 Most often the rash begins as small, flat, pink, nonitchy spots (macules) on the wrists, forearms, and ankles.These spots turn pale when pressure is applied and eventually become raised on the skin.The characteristic red, spotted (petechial) rash of Rocky Mountain spotted fever is usually not seen until the sixth day or later after onset of symptoms, but this type of rash occurs in only 35 to 60% of patients with Rocky Mountain spotted fever.