Diseases in DnD 5E explained

Navigate the perils of Diseases in DnD 5E. Understand their effects and the threats they pose to adventurers.

© Dice Cove

Plague and Disease! Oh, the horror… NOT! Of all the systems that are useless in 5e, this is the one that gets the most flak. Because a 1st level Paladin, 1st level, can cure a creature of disease. Instantly. Granted, it’s only once per day at that point, but even still, this could be a thrilling system to use if it weren’t so… Easy to beat. So we are going to go over what’s wrong with disease in 5E, and how to make it a thrilling way to up the stakes.

So weak, so rejected

First off, we have the whole issue of everything healing it. At 3rd level, you might as well forget about it if you have A healer in your party that picked up the spell. 1st level if there’s a Paladin because Lay on Hands can cure diseases for just 5 of the points. And the reason 3rd level makes this whole thing null and void is because not 1 not 2, but 5 classes (including Celestial Warlocks and Divine Soul Sorcerers) get access to Lesser Restoration, and 2 more classes get access at 5th, not including the Paladin, because we all know what they’d rather spend spell slots on. Also Paladins cannot become Diseased at 3rd level, so don’t even think about adding disease to an all paladin game. Plague Inc in 5e would be impossible for the disease.

Second, there aren’t any well-established sources of disease apart from a few specific monsters often marked with “diseased” and a single 5th level spell called Contagion, but nothing else. And a 5th level spell… Yeah, it’s good against enemies without magic, but it doesn’t even spread. It’s just a single target made ill. Oh yeah, we forgot to mention that getting this 5th level healed should only cost a few gold if you can find a decent healer. We went through an entire campaign, and disease never really even came up. I’m not sure there was even a single saving throw that was made for it.

Third, there also aren’t many official diseases. This isn’t as much of an issue as the others, but even traps have more than three examples (outside of Contagion), and they even have helpful little tips on how harmful a trap should be, what can trigger it, and what it can do. Diseases get the short end of the stick, don’t they?

Now that’s a lot of issues. No wonder people overlook it so much. Well, there’s nothing more the core rules have on this, so put down your copy of the DMG before we go crazy here, and let’s break out some homebrew!

Disclaimer – These are suggestions only. If you decide to use these at your game table, understand that they may not work, and might make the game worse if you don’t plan accordingly. Nobody wants to memorize additional rules if you’re never going to use them.

Reincarnating the plague

To begin, we want to address the first issue: Healing. Because you can slap on any spell and have it gone like that, we would propose the following rules to counter this:

  • When you attempt to cure a disease with magic such as Lesser Restoration or Lay on Hands, you must make a skill check with your spellcasting modifier or the target’s Constitution modifier against the DC of the disease. On a success, the disease is cured, but on a failure, nothing happens, as the magic is wasted.
  • Healing Magic such as Lesser Restoration and Lay on hands do not cure diseases, unless they’re incubating. They instead negate a single failed save, and/or suppress any penalty until the next save.
  • Casting spells that cure disease at a higher level adds +1 to the next saving throw against disease for each level above the spell’s standard level.

Already we’re off to a good start! This way, Disease can bite into your resources as it does in real life, taking up a lot of resources you might need for other things such as the tank. Or by debilitating an ally for a while instead of the Paladin slapping the disease out of them. And more potent spells become better for ensuring complete recovery, giving disease some weight when it does come up.

Next, we have problem two, all about contracting diseases. Take a look at these ideas:

  • When you take damage from a weapon that hasn’t been cleaned recently or a natural weapon, you run the risk of contracting a disease.
  • When you’re damaged by foreign magic, you can catch a disease.
  • When attacked by a creature, the DM rolls 1d4, 1d6, 1d8, 1d10, 1d12, or 1d20 to determine if that creature can make you sick (use highest or lowest value, or a custom range).
  • If you move adjacent to a diseased creature (unless no longer contagious), they can spread the disease.
  • If mishandled, certain herbs can cause illness.
  • Touching filth or unknown substances while missing health may cause infection.
  • Sometimes when an encounter would happen, sickness strikes instead (have everybody save against a disease instead of fighting monsters).

Talk about spreading like wildfire! We all know how a disease can spread (unless you weren’t here for 2020, in which case… Yeah, that was a thing), especially when we don’t take precautions, hence why you don’t question the paladin entering a quarantine or people taking steps to avoid illness.

