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nonspecific viral exanthem in a child in whom other diagnoses have been excluded and who may have signs of associated illness or systemic features such as fever If specific diagnosis is required, it can be determined by viral isolation and/or a rise in diagnostic titer Generalized Eruptions Without Fever Many generalized eruptions are not associated with fever Many are fairly easily recognizable, such as psoriasis, contact dermatitis, pityriasis rosea Guttate Psoriasis and Pityriasis Rosea Please see Chapter 70 Rash: Papulosquamous Eruptions and Viral Exanthems for full discussion of papulosquamous skin rashes Rubella Rubella is rarely seen in the postvaccine era in the United States In a classic case of rubella, the rash, similar to measles, begins on the head and spreads caudally The progression occurs over to days, and typically, the rash is entirely gone by the fourth day The rash always remains macular and never becomes confluent, which is an important distinguishing characteristic from measles One-third of all rubella virus infections is clinically silent (i.e., they have no exanthem) The rash of rubella may show extensive variation in location, progression, and duration, at times disappearing within 12 hours or being localized to one part of an extremity without any progression Unlike measles, in which systemic toxicity and fever are the rule, fever is uncommon Associated symptoms and complaints in rubella include joint pain and adenopathy (most commonly suboccipital, postauricular, and cervical) Arthralgia that occurs with a viral exanthem is highly characteristic for rubella Diagnosis is based on clinical presentation, and treatment is supportive Vesicles/Bullae Enterovirus Infections Enterovirus infection can not only cause morbilliform exanthems but can also cause vesicles and blisters The classic exanthem of coxsackievirus A16 infection, also appropriately called hand–foot–mouth disease , is common and easily recognized Infections may occur in epidemics, most commonly in the late summer or early fall Multiple infected members within a household are common Coxsackievirus A16 infection begins with a prodrome of low-grade fever, anorexia, mouth pain, and malaise, followed within to days by an oral