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Chart 1: Acute, Generalized Vesicular or Pustular Rash Illness Protocol

Flow-chart depicting Acute, Generalized Vesicular or Pustular Rash Illness Protocol.
  1. When a patient presents with an acute, generalized vesicular or pustular rash illness, institute airborne and contact precautions. Alert infection control on admission.
  2. Determine the patient’s risk of smallpox using the MAJOR and MINOR criteria.
    1. There are three MAJOR criteria:
      1. Febrile prodrome: Fever of ≥101°F, 1–4 days prior to rash onset with at least prostration, headache, backache, chills, vomiting or severe abdominal pain
      2. Classic smallpox lesions: Deep-seated, firm/hard, round well-circumscribed vesicles or pustules; lesions may umbilicate or become confluent
      3. Lesions in same stage of development: On any one part of the body all lesions in same stage of development
    2. There are five MINOR criteria:
      1. Centrifugal distribution of lesions
      2. First lesions on the oral mucosalpalate, face, or forearms
      3. Patient appears toxic or moribund
      4. Slow evolution of lesions from macule, to papule, to vesicle (1-2 days each stage)
      5. Lesions on the palms and soles
    3. If the patient has no febrile prodrome OR has febrile prodrome AND <4 MINOR criteria, the patient’s risk of smallpox is low.
      1. If the patient has a history and exam suggestive of varicella, varicella testing is optional, and risk of smallpox is low.
      2. If the diagnosis is uncertain, test for varicella and other conditions as indicated. Risk of smallpox is low.
    4. If the patient has a febrile prodrome AND one other MAJOR smallpox criterion OR if the patient has a febrile prodrome AND ≥ 4 MINOR criteria, the patient’s risk of smallpox is moderate.
      1. Obtain Infectious Disease and/or Dermatology consultation.
      2. Test for Varicella and other conditions as indicated.
        1. If tests confirm a non-smallpox diagnosis, report results to infection control. The patient’s risk of smallpox is low.
        2. If no diagnosis is made after tests are completed, ensure specimen adequacy and re‑evaluate the patient. At this point, the patient’s risk of smallpox is moderate.
        3. If re‑evaluation does not reveal a diagnosis, you CANNOT rule out smallpox. Patient’s risk of smallpox is HIGH.
    5. If the patient has a febrile prodrome AND classic smallpox lesions AND lesions in the same stage of development, the patient’s risk of smallpox is HIGH.
      1. Obtain Infectious Disease and/or Dermatology consultation and alert local and state public health departments immediately.
      2. The Response team from the local and/or state public health department will advise on management and specimen collection.
      3. Perform variola testing at variola testing laboratory and at CDC
        1. If variola testing rules out smallpox, continue other diagnostic testing. Patient’s risk of smallpox is low.
        2. If variola is positive, then smallpox is confirmed.

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