Fifth Disease (Slapped Cheek) in Children: The Rash That Looks Alarming but Usually Isn't
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This health information is reviewed by board-certified pediatricians and follows current American Academy of Pediatrics (AAP) guidelines.
Every spring, classrooms across Robbinsville, Hamilton, East Windsor, Plainsboro, and Mercer County see outbreaks of a rash that sends parents rushing to call the pediatrician. The cheeks are suddenly fiery red, as if someone slapped them, and parents worry it's an allergic reaction, roseola, or something serious.
Most of the time, it's fifth disease. And most of the time, you can take a deep breath.
What Is Fifth Disease?
Fifth disease is a common viral illness caused by parvovirus B19. It earned its rather unimaginative name because it was historically fifth on a list of classic childhood rash illnesses. It is extremely common, highly contagious before the rash appears, and almost universally mild in healthy children.
Most children who get fifth disease feel like they have a mild cold for a few days: runny nose, low-grade fever, mild headache, and then the distinctive rash appears. Many children have so few symptoms before the rash that parents have no idea anything was going on.
The Two-Stage Rash
Fifth disease has a very recognizable rash pattern that unfolds in two stages:
Stage 1: The Slapped Cheek: Bright red, warm, flat redness on both cheeks. The area around the mouth and nose is notably pale by comparison. It can look dramatic and even alarming. The cheeks may feel slightly warm. This stage typically lasts 2–4 days.
Stage 2: The Lacy Body Rash: A day or two after the cheek rash appears, a pink, lacy, net-like rash spreads to the trunk, arms, and legs. It is usually not itchy, though some children do notice mild itching. This rash fades and reappears over 1–3 weeks, often seeming worse after sun exposure, heat, a bath, or exercise.
The Most Important Thing to Know: Contagiousness Timing
This is what most parents don't know and it's genuinely reassuring: by the time the distinctive rash appears, your child is no longer contagious.
Parvovirus B19 is spread through respiratory droplets: coughing, sneezing, close contact, during the illness phase before the rash develops. Once that dramatic red cheek rash shows up, the contagious window has passed. This means children with fifth disease do not need to be kept home from school once the rash has appeared. The rash itself is not contagious.
When Fifth Disease Really Does Matter
For healthy children, fifth disease is a non-event. But there are two situations where it requires more careful attention:
Pregnancy: Parvovirus B19 can cross the placenta and affect the developing baby. In rare cases, it can cause a condition called hydrops fetalis. If a pregnant woman is exposed to fifth disease, especially a teacher, childcare worker, or pregnant parent of a child with the illness, she should contact her OB or midwife promptly. About 50% of pregnant women are already immune from past infection, but blood testing can determine immunity status.
Children with sickle cell disease or other chronic hemolytic anemias: Parvovirus B19 temporarily suppresses red blood cell production. In healthy children, this is not a problem. In children with sickle cell disease, this can trigger an aplastic crisis with a severe drop in red blood cell count requiring urgent medical attention. If your child has sickle cell disease and is exposed, contact us immediately.
Children with weakened immune systems may also experience a more prolonged or severe infection and should be evaluated.
Symptoms and Home Care
- Rest as needed
- Fluids to stay hydrated
- Acetaminophen or ibuprofen if there is fever or discomfort: follow package dosing instructions for your child's age and weight
- Avoid extended sun exposure and hot baths during the lacy rash phase, as heat tends to make the rash more visible
The rash may come and go for 2–3 weeks, especially with temperature changes. This is entirely normal and does not mean the illness is getting worse.
When to Call Hummingbird Pediatrics
- You are unsure whether your child's rash is fifth disease or something else
- Your child has sickle cell disease or a compromised immune system and has been exposed to or diagnosed with fifth disease
- Your child has a high fever (above 104°F/40°C) or is unusually ill
- A pregnant household member or caregiver has been exposed
- The rash is accompanied by joint pain or swelling (joint symptoms occasionally occur, especially in older children and adults)
- You have questions about whether your child needs to be seen
Fifth disease is one of the most common spring classroom illnesses in New Jersey, and nearly every healthy child who gets it sails through it without complication. We are always here if you have questions.
Frequently Asked Questions
Is fifth disease contagious? Can my child go to school with it?
Here is the reassuring news: by the time the distinctive bright-red cheek rash appears, your child is no longer contagious. Fifth disease (parvovirus B19) is spread through respiratory droplets during the illness phase, the week or two before the rash develops. Once that slapped-cheek rash shows up, the contagious window has passed. Children with fifth disease do not need to be kept home from school once the rash has appeared, as long as they feel well enough to participate.
How do I know if the rash is fifth disease or an allergic reaction?
Fifth disease produces a very characteristic bright red rash on both cheeks with notable paleness around the mouth and nose (it genuinely looks like someone slapped both cheeks). It then progresses to a lacy, net-like rash on the trunk and limbs that fades and reappears over 1–3 weeks, often getting temporarily redder with heat, sun, or a bath. An allergic reaction typically appears in hives (raised welts), comes on suddenly after exposure to something, and may be accompanied by itching or other allergic symptoms. If you are unsure, call us; we are often able to help identify it over the phone.
Why does fifth disease matter if someone in our household is pregnant?
Parvovirus B19 can cross the placenta and, in rare cases, affect the developing baby (particularly causing a condition called hydrops fetalis). This is most concerning during the first 20 weeks of pregnancy. If a pregnant woman is exposed to fifth disease or lives in a household with a child who has it, she should contact her OB or midwife promptly. About 50% of adults are already immune from childhood infection, and a blood test can determine immunity. Most pregnancies exposed to parvovirus B19 have no complications.
My child's fifth disease rash keeps coming and going. Is that normal?
Yes, completely. The lacy body rash of fifth disease is notorious for fading and then reappearing, sometimes for 2–3 weeks or even longer. It tends to look worse after heat exposure, a warm bath, exercise, or time in the sun. This is normal and does not mean the illness is getting worse or spreading. The coming-and-going pattern is characteristic of fifth disease and not a sign that anything else is wrong. Your child remains symptom-free and non-contagious during these reappearances.
Can adults get fifth disease? What does it look like in adults?
Yes, adults can get fifth disease if they have not been previously infected. Interestingly, the slapped-cheek rash is much less prominent in adults. Instead, adults with parvovirus B19 infection often experience significant joint pain and swelling (especially in the hands, wrists, knees, and ankles) that can mimic arthritis and last several weeks. Adults with fifth disease are contagious before their symptoms develop, just like children. Most adults recover fully, though joint symptoms can occasionally persist for months.
Need Personal Guidance?
This article provides general information. For questions specific to your child's health, please call our office or book an appointment online.