Measles

By Ruth Carol, Contributing Writer, August 1, 2025

Dermatologists routinely treat viral rashes, but they may not be familiar with the particular cluster of symptoms associated with measles. That’s because the disease was declared eliminated in the United States in 2000.

“Many of us haven’t seen measles during our training or practice,” noted Esther Freeman, MD, PhD, FAAD, chair of the American Academy of Dermatology’s (AAD) Emerging Diseases Task Force. “Certain generations of dermatologists practicing in the United States don’t remember a time when measles was endemic.”

Measles was identified as an infectious agent in 1757. In 1912, measles became a nationally notifiable disease in this country, which means that physicians and laboratories were required to report all diagnosed cases. In the first decade of reporting, an average of 6,000 measles-related deaths were reported annually. A vaccine was developed in 1963 but an improved version came out in 1968. In 1971, the measles vaccine was combined with the mumps and rubella vaccine to create the MMR vaccine. Measles cases continued to decline, but in 1989, a measles outbreak occurred among vaccinated school-aged children. That prompted the Advisory Committee on Immunization Practices (ACIP), American Academy of Pediatrics, and American Academy of Family Physicians to recommend a second dose of MMR vaccine for all children. Measles cases dropped even more until the disease was declared eliminated in the U.S. due to high vaccination rates.

But that could change if the number of reported cases continues to climb. As of July 2025, a total of 1,288 confirmed measles cases were reported by 39 jurisdictions, the Centers for Disease Control and Prevention (CDC) reports. Of those, 162 (13%) patients were hospitalized, and three deaths from measles have been confirmed. The CDC states that 92% of these cases were unvaccinated or had unknown vaccine status.

If the current state-level vaccination rates remain steady, measles could stage a comeback and become endemic within the next 25 years, according to a recent modeling study published in JAMA. “However, even a small increase in vaccination rates could potentially stave off this effect,” Dr. Freeman said. “The concern is that we are headed in the opposite direction. This is a critical point in history from a public health perspective. We risk having measles return to endemic levels unless we make some positive changes with people’s understanding, approach, and acceptance of vaccines.”

“We risk having measles return to endemic levels unless we make some positive changes with people’s understanding, approach, and acceptance of vaccines.”

Why now?

Dr. Freeman said the outbreak reflects broader patterns that have been building in recent years. There has been growing vaccine misinformation and expansion of families opting out of vaccination for reasons beyond medical exemptions. Vaccine hesitancy and vaccine misinformation then exploded during the COVID-19 pandemic, which disrupted the vaccination schedule for some children. National coverage for the MMR, DTaP, polio, and varicella vaccines for the 2019-20 (pre-pandemic) school year was about 95%, which dropped to an average of about 92.5% in the 2023-24 school year, according to the CDC. Coverage for the four vaccines dropped in more than 30 states in the 2023-24 school year compared with the previous school year.

“We’ve watched the growing vaccine hesitancy in response to financially motivated misinformation,” said Misha Rosenbach, MD, FAAD, deputy chair of the AAD’s Emerging Diseases Task Force. States with lax vaccine requirements or free-flowing exemptions for medical, religious, or personal reasons, such as Idaho, Oklahoma, and Texas, have vaccination rates lower than what is needed for community or population immunity, also known as herd immunity. The CDC reports that vaccine exemptions increased in 41 jurisdictions, 14 of which reported that more than 5% of kindergartners had an exemption from one or more vaccine in the 2023-24 school year. “We’ve seen intermittent outbreaks of measles in communities with historically low vaccine rates, such as highly religious groups. Often, someone travels and returns home with measles, and it spreads,” he said. “It is not at all surprising to see persistent outbreaks when community vaccine rates are low, including this one, which has now spread to Mexico and Canada from the U.S.”

