Monkeypox (Mpox) is a viral infection caused by the monkeypox virus, an orthopoxvirus related to smallpox but generally less severe1 . The illness spreads through close contact and typically causes flu-like symptoms followed by a distinctive rash that lasts 2 to 4 weeks2 . The rash can appear on various body parts including the face, hands, feet, genitals, and anus, and may cause pain or itching3 . Understanding the stages and symptoms of the Mpox rash is essential for early recognition, diagnosis, and management4 .
Monkeypox Rash Stages with Pictures
Mpox skin lesions evolve through five distinct stages during the infection: macules, papules, vesicles, pustules, and scabs5 6. These lesions often appear synchronously and can affect any part of the body, including the chest, hands, feet, face, mouth, and genital areas7 83. The rash may be numerous, with some cases reporting a mean of 370 lesions5 9.
Stage 1: Macules
The first stage of the Mpox rash is the macular stage. Macules are flat, discolored spots on the skin without any raised surface5 6. They typically last up to two days and may appear as round pink or red patches10 . Oral mucosal rashes, known as enanthem, can sometimes precede the skin lesions5 6. Macules mark the initial visible sign of the rash and are often painless but noticeable.
Stage 2: Papules
Macules evolve into papules, which are raised, firm bumps on the skin5 6. The papular stage also lasts up to two days and represents the progression of the rash from flat to raised lesions5 6. Papules are usually round and solid, signaling the immune response to the virus in the skin10 . This stage is important as the lesions become more prominent and easier to identify.
Stage 3: Vesicles
Papules then fill with clear fluid to become vesicles, small fluid-filled blisters5 6. Vesicles last about one to two days and are typically painful rather than itchy5 6. The clear fluid inside the vesicles contains viral particles, making this stage highly contagious10 . Vesicles can appear on any part of the body and often cluster in groups.
Stage 4: Pustules
Vesicles progress into pustules, which are raised lesions filled with opaque, pus-like fluid5 610. Pustules are usually round, firm, and may develop a central indentation or "divot" 10. This stage lasts about 5 to 7 days and is often the most painful phase of the rash5 6. Pustules can be numerous and may cause scarring after healing6 .
Stage 5: Scabs
Finally, pustules crust over to form scabs or crusts5 6. Scabs last 1 to 2 weeks before falling off naturally, marking the healing phase of the rash5 610. Once all scabs have fallen off and new skin has formed, the person is no longer contagious2 10. Scabs may leave scars, especially if lesions were extensive or became secondarily infected.
💡 Did You Know?
Below are various photos of monkeypox rash and what it can look like. Examples of monkeypox lesions include multiple lesions on a person's back and lesions on a person's hand11 .
Diagnosing Monkeypox
Diagnosing Mpox relies on clinical suspicion based on typical skin lesions and systemic symptoms, supported by molecular testing such as PCR of lesion swabs7 82. The rash morphology can be polymorphic and may resemble other infections, making differential diagnosis essential7 8. Lesions usually appear and evolve synchronously, which helps distinguish Mpox from other diseases7 8.
Mpox vs. Other Bumps
Mpox lesions can be mistaken for other poxvirus infections like chickenpox, cowpox, and smallpox, as well as sexually transmitted infections such as herpes simplex virus and syphilis7 8. However, Mpox lesions progress through distinct stages synchronously, unlike chickenpox where lesions appear in crops at different stages7 8. Mpox lesions are often painful rather than itchy, which can help differentiate them from other rashes5 6.
Key differences include:
- Chickenpox is caused by the varicella-zoster virus, not an orthopoxvirus7 8.
- Mpox lesions frequently involve the genital area, which is less common in chickenpox7 8.
- Herpes lesions tend to be grouped vesicles on an erythematous base, while Mpox lesions progress through defined stages7 8.
- Syphilis rash is usually non-pustular and accompanied by other systemic signs7 8.
“While the mpox rash can be mistaken for chickenpox, shingles, or herpes, there are differences between these rashes.”
— Esther E. Freeman, Massachusetts General Hospital, Harvard Medical School2
Mpox Rash Duration
The median time from initial viral symptoms to rash onset is approximately 5.5 days, with a range of 1 to 33 days12 . The rash itself typically lasts between 2 and 4 weeks but can persist as long as 60 days in some cases12 . Most patients recover within a few weeks, but immunocompromised individuals may experience prolonged symptoms and delayed rash resolution7 8.
Mpox lesions evolve synchronously and the rash can affect any body part, including sensitive areas such as the genitals, anus, mouth, and eyes7 83. Patients remain contagious until all lesions have crusted over and healed2 10. The infectious period can last up to four weeks from symptom onset10 .
“If you have a new, unexplained skin rash or lesion on any part of your body that you think could be mpox, seek medical care immediately.”
— Esther E. Freeman, Massachusetts General Hospital, Harvard Medical School2
Additional Mpox Symptoms
Besides the rash, Mpox commonly causes systemic symptoms including fever, headache, muscle aches, back pain, swollen lymph nodes, chills, exhaustion, sore throat, and respiratory symptoms2 313. These flu-like symptoms may precede or follow the rash, but some patients only experience the rash without systemic signs10 .
Other symptoms and complications can include:
- Proctitis causing severe pain and genital inflammation leading to urinary difficulties1 .
- Secondary bacterial infections of skin lesions15 13.
- Severe complications such as encephalitis, pneumonitis, myocarditis, and vision loss from conjunctivitis or keratitis15 13.
- Fatigue and low energy lasting throughout the illness1 .
Most infections resolve with supportive care, but severe cases may require antiviral treatment such as tecovirimat13 14.
When to Contact a Doctor
Recognizing Mpox Rash: The mpox rash can look like pimples, blisters, or sores and often begins on the face before spreading to other body parts. Lesions progress through five stages and can be painful, especially during the pustular phase. Early identification and medical care are critical to prevent spread and complications2 45.
It is important to seek medical care if you suspect Mpox exposure or develop symptoms, especially if you have a new, unexplained rash or lesion7 82. Early diagnosis allows for timely treatment and reduces the risk of spreading the virus to others2 .
Contact a healthcare provider if you experience:
- Fever, rash, swollen lymph nodes, or flu-like symptoms after possible exposure7 8.
- Rash spreading to sensitive areas such as the anus, eyes, genitals, or mouth7 8.
- Signs of complications like dehydration, diarrhea, nausea, vomiting, or infected lesions7 8.
- Worsening symptoms or lack of improvement over time7 8.
“Not every new rash is mpox. However, if you do think you have mpox, it's important to see your doctor quickly. Patients who delay getting medical attention may be diagnosed later when fewer treatment options are available. Waiting also means that you can expose more people to the virus, so family and others may develop mpox.”
— Esther E. Freeman, Massachusetts General Hospital, Harvard Medical School2
Summary of Mpox Rash
Monkeypox rash is a hallmark feature of Mpox infection, progressing through five well-defined stages: macules, papules, vesicles, pustules, and scabs5 6. The rash often appears on the face, hands, feet, chest, genitals, and anus, and may be painful rather than itchy5 63. The illness usually begins with flu-like symptoms followed by the rash within about a week of exposure2 4.
Diagnosis requires clinical suspicion supported by PCR testing of lesion samples7 82. The rash typically resolves in 2 to 4 weeks, but can last longer in immunocompromised patients12 14. Complications may include bacterial infections, encephalitis, and vision loss, highlighting the importance of early medical evaluation15 13.
Prevention includes vaccination for at-risk individuals, avoiding close contact with infected persons, and practicing good hygiene1 13. Patients remain contagious until all lesions have healed and new skin has formed2 10.
