have been 1046 cases of measles in the US, and that number is growing. This is a large growth over 2024, when there were only 285 cases.
Symptoms
These typically come on 7-14 days after exposure -
Fever
Cough
Red watery eyes ("pink eye" or conjunctivitis)
Runny nose
White spots in the mouth - Koplik spots, which usually appear 3-5 days after cold symptoms appear.
Rash - This usually comes on 3-5 days after "cold" symptoms began. The rash is characterized by small red spots, many of which are joined together. This rash usually begins on the head and face and spreads downward to the trunk and extremities.
The problem lies mainly in the complications that can develop from the measles: Ear infections, diarrhea, pneumonia, encephalitis (brain disease), and death (reportedly 1-3 out of 1000). Pregnancies can also be adversely affected by miscarriages, low birth weight, respiratory complications, and others.
How is It Spread?
It is airborne (droplet) and stays in the air for about two hours after the infected person has been there; it can also be spread by touching an infected surface.
Testing
Serology tests can be done to determine if a person has an active case of measles or real-time PCR testing can also be done (more accurate). An antibody test can also determine whether or not you have immunity, and you can order your own at a lab. Check with your insurance company to see if they will cover a rubeola titer or MMR titer. Usually, the measles, mumps, and rubella (MMR) titers are done together, but I was able to find and order my own measles (rubeola) titer at Any Lab Test for just $49 cash pay. I wanted to see if I still had antibody protection from measles from a prior MMR I had years ago.
Treatment
Symptomatic treatment is the key to treating measles.
Fever and body aches - Use an antipyretic (common: ibuprofen, or acetaminophen over-the-counter as directed). NO ASPIRIN IN KIDS!! Also see fever.
Comfort - Aveeno or oatmeal bath for comfort
Cough - Use antitussives or over the counter like dextromethorphan or, when appropriate, multi-symptom cold medicines.
Runny Nose and Nasal Congestion - Decongestants or Antihistamines (over-the-counter as directed or consult pharmacist).
Vitamin A - While there are no approved antiviral medications for those who may be infected, CDC has recently updated their recommendation, following the new director of Health and Human Services, in supporting the use of Vitamin A (Oxford Academic) for those with mild, moderate, and severe infection - suggesting that it may reduce mortality. Since vitamin A is not excreted by the body (and builds up), it can be toxic in large doses, so be careful. Because of this, a person should take vitamin A with the advice of a pharmacist or under the care of a physician.
Rest and Fluids
Isolate: You are considered contagious for four days before the rash develops to four days after the rash develops.
Who is at Risk of Getting Sick From Measles?
Those at risk of getting measles are people who never got the MMR vaccination (most older adults were given this when they were kids) or others whose immunity from the vaccine may have worn off years after getting the vaccine. People at higher risk, such as older adults, those with diabetes, healthcare workers, and individuals with weakened immune systems, may struggle to fight off this disease. To stay protected, they should have their titers checked. If they no longer have active antibodies, an MMR vaccine may be recommended. If you have questions, consult a healthcare provider for guidance.
Prevention
Keep your distance from people with respiratory symptoms and/or rashes
Wear a mask
Wash Hands
Those around you with measles should isolate
How to Know if Your Measles Is Getting Worse
Some of the signs and symptoms of worsening measles include the following:
Dehydration - dry lips and tongue, Less urination, darker urine, sunken eyes
dry skin
Lethargy (even with medication for fever)
A fever of 104°F. or higher (especially if you cannot bring it down with acetaminophen or ibuprofen)
Difficulty breathing, wheezing
Change in behavior or confusion (even with medication for a fever)
If you feel very sick from measles, despite trying to treat your symptoms, consult with a healthcare provider (please wear a mask if you see them in person)
Identification and Approaches to a Viral Rash: SHINGLES (Herpes Zoster)
You don't want this. Shingles is typically an adult disease caused by the chickenpox virus, which lies dormant on a person's nerves forever after they have had chickenpox. You say you have never had chickenpox? You probably did when you were a baby, but it was a mild case (or so I am told).