What is happening with measles raises concerns for other infectious diseases, Dr. Rosenbach added. The World Health Organization (WHO) recently warned that the threat of preventable disease outbreaks is growing amid vaccine misinformation and potential funding cuts across the globe. Measles has been on the rise worldwide since 2021, increasing to 8.6 million cases in 2022 and 10.3 million cases in 2023, while vaccine coverage has declined. Additionally, yellow fever, which had dramatically declined globally, is returning and diphtheria, which has remained steady, is at risk of re-emerging. “In some ways, measles is the canary in the coalmine,” he noted. “We can eliminate this disease again if people follow the science. People have an obligation to protect the vulnerable, and getting vaccinated is the best way to do that,” Dr. Rosenbach said, adding, “You protect yourself and save the lives of others. That’s a hard thing to argue with.”

Measles 101

Another indisputable fact is that measles is highly contagious. It is more infectious than the flu, COVID, smallpox, or Ebola. Measles can be transmitted after a brief exposure and at nearly 100 feet away. “A person with measles could pass through your waiting room and infect another person who comes in two hours later,” Dr. Freeman noted. Additionally, it can spread from four days before its characteristic rash appears to four days after its onset, added Carolyn Goh, MD, FAAD, a member of the AAD’s Emerging Diseases Task Force.

Herd immunity requires a 95% vaccination rate, per the CDC standard. With rates below that figure, one infected person can spread measles to as many as 18 people (if no one is vaccinated). In the 2023-24 school year, MMR vaccination coverage among kindergarteners varied widely across states from a low of 79.6% in Idaho to a high of 98.3% in West Virginia. West Virginia until recently only allowed medical exemptions; that has changed in the past year, and vaccination rates are anticipated to go down in response to loosening of requirements. All told, 39 states had MMR vaccination rates below the CDC target rate of 95%, representing an increase from 28 states during the 2019-20 school year.

One in four cases of measles result in hospitalization, the CDC estimates. One in 1,000 cases result in death.

Recognizing measles is as easy as spotting the 3 C’s: cough, conjunctivitis, and coryza. These tend to be the early symptoms along with the pathognomonic Koplik spots, which are small white papules on the buccal mucosa. Later symptoms include the characteristic maculopapular rash, which starts on the face and neck and spreads to the trunk, arms, legs, and feet, but spares the palms and soles. Red macules may merge as the rash spreads. A high fever may occur with the onset of the rash, which typically resolves after five or six days.

Time for a booster?

Most people who have received two doses of the measles vaccine maintain lifelong immunity and will not need a booster, Dr. Goh stated. There are, however, a few exceptions. The ACIP recommends that individuals vaccinated between 1963 and 1967 who may have received the killed measles vaccine get revaccinated, Dr. Freeman said. The CDC estimates that less than 5% of the adult population falls into this category. If a dermatologist is unsure of their vaccination record, she suggested that they contact their state health department, which may have a registry for adult vaccines known as the Immunization Information System. Individuals born before 1957 are presumed to have had measles, Dr. Freeman added.

“For most, there’s no need to rush out to get your titers checked but if you’re worried for individual reasons, such as you are immunocompromised or come in close contact with people who are immunocompromised, it’s not unreasonable to talk to your doctor for personalized advice,” Dr. Rosenbach said. The CDC recommends a third lifetime dose of the measles vaccine for high-risk adults, such as health care workers, international travelers, and people in college settings.

Be prepared

“Maintaining a high degree of suspicion for measles is important since the rash can be a later finding,” Dr. Goh said. Dermatologists who are in a community with a measles outbreak may want to consider screening patients with a pre-visit telephone triage done by a clinically trained staff member, she noted. Patients should be asked if they have had measles symptoms within the last week. For those who report one or more symptoms, assess the risk of exposure by asking if there are any cases in their community, if they spent time out of the country or in a high-risk area in the 21 days before symptom onset, and if they ever received the MMR vaccine. “Even if there aren’t any cases in your area, keep in mind that people travel to locations with outbreaks,” Dr. Goh added.

