What Is the First Sign of Measles?

Ask a Doctor

I live in Southern California, where there is a measles outbreak. Over the last couple days, I’ve been feeling run down and coughing. I thought it was a cold virus, but I developed a fever today and called off work. It’s probably the flu, but how do I know if it’s measles? What is the first sign of measles?

Doctor’s Response

Both types of measles, rubella and rubeola, start out with flu-like symptoms (see below), and the rash appears within two to four days. In general, both children and adults who have a fever and a rash should contact their physician. People who encounter an infected person should also be evaluated to see if they need special measures to keep them from getting sick. Normally, measles is not a disease that requires emergency care.

Rubeola ("red measles" or "hard measles")

Symptoms appear about eight to 12 days after the rubeola virus infects a person. This is the incubation period. During this period, the virus is multiplying. Symptoms occur in two phases.

  • The early phase begins with these symptoms:
    • Fever
    • A run-down or lethargic feeling
    • Cough
    • Red eyes without discharge (conjunctivitis)
    • Runny nose
    • Loss of appetite
  • The red measles rash develops from two to four days later.
    • The rash usually starts on the face, spreading to the trunk and then to the arms and legs.
    • The rash is initially small red bumps that may blend into each other as more appear. From a distance, the rash often looks uniformly red. The rash lasts for five to seven days.
    • People with measles may develop small grayish spots on the inside of the cheek, called "Koplik spots."
    • The rash is usually not itchy, but as it clears up, the skin may shed (this looks like skin that is peeling after sunburn).
    • Although red measles is often a mild disease, a few serious complications may occur. Red measles makes people more vulnerable to pneumonia and bacterial ear infections. Pneumonia as a complication of measles is especially serious in infants and is responsible for most deaths in this age group. Inflammation of the brain (encephalitis) occurs about once in every thousand cases of measles and is a serious complication that can be fatal.
    • Red measles is particularly severe in people with weakened immune systems, including people who are malnourished or have HIV.

Rubella ("German measles")

German measles causes milder symptoms than red measles. The incubation period between getting the virus and getting sick is 16-18 days.

  • Initially, some people experience fatigue, low-grade fever, headache, or red eyes several days before the rash appears. These symptoms are more common in adults than in children.
  • Swollen, tender lymph nodes may occur in the back of the neck.
  • The rash is light red to pink. It starts as individual spots that may merge over time. The rash usually starts on the face and moves down to the trunk.
  • The rash does not usually itch, but as it clears up, the skin may shed. Individuals are most contagious a few days before the rash develops to seven days after it first appeared.
  • Adolescents and adults who get rubella may get painful joints for days to weeks after the infection. This typically affects the hands, wrists, and knees.
  • Symptoms and signs may be so mild that people do not notice them, especially in children. Studies have shown that approximately 25%-50% of infected people do not have any symptoms or signs. Most symptoms resolve in a few days, but swollen lymph nodes may persist for a few weeks.
  • The most feared complication of rubella is "congenital rubella," which occurs when an infected pregnant woman passes the virus to her unborn child. Among other problems and birth defects, affected infants may have cataracts, heart defects, hearing impairment, and learning disabilities. The risk of transmission is highest early in pregnancy. The virus may also cause miscarriage or stillbirth.

For more information, read our full medical article on measles.

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American Academy of Pediatrics. "Measles (Rubeola)." In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics, 2018: 537-550; 705-710.

American Academy of Pediatrics. "Rubella." In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics, 2018: 705-710.

United States. Centers for Disease Control and Prevention. "Measles -- United States, 2011." MMWR 61.15 Apr. 20, 2012: 253-257.