Professional Guide to Signs and Symptoms
5th Edition

Papular rash
A papular rash consists of small, raised, circumscribed—and perhaps discolored (red to purple)—lesions known as papules. It may erupt anywhere on the body in various configurations and may be acute or
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chronic. Papular rashes characterize many cutaneous disorders; they may also result from allergy and from infectious, neoplastic, and systemic disorders. (To compare papules with other skin lesions, see Recognizing common skin lesions.)
HISTORY AND PHYSICAL EXAMINATION
Your first step is to fully evaluate the papular rash: note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have him describe associated signs and symptoms, such as fever, headache, and GI distress.
Next, obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, including any sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an
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infectious disease? Finally, obtain a complete drug history.
MEDICAL CAUSES
  • Acne vulgaris. With this disorder, rupture of enlarged comedones produces inflamed—and perhaps, painful and pruritic—papules, pustules, nodules, or cysts on the face and sometimes the shoulders, chest, and back.
  • Anthrax (cutaneous). Anthrax is an acute infectious disease caused by the gram-positive, spore-forming bacterium Bacillus anthracis. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Cutaneous anthrax occurs when the bacterium enters a cut or abrasion on the skin. The infection begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days it develops into a vesicle and then a painless ulcer with a characteristic black, necrotic center. Lymphadenopathy, malaise, headache, or fever may develop.
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  • Dermatitis (perioral). This inflammatory disorder causes an erythematous eruption of discrete, tiny papules and pustules on the nasolabial fold, chin, and upper lip area. The lesions may be pruritic and painful.
  • Dermatomyositis. Gottron’s papules—flat, violet-colored lesions on the dorsa of the finger joints and the nape of the neck and shoulders—are pathognomonic of this disorder, as is the dusky lilac discoloration of periorbital tissue and lid margins (heliotrope edema). These signs may be accompanied by a transient, erythematous, macular rash in a malar distribution on the face and sometimes on the scalp, forehead, neck, upper torso, and arms. This rash may be preceded by symmetrical muscle soreness and weakness in the pelvis, upper extremities, shoulders, neck and, possibly, the face (polymyositis).
  • Erythema migrans. Transmitted through a tick bite, this systemic disorder is characterized by a papular or macular rash starting from a single lesion (usually on the leg) that spreads at the margins while clearing centrally. The rash commonly appears on the thighs, trunk, or upper arms and is the classic early sign of Lyme disease, but about 25% of patients don’t develop this skin manifestation. It may be accompanied by fever, chills, headache, malaise, nausea, vomiting, fatigue, backache, knee pain, and stiff neck.
  • Follicular mucinosis. With this cutaneous disorder, perifollicular papules or plaques are accompanied by prominent alopecia.
  • Fox-Fordyce disease. This chronic disorder is marked by pruritic papules on the axillae, pubic area, and areolae associated with apocrine sweat gland inflammation. Sparse hair growth in these areas is also common.
  • Gonococcemia. With this chronic STD, sporadic eruption of an erythematous macular rash is characteristic, although fistulas and petechiae may appear. The rash typically affects the distal extremities (palms and soles) and rapidly becomes maculopapular, vesiculopustular and, commonly, hemorrhagic. Bullae may form. The mature lesion is raised; has a gray, necrotic center; and is surrounded by erythema. Typically, it heals in 3 to 4 days. Eruptions are commonly accompanied by fever and joint pain.
  • Granuloma annulare. This benign, chronic disorder produces papules that usually coalesce to form plaques. The papules spread peripherally to form a ring with a normal or slightly depressed center. They usually appear on the feet, legs, hands, or fingers, and may be pruritic or asymptomatic.
  • Human immunodeficiency virus (HIV) infection. Acute infection with the HIV retrovirus typically causes a generalized maculopapular rash. Other signs and symptoms include fever, malaise, sore throat, and headache. Lymphadenopathy and hepatosplenomegaly may also occur. Most patients don’t recall these symptoms of acute infection.
  • Insect bites. Salivary secretions from insect bites—especially ticks, lice, flies, and mosquitoes—may produce an allergic reaction associated with a papular, macular, or petechial rash. The rash is usually accompanied by nonspecific signs and symptoms, such as fever, myalgia, headache, lymphadenopathy, nausea, and vomiting.
  • Kaposi’s sarcoma. This neoplastic disorder is characterized by purple or blue papules or macules of vascular origin on the skin, mucous membranes, and viscera. These lesions decrease in size with firm pressure and then return to their original size within 10 to 15 seconds. They may become scaly and ulcerate with bleeding.