Dr. Freeman cautioned, “If you are aware of a possible measles case and the individual is not yet in your clinic, the first step is to redirect them to a facility with an appropriate airborne isolation room, which your clinic may not have. So, depending on where you practice, the most important step may be giving the patient clear instructions on where to go, and the answer may not be the dermatology clinic.” Send the patient to a facility with an airborne isolation room. The patient should be wearing a mask as they make their way to the facility. Notify the facility that a patient with suspected measles is on the way.

If the patient is already at the office, move them out of the waiting room as quickly as possible, Dr. Freeman recommended. Most guidelines suggest having them mask and keeping them as isolated as possible in a private room with the door closed. But remember that another patient can’t enter that room for two hours after the first patient has left and it has been thoroughly cleaned. She emphasized the importance of following local and state guidelines for infection control.

Only staff with a known immunity status should take care of the patient. While staff should wear fitted N95 masks, Dr. Goh noted that even those might be insufficient to prevent exposure. “If I was practicing in Texas or Oklahoma, and a patient came in with a suspected case, I would have my entire staff wearing masks,” Dr. Rosenbach said. “During flu season, I wear a mask all the time.” He has masks available and encourages patients to wear them in the waiting room. Staff members should be comfortable wearing a mask, as well. “The more routinized this becomes, the fewer unnecessary exposures you’ll have from measles, chicken pox, the flu, and COVID,” he added.

If measles testing is needed, dermatologists should consider offering measles testing outside of the office to avoid unnecessary exposures, Dr. Goh recommended. Seek out the local public health department for guidance, she added. Dr. Rosenbach suggested that dermatologists take this opportunity to review their transmittable disease protocol.

Following exposure

Despite being vigilant, someone in the practice may get exposed to measles. The response will depend on their evidence of immunity. According to the American Academy of Pediatrics, if the individual has immunity, no additional post-exposure prophylaxis (PEP) is necessary, and neither are work restrictions. They should monitor daily for signs and symptoms.

If the person lacks immunity, provide appropriate measles PEP as soon as possible after exposure, in accordance with the CDC and ACIP recommendations, Dr. Goh said. That means getting a vaccine within 72 hours of exposure or immunoglobulin within six days. Implement work restrictions and daily monitoring for signs and symptoms from day 5 after their first exposure through day 21 after their last exposure.

The same applies if someone in the practice, either a staff member or patient, is suspected of having measles or is diagnosed with the disease. While a staff member with known or suspected measles should be excluded from work for four days after the rash appears, an immunocompromised team member should be excluded from work for the duration of their illness.

Both suspected and confirmed cases of measles must be immediately reported to the local or state health department to ensure rapid testing and investigation. Dermatologists can report cases at Epi-on-Call, which provides a 24-hour contact list for all states. States will report cases to the CDC, Dr. Goh said. “Notify the state even if measles is suspected,” she stressed. “Don’t wait for lab confirmation, just take the necessary steps.”

Be sure to contact the local or state health department to learn the state-specific requirements, which can change over time. Mostly likely, some form of notification will be necessary, Dr. Freeman said. Standard cleaning and disinfection procedures are adequate to clean the room that was occupied by someone with a suspected or confirmed case of measles, Dr. Goh said.

Prevention above all else

“This is a vaccine-preventable disease, and we all play a role in preventing measles from becoming endemic again,” Dr. Freeman stressed. “Physicians are still a trusted source of information for many patients. We all have a role to play in talking to our patients about vaccination.”

In general, dermatologists should speak out in support of science and evidence-based medicine, Dr. Rosenbach said. They should be talking to their younger patients about vaccines for measles or HPV and speaking with older patients about the shingles vaccine. Regarding measles, explain that it is on the rise, and getting a vaccine is much better than getting the disease. “People need to understand that this vaccine is safe and effective,” he added.

Dermatologists see viral rashes all the time, Dr. Rosenbach said. In the past, they didn’t have to think about testing for measles, but they now need to be open to the possibility, he added. Dr. Freeman couldn’t agree more. “A patient may come in because of a rash, not thinking about measles, but it has to be on our radar now because a rash is a major sign of measles,” she said. “It’s an issue that we’re going to have to deal with because it will probably not go away anytime soon.”

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