Experts Provide Measles Tips for Dermatologists

By the late 1990s, annual cases of measles in the United States dwindled to a few dozen, down from more than 27,000 in 1990. However, the disease remained a mainstay of medical education for dermatologists. While few trainees might see measles in practice, the thinking went, the lesions were still a useful benchmark for diagnosing viral skin diseases.

“We naturally compare things to measles,” said Esther Freeman, MD, PhD, director of Global Health Dermatology at Massachusetts General Hospital and Harvard Medical School, Boston, and chair of the American Academy of Dermatology (AAD)’s Emerging Diseases Task Force, in an interview. “We’re taught that the morbilliform rash — morbilliform literally means measles-like — is a particular characteristic viral rash.”

Now, as a measles outbreak spreads in the American Southwest and elsewhere, it’s becoming more and more likely that measles-like lesions are actually signs of measles. 

As of April 4, 2025, the Centers for Disease Control and Prevention (CDC) confirmed 607 measles cases in six outbreaks, up from 285 cases in 2024 and 59 in 2023. As of April 8, Texas, where an outbreak has struck the South Plains and Panhandle regions, reports 505 cases since early January, and New Mexico reports 56, almost all in Lea County near the Texas Panhandle. The other affected states are Alaska, California, Colorado, Florida, Georgia, Kansas, Kentucky, Maryland, Michigan, Minnesota, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Vermont, and Washington. On April 8, a case was reported in Hawaii in an unvaccinated child younger than 5 years.

“We are absolutely expecting the number of cases and states to rise,” said Freeman, whose AAD task force has posted a new Measles Resource Center for dermatologists. “As dermatologists, it’s really important to have this on our radar, although many of us have not seen measles cases,” she said.

The following are six recommendations for dermatologists regarding measles and the current outbreak:

1. Any Possible Cases Should Be Isolated Immediately

“Measles is one of the most infectious viruses that we have,” Freeman said. “It can stay in the air after an individual has left a room for 2 hours and affect someone at a distance of 100 feet away.” In dermatology, “we’re not used to a virus this infectious,” she added, so special precautions are needed.

The AAD Measles Resource Center suggests that dermatology clinics in measles-affected areas institute a previsit telephone triage system to screen patients for symptoms of measles within the last week — high fever, cough, runny nose, conjunctivitis, and maculopapular rash. When possible, patients with a possible case of measles should be seen in a facility with an airborne infection isolation room, Freeman said.

If a patient with suspected measles does turn up in a dermatology clinic, the patient should be masked immediately and not left in the waiting room, she said. “Only healthcare personnel with known immunity to measles should be taking care of that individual, and they should be wearing an N95 mask or other appropriate PPE [personal protective equipment].”

When a case of measles is suspected, don’t wait for the case to be confirmed before contacting your local and state health departments, Freeman said. Reach out to them immediately, and “they will take you through the process from there.”

The AAD Measles Resource Center includes contact information for state/territory, city/county, and tribal health departments. It also lists emergency “Epi-on-Call” phone numbers for state/territory health departments along with some local health departments.

2. Measles Diagnosis Relies on Multiple Symptoms and Testing

Measles-like rashes alone aren’t definitive signs of measles since they can be caused by other viruses, Freeman said. Other symptoms, along with their timing, can assist in making the diagnosis.

“Before you come down with measles, you have a prodrome. You don’t just wake up one day with a rash,” said Sharon Nachman, MD, professor of pediatrics at SUNY Stony Brook and chief of the Pediatric Infectious Disease Division at Stony Brook Children’s Hospital, Stony Brook, New York, in an interview.

A useful mnemonic refers to the “three Cs” of measles: Cough, conjunctivitis, and coryza. “We’re not talking about a little runny nose. They have a horrible, yucky, nasty glop coming down the nose,” Nachman said.

These symptoms, along with small white spots inside the mouth (Koplik spots), appear first, Freeman said. Then comes a maculopapular rash.

“Generally, the rash begins about 7-18 days after exposure, starts on the face and the upper neck, and then spreads across the trunk, arms, and legs over the course of about 3 days,” Freeman said. “The rash usually lasts around 5-6 days.”

In addition, the rash never begins on the lower body and goes upward Nachman said. “It always starts on your head and goes downwards.”

Serology testing and real-time reverse transcription–polymerase chain reaction tests are available to confirm measles, and the tests are sometimes conducted outdoors. “This is not something that we suddenly expect a lot of dermatologists to be doing because the goal really is to potentially screen people out and not have them show up in your office,” Freeman said. “But at times they will.”