Now finally, the challenging part: Making diseases. We don’t have that much to say about that, so we would like to share my template for making a disease and give you some inspiration for making your PCs sick. Sections in these <> are to be replaced, and everything else just needs filling in.

<Disease Name>
Source: <How the Disease is Contracted>
DC: <How Difficult is Recovery>
Incubation Time: <How long until the debuff takes place?>
Debuff: <What does the disease do?>
End Condition: <What can cure it, or when does it pass?>

Example diseases

Snow Blight

Source: Spending one hour in snowy/cold weather without winter clothing.
DC: 12
Incubation Time: 1d8 days
Debuff: when you are affected by this disease, you gain 1 level of exhaustion. When you take a long rest or take cold damage greater than 8 + Your Constitution Bonus + Your Proficiency Bonus, you must save against this disease (Constitution Save). On a failed save, you gain 1 level of exhaustion. On a success, nothing happens. If your long rest was in a Hot climate, you automatically save and lose 1 level of exhaustion.
End Condition: When all exhaustion has been lost.

Weavers Fever

Source: Taking damage from a diseased creature or being exposed to wild magic.
DC: 14
Incubation Time: 1d6 Hours
Debuff: When you succumb to this disease, you gain 1 Level of Exhaustion that cannot be removed until this disease is cured. Whenever you cast any spell, you must make a Constitution Saving Throw with a DC equal to 10 + the level spell slot used. On a failed save, you gain a level of exhaustion. On a successful save, you take 1d4 necrotic damage for each level of the spell (does not cause a concentration check).
End Condition: At the end of each long rest, you must make a Constitution Saving Throw. If you pass three times, the disease is cured. If you fail three times, you lose all successes.

Abyssal Flames

Source: Taking damage from a fiend, or taking a long rest in a fiendish area (such as the home planes demons and devils, whatever that might be in your campaign.)
DC: 13
Incubation Time: 1d6 hours
Debuff: at the end of each long rest, make a Constitution Saving Throw. On a success, nothing happens apart from searing pain. On a failure, you take 1d8 fire damage that ignores resistance and treats immunity as resistance. Your Hit Point Maximum is also reduced by that amount until cured. If this effect reduces your Hit Point Maximum to 0, that creature dies. If a creature dies of this disease, it cannot be resurrected by anything short of a wish spell. Lesser Restoration cannot cure this but does cause you to automatically succeed the following Saving Throw you make against this disease.
End Condition: When the target is doused in holy water, or targeted with Greater Restoration, or similar 5th level or higher magic.

Holy guacamole! Now those are some nasty bugs! We know we wouldn’t want to contract Abyssal Flames; that would be intense! But it does give your party something to combat while trying to save the world! Or perhaps just their own lives. Either way, these all look like fun ways to up the stakes in your game, and maybe even give you ideas for your own!

How to roleplay Diseases

Need some help roleplaying diseases? Here are some examples to help you out:

  • As you start to feel the first symptoms of the disease, you notice a growing feeling of fatigue that seems to weigh down your limbs. Your muscles ache and your throat feels scratchy, making it difficult to swallow. Your vision blurs slightly as your body struggles to fight off the infection.
  • The disease takes hold quickly, causing a high fever that leaves you delirious and unable to focus on anything. Your skin is hot to the touch and covered in a light sheen of sweat. You feel a pounding headache that seems to throb in time with your heartbeat.
  • The disease seems to be affecting your breathing, making each breath more difficult and shallow than the last. You start to cough uncontrollably, feeling a tightness in your chest as your lungs struggle to clear themselves. Your voice comes out in hoarse whispers as your throat feels raw and inflamed.
  • As the disease progresses, you start to notice a series of small, painful blisters appearing on your skin. They itch terribly and seem to spread rapidly, covering more and more of your body. The blisters ooze a clear fluid that smells slightly acrid and leaves a sticky residue on anything it touches.
  • The disease seems to be affecting your mind, causing confusion and disorientation. You find yourself struggling to remember things you knew just moments before, and your thoughts seem to move sluggishly. You feel dizzy and lightheaded, and your coordination is off, making it difficult to walk or perform any complex tasks.

The aftermath

Now perhaps you see why illness should be more severe than it is currently. You might even have a use for the Contagion spell or even healers specializing in curing disease. In the end, it’s all about the exciting adventure you and your group have along the way, and disease is just another reason to go adventuring. Now, if you’ll excuse me, a world is calling my name because somebody started an apocalypse for no good reason.