In the clinic, we see a lot of shingles cases. It has a classic presentation: It begins with "deep" pain, followed several days later by the appearance red, raised rash. It becomes a cluster of vesicles (blisters) followed by scabbing. It tends to follow the path of an underlying nerve, typically in the rib, chest, or back area - although it can occur on other parts of your body as well (see photos below). This rash will rarely cross the midline - it stays on one side of the body (I have seen many cases of shingles, but have only seen one case where a person had it on both sides of his body). Also, the shingles rash typically does not travel to areas of the body far from the site of origin - it spreads locally. People often describe the pain as "burning", "itching", "numb", and "tingling". Occasionally, the rash is accompanied by a headache, fever, and fatigue.
How are shingles diagnosed? In many cases, people initially present at the healthcare provider's office with deep, annoying pain (no rash yet). The pain is challenging to diagnose before the cluster rash comes on: Pain in the rib area is often misdiagnosed as costochondritis (rib pain). Or, if the pain is in the back, it is misdiagnosed as musculoskeletal back pain, and so on. Once the rash breaks out, it is pretty easy for a healthcare provider to diagnose (sometimes, patients have already diagnosed the rash before they come to the clinic because they have Googled it!). If there is any question about it, a culture of the lesions can be done by a healthcare provider and sent to the lab for confirmation.
The rash usually lasts about two to four weeks, but the pain (postherpetic neuralgia) may last weeks, months, and sometimes even years, causing a person significant distress.
Some people can withstand the discomfort of shingles and may want to wait it out until it goes away(typically three to five weeks). However, there are some cases when you should not wait it out: If it is near your eye or your ear, it can cause blindness or deafness, respectively, so you need to see a healthcare provider ASAP. Shingles can spread to your internal organs (rare). No matter where it is located, the sooner you start an antiviral medicine, the sooner you can knock it out.
Shingles
Note above photo: When the rash breaks out, it typically starts as red lesions followed by blistering and then scabbing. - It develops along a nerve in a linear fashion on only one side of the body: The typical rash.
Treatment and Remedies for Shingles and Postherpetic Neuralgia
Initially, when the rash appears, keep the area clean and dry with mild soap and water (pat day). Use cool, moist cloths and wear loose-fitting, soft clothes for comfort.
Over-the-Counter (OTC) Treatment
For Acute Shingles and post-herpetic neuralgia:
Nonsteroidal anti-inflammatories like Ibuprofen (common: Motrin, Advil) or Naproxen
ForPost-Herpeticc Neuralgia (the pain that continues after the rash is gone)
Apply to intact skin
Natural Remedies
Herbal/Alternative approaches to shingles
Oatmeal baths - Oatmeal has anti-inflammatory and anti-itch effects.
Raw or Manuka Honey can be used directly ON the skin. This has antibiotic AND antiviral properties (Manuka may be better but tends to be more expensive).
Herbal/alternative approaches to postherpetic neuralgia - the pain that comes after the shingles (and often lasts for a while), oral treatment possibilities
Calendula preparations may be used.
Prescriptive Treatment
Highly recommended in early stages - If your healthcare provider diagnoses you with shingles, they may give you the following:
An antiviral medicine (to shorten the course, stop the lesions from spreading, and hopefully decrease the pain and lessen postherpetic neuralgia). Valacyclovir (Valtrex), Acyclovir (common: Zovirax), or famciclovir (common: Famvir). The sooner you start these, the better off the more efficacious they are to stop the spread.
Pain medicine (usually higher dose anti-inflammatories that you cannot get over the counter.
Opioids Opioids (short-term) - These are painkillers such as oxycodone or hydrocodone (combo opioids with Tylenol: Lortab, Percocet, and Vicodin) and Tramadol (i.e. Ultram). Because these are highly addictive, they are not the drug of choice for long-term pain.
A corticosteroid, like prednisone, for severe shingles. Occasionally, a provider will give you a corticosteroid for the inflammation; It is a great anti-inflammatory, however, as noted above, this is controversial because, while it decreases inflammation, it may weaken your immunity (sometimes corticosteroids actually can cause shingles!).
Postherpetic neuralgia:
Amitriptyline decreases pain signals to the brain
Duloxetine (Cymbalta) is known for its treatment of nerve pain
Gabapentin for pain transmission along the nerve.
Topical lidocaine gel (the lidocaine patch is also over-the-counter)
So, Why Do Some People Get shingles?
