Papular rash
Papular rash: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
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 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, pages 488 and 489.)
History
Find out when the rash erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have the patient describe associated signs and symptoms, such as fever, headache, and GI distress.
Obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or a rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.
Physical assessment
Fully evaluate the papular rash: note its color, configuration, and location on the patient’s body. Then complete a whole-body examination of the patient’s skin, hair, and nails.
Medical causes
Acne vulgaris
With acne vulgaris, rupture of enlarged comedones produces inflamed — and possibly painful and pruritic — papules, pustules, nodules, or cysts on the face and sometimes the shoulders, chest, and back.
Anthrax (cutaneous)
Cutaneous anthrax begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 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.
Dermatitis (perioral)
Perioral dermatitis is an inflammatory disorder that 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.
Erythema migrans
Transmitted through a tick bite, erythema migrans is a systemic disorder 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.
Gonococcemia
In gonococcemia — a 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.
Human immunodeficiency virus infection
Acute infection with human immunodeficiency virus (HIV) 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 such nonspecific signs and symptoms as fever, myalgia, headache, lymphadenopathy, nausea, and vomiting.
Kaposi’s sarcoma
Kaposi’s sarcoma 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.
Lichen amyloidosis
Lichen amyloidosis, an idiopathic cutaneous disorder, produces discrete, firm, hemispherical, pruritic papules on the anterior tibiae, feet, and thighs. Papules may be brown or yellow and smooth or scaly.
Lichen planus
Discrete, flat, angular or polygonal, violet papules, commonly marked with white lines or spots, are characteristic of lichen planus. The papules may be linear or may 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.
Mononucleosis (infectious)
A maculopapular rash that resembles rubella is an early sign of infectious mononucleosis 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.
Pityriasis rosea
Pityriasis rosea 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 skin exposure.
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.
Psoriasis
Psoriasis is a common chronic disorder that 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.
Rosacea
Rosacea, a 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
Sarcoidosis, a 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 seborrheic keratosis, 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
Initial signs and symptoms of smallpox (also known as variola major) 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.
Systemic lupus erythematosus
Systemic lupus erythematosus (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 of SLE 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.
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; phenylbutazone; 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 avoid scratching the rash, and to wear loose-fitting, nonirritating clothing. Instruct him to promptly report any change in the rash’s color, size, or configuration as well as the onset of itching or bleeding. Also 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.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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