    Multiple variants of Kaposi’s sarcoma are known; most individuals are immunocompromised in some way, especially those with HIV/AIDS (acquired immunodeficiency syndrome). Human herpes virus-8 (HHV-8) has been strongly implicated as a cofactor in the development of Kaposi’s sarcoma.
  • Leprosy. This chronic infectious disorder produces various skin lesions. Early papular or macular lesions are erythematous, hypopigmented, and symmetrical (with lepromatous leprosy) or asymmetrical
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    (with tuberculoid leprosy). The lesions may spread over the entire skin surface. Later, plaques and nodules form, especially on the ear lobes, nose, eyebrows, and forehead. Associated findings include hypoesthesia or anesthesia, anhidrosis, and dry, scaly skin in affected areas; enlarged, palpable peripheral nerves with severe neuralgia; and muscle atrophy and contractures.
  • Lichen amyloidosis. This idiopathic cutaneous disorder produces discrete, firm, hemispherical, pruritic papules on the anterior tibiae. Papules may be brown or yellow, smooth or scaly.
  • Lichen planus. Discrete, flat, angular or polygonal, violet papules, commonly marked with white lines or spots, are characteristic of this disorder. The papules may be linear or coalesce into plaques and usually appear on the lumbar region, genitalia, ankles, anterior tibiae, and wrists. Lesions usually develop first on the buccal mucosa as a lacy network of white or gray threadlike papules or plaques. Pruritus, distorted fingernails, and atrophic alopecia commonly occur.
  • Monkeypox. Usually preceded 1 to 3 days by a fever, a papular rash is a characteristic sign of monkeypox. The rash is often blisterlike and can follow these stages: vesiculation, postulation, umbilication, and crusting. Frequently beginning on the face and spreading to the trunk and extremities, the rash may be either localized or generalized. Other accompanying symptoms in humans include lymphadenopathy, chills, throat pain, and muscle aches. Most humans recover within 2 to 4 weeks.
  • Mononucleosis (infectious). A maculopapular rash that resembles rubella is an early sign of this infection in 10% of patients. The rash is typically preceded by headache, malaise, and fatigue. It may be accompanied by sore throat, cervical lymphadenopathy, and fluctuating temperature with an evening peak of 101° to 102°F (38.3° to 38.9° C). Splenomegaly and hepatomegaly may also develop.
  • Mycosis fungoides. Stage I (premycotic stage) of this rare, cutaneous T-cell lymphoma is marked by the eruption of erythematous, pruritic macules on the trunk and extremities. In stage II, these lesions coalesce into pruritic papules and plaques, and nodes become irregular. Stage III is evidenced by large, irregular, brown to red tumors that ulcerate and are painful and itchy.
  • Necrotizing vasculitis. With this systemic disorder, crops of purpuric, but otherwise asymptomatic, papules are typical. Some patients also develop low-grade fever, headache, myalgia, arthralgia, and abdominal pain.
  • Parapsoriasis (chronic). This disorder mimics psoriasis, producing small to moderately sized asymptomatic papules with a thin, adherent scale, primarily on the trunk, hands, and feet.
  • Pityriasis rosea. This disorder begins with an erythematous “herald patch”—a slightly raised, oval lesion about 2 to 6 cm in diameter that may appear anywhere on the body. A few days to weeks later, yellow to tan or erythematous patches with scaly edges appear on the trunk, arms, and legs, commonly erupting along body cleavage lines in a characteristic “pine tree” pattern. These patches may be asymptomatic or slightly pruritic, are 0.5 to 1 cm in diameter, and typically improve with moderate skin exposure to sunlight. This treatment should be used cautiously, however, to avoid sunburn.
  • Pityriasis rubra pilaris. This rare chronic disorder initially produces scaling seborrhea on the scalp that spreads to the face and ears. Scaly red patches then develop on the palms and soles; these patches thicken, become keratotic, and may develop painful fissures. Later, follicular papules erupt on the hands and forearms and then spread over wide areas of the trunk, neck, and extremities. These papules coalesce into large, scaly, erythematous plaques. Striated fingernails may appear.
  • Polymorphic light eruption. Abnormal reactions to light may produce papular, vesicular, or nodular rashes on sun-exposed areas. Other symptoms include pruritus, headache, and malaise.
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  • Psoriasis. This common chronic disorder begins with small, erythematous papules on the scalp, chest, elbows, knees, back, buttocks, and genitalia. These papules are sometimes pruritic and painful. Eventually they enlarge and coalesce, forming elevated, red, scaly plaques covered by characteristic silver scales, except in moist areas such as the genitalia. These scales may flake off easily or thicken, covering the plaque. Associated features include pitted fingernails and arthralgia.