Shingles almost always appears in people when their immune response has been weakened by something - see risk factors. If you get shingles, look at yourself and try to understand why this may have occurred. At least 50% of people who get shingles are over 60 because their immune system is weakening due to age. Those given steroids or immunomodulators, which weaken the immune system, also tend to get shingles. Stress and anxiety also play a huge role in lowering the immune system, which, in turn, causes shingles. Strengthening your immune system plays a key role in avoiding shingles. If you figure out what the underlying cause of your shingles is, try to do something about it: That is, stay away from stress, get enough sleep, stay well-hydrated, take multivitamins, eat a nutritious diet, and so on.
Shingles are contagious ONLY to people who have not had chickenpox. Also, patients ask how they got shingles if they never had chickenpox. Typically, they have either had chickenpox and do not remember, or they had a very mild case of chickenpox and never showed many symptoms, so never knew it.
Prevention: Get a shingles vaccine (Shingrix)—two doses 4-8 weeks apart when you are NOT having an outbreak. It is well tolerated by most people. It is also expensive unless you have insurance, which often covers it. It may well be worth the pain of shingles.
Shingles Q+A
Can I spread shingles to someone else? This is a tricky question. Some resources say yes, others say no, and still others say maybe. I have read that you can spread it from open sores—particularly around babies, someone who has not had chickenpox, or an immunocompromised person. I don't know of that happening, but I am not sure I would take the chance. It is best to keep it covered when you are around others.
HERPES SIMPLEX 1 (HSV-1)- COLD SORES - FEVER BLISTERS
Herpes simplex is a viral disease that stays with you throughout your life, just as the other herpes viruses do. Because it is called "herpes," don't jump to the conclusion that your partner has been cheating on you. Nearly 65% of people in the US carry HSV-1, and you could have gotten it in so many ways! (HSV-2 is the genital herpes.)
Herpes simplex 1 is most contagious when you have skin lesions - from direct contact, like kissing, from saliva, or from sharing things that have been in contact with your mouth (yes, presumably that would be from sharing vapes to cigarettes, to blunts). You can still pass it on when you have NO sores, but that is much less common. You can also remotely get (or give) herpes 1 via oral-genital contact, but again, this is pretty rare. Just don't go there if you have open mouth lesions (although even people without open lesions can spread it this way!).
HSV I is characterized by a blister-type rash that typically shows up on your lips but can also show up in your mouth and on other parts of your face. Some people call these "cold sores," and they often show up in the same place whenever there is a flare. Again, it is often caused by stress; it may come on during a woman's period, after exposure to too much sun, or it can flare up because you are getting sick (these sores are a kind of "barometer" of underlying health problems or mental wellbeing).
Initially, there may be some tingling in the area (people who have had these can sometimes feel them coming on before it actually turns into an outbreak). Some redness follows this, then a blistering lesion that eventually scabs over. People hate these things because they are often on the face and are unsightly. The lesions can be painful and cause burning and itching. When you notice these things coming on, no matter what course you choose, to prevent a secondary infection, wash the area twice a day with mild soap and water and pat dry. You can use ice (wrap it in something) for about 15 minutes, several times a day, Tylenol, or Ibuprofen for pain and swelling, but these measures will not make it go away. They will only help with the discomfort.
Diagnosis: HSV-1 can usually be diagnosed through an exam and patient history, but a wound culture or a blood test will be definitive. You can also do this through a home testing kit (be sure it is an FDA-approved test).
Treatment and Remedies for Herpes I - Herpes Labialis
Conventional OTC Treatment
One of the best-known over-the-counter medicines for these sores is a topical (skin) cream called Abreva. This is an FDA-approved antiviral medicine that speeds up the healing of cold sores by stopping the virus from replicating or multiplying. You begin using it at the VERY FIRST SIGN of a cold sore. This cream will shorten the lifespan of a sore by about 1 to 3 days. From patient accounts, it works marginally well—that is, it is probably better than nothing—and costs around $20.00 to $25.00.
Alternative and Natural Remedies
Many herbs claim to have antiviral properties
Aloe Vera: The fluid from an aloe vera plant or aloe vera gel.
Lysine: Supplemental oral Lysine may help shorten the duration and, if taken regularly, may prevent future flare-ups.
Lemon Balm: Several studies have been done on lemon balm, which show that the herb helps heal and shorten the course of a herpes I outbreak. Different preparations of creams, oils, and extracts are available.
Garlic Preparations- Topical, dilute
Various recipes can be found online. If you are using any oils or extracts, be sure to dilute them accordingly.
