Recognizing the Monkeypox Rash and Common-Sense Precautions

The monkeypox virus can be transmitted via close, personal contact, and for the first several months of the outbreak it appeared to be closely associated with sexual contacts. However, it is possible to transmit monkeypox person-to-person without any sexual contact, as recently reported by the CDC regarding a young man in his 20s who sought care at an Emergency Department (ED) in Stanford, California.

A case of monkeypox detected in the emergency room

The young man came to the Stanford ED on day 7 of a diffuse rash on his back, knuckles, lip and palm. He had no viral prodrome—fever, cough, muscle aches, chills, headache, swollen lymph nodes, or fatigue. He had been traveling in the UK and attended several large outdoor gatherings during his visit, and at one of them he reported close contact with people wearing shorts and sleeveless tops while dancing. He first noticed his symptoms approximately 14 days after attending these gatherings.

The ED was able to do a swab and get results back within 12 hours which confirmed monkeypox infection (clade 2/3 West Africa). He did not test positive for SARS-CoV-2 and did not receive any specific treatment because he was not considered high risk and did not have any serious complications of his illness.

Stages of the rash

Although many early reports of monkeypox lesions have described painful anorectal lesions, epidemiologists recognize that the “typical” case will evolve with community spread. In fact, in nearly two-thirds of cases in a recent report from 16 countries, there were no more than 10 lesions present. Thus, it is important to appreciate the wide variety of symptoms, and the stages of the rash, to prevent onward transmission to others.

The CDC provides an excellent overview of the rash progression, from the first lesions to appear through the scab stage.

• Enanthem – these are viral lesions which appear in mucus membranes, such as in the mouth (exanthem means outside the body). Lesions may be visible on the tongue or in the mouth or oral cavity.
• Macules –These small patches of skin are discolored but not yet elevated.
• Papules – The lesions typically progress from flat discolored papules to papules (raised bumps) lasting for 1-2 days.
• Vesicles –Vesicles are raised lesions filled with clear fluid. This stage usually lasts 1-2 days.
• Pustules – The fluid will become opaque, sharply raised and round, and usually firm. They may develop a spot or depression in the center (called umbilication). This stage may last 5-7 days before the lesions start to scab over.

When the rash heals, the skin may remain discolored—lighter or darker—and may be pitted with scars. A person is no longer contagious once the scab has fallen off and a fresh layer of skin has grown over the rash lesions. The entire process of illness and healing may take 3 to 4 weeks. In the case of the young man who acquired monkeypox.

What is the latest information about the spread of monkeypox?

This case and other studies suggest there are likely to be alternative modes of transmission in addition to sexual contact. Does this mean it is possible to pass monkeypox through close-contact sports or high-energy packed concerts, clubs or other activities? Possibly. However, scientists do not yet know how long the virus can live in the environment and how much virus is necessary to be infectious.

A study of surfaces in a household found positive samples in high-contact areas, particularly on porous items like cloth furniture and blankets but no infectious virus was detected. Another study was able to detect viable virus on porous household surfaces but only at very low concentrations.

Common-sense precautions

Being infected does not necessarily mean disease (symptoms) will occur. Recall that approximately half of all SARS-CoV-2 cases are asymptomatic—the person is infected but not sick. The ability of a virus to make a person sick depends on many factors: the virus’ ability to stay alive long enough to be infectious, a portal of entry (inhaling it, through a break in the skin, contact with mucus membranes, etc.), the vigor of the immune system, the ability of the virus to replicate within the human body, and other factors.

Taking care of your health by getting enough sleep, exercise, good nutrition and stress management can all support your immune defenses against the wide variety of microbes we encounter every day. Common sense precautions for monkeypox include staying home when sick. It also makes sense to keep an eye out for any rash, especially accompanied by a viral prodrome (fever, chills, headache, fatigue, nausea, etc.) and contact your family doctor if you have questions.

Remember that the skin is full of special dendritic cells which look for invaders and activate your immune system. This is one reason why the JYNNEOS vaccine can be given intradermally (just under the skin) at 1/5th the usual dose and still be effective. Contact your doctor if you have a new rash illness and have a weakened immune system so that early testing and treatment can be provided if necessary.

A special note to college students

Being away at university is an exciting time—experiencing events and festivals all geared to establishing new friendships and a new home. It’s also a time when you are likely to pick up new infections because you are meeting people from all over the country and the world. This is not a time to be particularly anxious about getting sick, but you should have a plan.

As our young man who presented to the ED in Stanford illustrates, it is possible to pick up monkeypox or another common respiratory illness at a party, especially if you’re in close quarters and in light clothing. You’ve probably read all you care to about sexually transmitted infections (STIs) but it makes sense to be vigilant for any new rash or symptoms and get seen by your clinic for testing. It might be helpful to make a mental note of when you go out—the young man’s symptoms started 14 days after the gatherings he attended. It might be hard to remember what happened last weekend, not to mention two weeks ago!