The AAD Measles Resource Center notes that serology tests that look for immunoglobulin M antibodies may be in short supply, so “clinicians should be vigilant in contacting their state or local health department for guidance on testing.”

3. Focus on Case Severity and Family Vulnerability

If a case of measles is suspected, one of the first steps is to vaccinate the rest of the family if needed, Nachman said. As the AAD’s Measles Resource Center notes, postexposure prophylaxis is available for vulnerable people via the measles, mumps, and rubella (MMR) vaccine (within 72 hours of exposure) or immunoglobulin (within 6 days of exposure), and “public health officials can help identify eligible people, assess contraindications, and weigh the benefits.”

It’s also crucial to determine how sick the patient is. Nachman said she may send a child with a fever home if they’re feeling all right. “But I would give the family a lot of cautious advice. If they’re working hard to breathe, breathing fast, and can’t catch their breath, they go to the hospital. If they’re not eating or drinking, they go to the hospital. I tell families of little kids that if they’re not playing, they’re not walking up and down the stairs, go to the hospital.”

According to Freeman, dermatologists should follow the usual drill when a patient appears to have a case of measles that requires extra management. “It’s not the dermatologist’s role to manage measles complications, such as severe pneumonia,” she said. “We’re going to use our usual protocol: When patients are very sick, we end up calling the ER [emergency room] or transfer our patient to an inpatient facility. Those rules are not going to change here.”

4. Treatment for Milder Cases Is Supportive

In milder cases, the recommendation is to “keep the kids comfortable,” Nachman said. “Every child that I’ve seen who has the measles is whining, crying, and miserable. Their whole body hurts.” Hydration is important, but don’t worry about lotions or special baths for the lesions, she said.

“We tell families to expect [their kids] to be sick for about 3 weeks,” she said.“It takes the kids a long time to get better and back to their usual selves.” Serious complications can include measles pneumonia, and several years after infection, subacute sclerosing panencephalitis, which causes brain swelling, affects an estimated 4-11 per 100,000 patients with measles and is nearly always fatal. “We’re not able to predict which kid it is going to happen to except to say it happens 10 years later,” Nachman said.

5. Current Outbreak Is Hitting Patients Hard

Prior to this year, the most recent pediatric death in the United States from measles was in 2003, and the most recent adult death was in 2015. As of April 7, there have been two reported deaths from measles in school-aged children, both in West Texas. One child died in February and another in April. In a suspected case, a person in eastern New Mexico died and was found to be positive for measles, but other details haven’t been released. According to health officials, none of the three victims was vaccinated against measles.

According to the CDC’s April 4 data, the current measles outbreak is affecting people of all ages (26% of cases are ≥ 20 years), but children make up a large number (32% of cases are younger than 5 years; 40% are between 5 and 19 years), with age unknown in 2% of cases.

Of the 607 confirmed cases, 12% have been hospitalized, including 21% of those younger than 5 years and 8% of those of other ages; in 8% of the cases, the ages are unknown. It’s not clear why the patients were hospitalized. In 2024, the CDC reported that 40% of 285 patients were hospitalized “for isolation or for management of measles complications,” but none died. Vaccination status in most of the 607 cases (97%) is listed as unvaccinated or “unknown.”

6. Measles Vaccination Is Crucial

“Vaccination is incredibly important,” Freeman said, especially in light of the high contagiousness of measles. “Herd immunity for measles is about 95%, meaning that 95% of us have to be vaccinated in order to not have it and in order to protect those around us who are unable to get vaccinated for a variety of reasons,” she said. “Unfortunately, vaccination rates have been falling over the last 5 or so years, and a number of states are below this threshold.”

A 2024 report found that 93% of kindergartners nationwide had received two doses of the MMR vaccine, ranging from a high of 98.3% in West Virginia to a low of 79.6% in Idaho. States with percentages below 95% are Alabama, Alaska, Arizona, Arkansas, Colorado, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Texas, Vermont, Virginia, Utah, Washington, Wisconsin, and Wyoming.

The District of Columbia and Puerto Rico also have rates below 95%, and Montana did not provide data.

“From the 2019-20 to the 2022-23 school year,” the report said, “national kindergarten coverage with state-required vaccinations declined from 95% to approximately 93%.” The AAD Measles Resource Center offers information about measles vaccines, including details regarding pregnant and immunosuppressed people and those taking certain medications.

Clinical photos of measles are available on the AAD’s resource center.

Freeman consults for philanthropic global health projects for CeraVe and L’Oreal and co-authored a report on COVID-19 for UpToDate. Nachman disclosed funding via the National Institutes of Health.