  • Rat bite fever. A maculopapular or petechial rash develops on the palms and soles several weeks after a bite from an infected rodent. Other findings typically include pain, redness, and swelling at the bite site; tender regional lymph nodes; fever with chills; malaise; headache; and myalgia.
  • Rosacea. This hyperemic disorder is characterized by persistent erythema, telangiectasia, and recurrent eruption of papules and pustules on the forehead, malar areas, nose, and chin. Eventually, eruptions occur more frequently and erythema deepens. Rhinophyma may occur in severe cases.
  • Sarcoidosis. This multisystem granulomatous disorder may produce crops of small, erythematous or yellow-brown papules around the eyes and mouth and on the nose, nasal mucosa, and upper back. Associated findings include dyspnea with a nonproductive cough, fatigue, arthralgia, weight loss, lymphadenopathy, vision loss, and dysphagia.
  • Seborrheic keratosis. With this cutaneous disorder, benign skin tumors begin as small, yellow-brown papules on the chest, back, or abdomen, eventually enlarging and becoming deeply pigmented. However, in blacks, these papules may remain small and affect only the malar part of the face (dermatosis papulosa nigra).
  • Smallpox (variola major). Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days the pustules form a crust, and later the scab separates from the skin leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.
  • Syphilis. A discrete, reddish brown, mucocutaneous rash and general lymphadenopathy herald the onset of secondary syphilis. The rash may be papular, macular, pustular, or nodular. It typically erupts between rolls of fat on the trunk and proximally on the arms, palms, soles, face, and scalp. Lesions in warm, moist areas enlarge and erode, producing highly contagious, pink or grayish white condylomata lata. The patient may also experience mild headache, malaise, anorexia, weight loss, nausea and vomiting, sore throat, low-grade fever, temporary alopecia, and brittle, pitted nails.
  • Syringoma. With this disorder, adenoma of the sweat glands produces a yellowish or erythematous papular rash on the face (especially the eyelids), neck, and upper chest.
  • Systemic lupus erythematosus (SLE). SLE is characterized by a “butterfly rash” of erythematous maculopapules or discoid plaques that appears in a malar distribution across the nose and cheeks. Similar rashes may appear elsewhere, especially on exposed body areas. Other cardinal features include photosensitivity and nondeforming arthritis, especially in the hands, feet, and large joints. Common effects are patchy alopecia, mucous membrane ulceration, low-grade or spiking fever, chills, lymphadenopathy, anorexia, weight loss, abdominal pain, diarrhea or constipation, dyspnea, tachycardia, hematuria, headache, and irritability.
  • Typhus. Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body louse. Initial symptoms include headache, myalgia, arthralgia, and malaise,
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    followed by an abrupt onset of chills, fever, nausea, and vomiting. A maculopapular rash may be present in some cases.
OTHER CAUSES
  • Drugs. Transient maculopapular rashes, usually on the trunk, may accompany reactions to many drugs, including antibiotics, such as tetracycline, ampicillin, cephalosporins, and sulfonamides; benzodiazepines such as diazepam; lithium; gold salts; allopurinol; isoniazid; and salicylates.
SPECIAL CONSIDERATIONS
Apply cool compresses or an antipruritic lotion. Administer an antihistamine for allergic reactions and an antibiotic for infection.
PEDIATRIC POINTERS
Common causes of papular rashes in children are infectious diseases, such as molluscum contagiosum and scarlet fever; scabies; insect bites; allergies and drug reactions; and miliaria, which occurs in three forms, depending on the depth of sweat gland involvement.
GERIATRIC POINTERS
In bedridden elderly patients, the first sign of pressure ulcers is commonly an erythematous area, sometimes with firm papules. If not properly managed, these lesions progress to deep ulcers and can lead to death.
PATIENT COUNSELING
Advise the patient to keep his skin clean and dry, to wear loose-fitting, nonirritating clothing, and to avoid scratching the rash. Instruct him to promptly report changes in the rash’s color, size, or configuration as well as the onset of itching or bleeding. Tell him to avoid excessive exposure to direct sunlight and to apply a protective sunscreen before going outdoors.
Warn patients with chronic conditions (such as SLE, psoriasis, or sarcoidosis) about the typical skin rashes that can develop. Tell them that these rashes can be an early sign of disease flare-up and that they should seek prompt treatment to prevent serious complications.