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ACEP Monkeypox Field Guide

Table of Contents

Clinical Characteristics and Recognition

Incubation period averages 7−14 days but can range from 5−21 days.

Prodrome/Invasion period (lasts between 0–5 days)

  • characterized by fever, headache, lymphadenopathy, back pain, myalgia, intense asthenia and possible sore throat
  • Lymphadenopathy is a distinctive feature of monkeypox compared to other diseases that may initially appear similar (chickenpox, measles, smallpox)
    • typically occurs with fever onset, 1–2 days before rash onset, or rarely with rash onset.
    • Lymph nodes may swell in the neck (submandibular & cervical), armpits (axillary), or groin (inguinal) and occur on both sides of the body or just one.

Rash/Skin Eruption

  • Usually begins within 1–3 days of appearance of fever.
  • Tends to be more concentrated on the face and extremities rather than on the trunk.
  • It affects the face (in 95% of cases), and palms of the hands and soles of the feet (in 75% of cases). Also affected are oral mucous membranes (in 70% of cases), genitalia (30%), and conjunctivae (20%), as well as the cornea.

Rash evolution

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Stage

Stage Duration

Characteristics

Enanthem

The first lesions to develop are on the tongue and in the mouth.

Macules

1−2 days

Following the enanthem, a macular rash appears on the skin, starting on the face and spreading to the arms and legs and then to the hands and feet, including the palms and soles.

The rash typically spreads to all parts of the body within 24 hours becoming most concentrated on the face, arms, and legs (centrifugal distribution).

Papules

1−2 days

By the 3rd day of rash, lesions have progressed from macular (flat) to papular (raised).

Vesicles

1−2 days

By the 4th-5th day, lesions have become vesicular (raised and filled with clear fluid).

Pustules

5−7 days

By the 6th-7th day, lesions have become pustular (filled with opaque fluid) – sharply raised, usually round, and firm to the touch (deep seated).

Lesions will develop a depression in the center (umbilication).

The pustules will remain for approximately 5 to 7 days before beginning to crust.

Scabs

7−14 days

By the end of the 2nd week, pustules have crusted and scabbed over.

Scabs will remain for about a week before beginning to fall off.

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For additional information and answers to Frequently Asked Questions About Monkeypox for Healthcare Professionals see CDC Clinician FAQs.

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Patient Classification/CDC Case Definitions

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Infection Prevention and Control in Healthcare Settings

Specimens Collection, Handling and Storage

The American College of Emergency Physicians Guide to Monkey Pox.

Management (CDC Interim Guidance)

The American College of Emergency Physicians Guide to Monkey Pox.

Treatment

The American College of Emergency Physicians Guide to Monkey Pox.

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