Prescriptive Treatment from a Healthcare Provider
If you can afford a visit with a healthcare provider, it is actually better to take an oral antiviral medication, which is a prescription (other antiviral creams, again, are only marginally effective). Examples: Acyclovir, Valacyclovir, Famvir. If you get these outbreaks frequently, get several refills so you can start them when you notice an outbreak in the future (some people use them on a daily basis to prevent an outbreak). The oral antivirals usually work quite well when started early.
GENITAL HERPES HSV-2
Have you been diagnosed with genital herpes? Well, hang on! Read this before you accuse your significant other of being unfaithful! First, genital herpes is NOT an uncommon problem: According to Johns Hopkins, about 1 in 6 people ages 14 to 49 have been diagnosed with HSV-2. This is a herpes virus, much like the others (above), but it is in your genital area.
HSV-2 is highly transmissible. A person usually gets this from sexual contact during an outbreak (it takes only one small sore!). You can also spread it when you do not have an outbreak (although this is rare). And, there are rare circumstances where it is been transmitted through oral-genital or skin-to-skin contact.
HSV-2 also lives dormant in your body. Often, when your body becomes immune-compromised for some reason - from stress or illness or from hormonal changes during menses - the sores appear. However, some people who carry never do get symptoms or an outbreak: Therefore, a person could, conceivably, have gotten this from another partner but never knew they had it. So, before blaming your significant other, think about that. You may have had it all along (unless you tested negative before that relationship). You will never know. Some people have no outbreaks, and some people have many recurrences. There is no way to eliminate it, but you can reduce the symptoms and make them disappear. And by the way, did I tell you? Don't engage in sex during an outbreak: You will likely spread it.
What are the symptoms? Again, some people get no outbreaks, and others get severe or frequent outbreaks. Typical symptoms include itching, tingling, burning, or painful lesions in the genital or anal areas - sometimes even the groin area. Like all herpes lesions, this one is usually characterized by redness and inflammation, followed by one or more blisters that scab. It can become excruciating.
HSV-2 can be diagnosed by a culture (swab) of the lesion, a blood test, or a home test (finger prick). If you do choose to do a home test, be sure it is FDA-approved.
Considered Approaches and Natural Remedies for HSV-2
Many of the supplements and remedies for HSV-1 (above) also apply to HSV-2. Of course, taking optimal care of yourself - getting enough rest, avoiding stress, taking a multivitamin, and staying well hydrated, eating healthy foods - are all essential in helping to fight off these problems.
Prescription Treatment from a Healthcare Provider
Again, there is no cure, but you can manage symptoms. The best way to do this is through prescription antiviral medications. Just like HSV I, you can take Acyclovir, Valacyclovir or Famvir. If you get the outbreaks frequently, you can either take them continually or you can use them episodically (to begin taking if there is any clue, for example, burning or tingling—that an outbreak is starting).
MONONUCLEOSIS "MONO"
Mono is caused by the Epstein-Barr virus. This is also called the "kissing disease" because it is spread by direct contact through a person's saliva, even if it is on an inanimate object like a cup. It is highly contagious.
Mono is common in ages 15 to 24 and presents with a severe sore throat, fever, malaise, headache, and tonsillar exudates (white stuff on your tonsils). Sometimes, a person develops an enlarged spleen and, occasionally, a non-itchy rash (this commonly shows up in a person who has been prescribed a penicillin-based medication). Sometimes, mono behaves very much like a strep and eludes diagnosis.
Mono can be diagnosed by a simple blood test - either at the lab, or by a quick test at a clinic, using a drop of blood from a fingerstick.
The illness typically lasts for two to four weeks, and a pain reducer like acetaminophen or Ibuprofen should help. Vigorous exercise - especially contact sports - needs to be avoided in the event that you have an enlarged spleen (it can rupture).
If you think you - or someone you know - has mono, especially if you have had direct contact, it would be smart to see your healthcare provider. The provider can test you and evaluate you for an enlarged spleen and can give you a prescription for pain medicine (if your sore throat is severe). Because it is caused by a virus, antibiotics will not help this illness. And, like many viruses, the Epstein-Barr stays in your body all your life in a dormant state. This virus rarely recurs in an active state after the initial illness.
To learn more about preventive vaccinations for some of these, visit our vaccination site.
Reminder: This is a site for those 12 years and older
Note: No aspirin in kids (even younger teens) who have viral illnesses. It can cause a severe illness called Reyes' Syndrome.
