Spotting Zika spots: descriptive features of the rash used in 66 published cases

Zika virus (ZV) is an important emerging infection. Rash is a key feature, but the summative literature lacks description of the rash beyond 'maculopapular'. Our aim was to identify the cutaneous features described in the published literature. A literature search using defined terms for ZV cases reports and series was performed on the OVID, Clinical Key and University of Dundee's e-library journals databases in December 2016; a later case report was included while the paper was under review. Diagnosis in all cases was via PCR. Exclusion criteria were Zika cases without rash or omitting any description of the rash. Ocular features (conjunctivitis) were not included. In total, 42 publications with 66 cases met the criteria. The most frequent descriptive features included maculopapular (59%), lower limb petechial purpura (11%) and erythematous/red (9%). Pruritus was described in 44% and tenderness in 3%. Lesions were located on the trunk (29%), limbs (5% arms, 11% both arms and legs), face (17%) and extremities (14%) or were diffuse/generalized (12%). There was facial sparing in 3%. Other features were centrifugal spread (6%), palmar and/or plantar involvement (6%), palmoplantar desquamation (2%) and malar erythema with oedema (2%). Mucosal features included gingival bleeding (11%), oral haemorrhagic blisters (8%) and painful blisters/vesicles (4%). Oedema/swelling was described in the upper limbs (5%), lower limbs (5%) and both (3%). Mean rash duration was 6 days (range 3-11 days). The ZV exanthema is most frequently maculopapular, pruritic, sometimes with centrifugal spread from the trunk to extremities. This may include lower limb petechial purpura, palmoplantar lesions, oedema of limb extremities, and gingival bleeding or painful oral bullae. As ZV becomes more prevalent, recognition of the clinical features will enable earlier diagnosis and appropriate testing.