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Diseases » Skin rash » Causes

Causes of Skin rash

Contents

Causes of Skin rash (Diseases Database):

The follow list shows some of the possible medical causes of Skin rash that are listed by the Diseases Database:

Source: Diseases Database

Skin rash Causes: Book Excerpts

Skin rash as a complication of other conditions:

Other conditions that might have Skin rash as a complication may, potentially, be an underlying cause of Skin rash. Our database lists the following as having Skin rash as a complication of that condition:

Yersiniosis

Skin rash as a symptom:

Conditions listing Skin rash as a symptom may also be potential underlying causes of Skin rash. Our database lists the following as having Skin rash as a symptom of that condition:

Medications or substances causing Skin rash:

The following drugs, medications, substances or toxins are some of the possible causes of Skin rash as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

Dextrothyroxine Sodium
Choloxine
Daunorubicin Hydrochloride
Cerubidine
Rubilem
more drugs...»

See full list of 2667 medications causing Skin rash

Drug interactions causing Skin rash:

When combined, certain drugs, medications, substances or toxins may react causing Skin rash as a symptom.

The list below is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

Amoxil and allopurinol interaction
Larotid and allopurinol interaction
Trimox and allopurinol interaction
Wymox and allopurinol interaction
Augmentin and allopurinol interaction
more interactions...»

See full list of 348 drug interactions causing Skin rash

Medical news summaries relating to Skin rash:

The following medical news items are relevant to causes of Skin rash:

Related information on causes of Skin rash:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Skin rash may be found in:

Causes of Skin rash: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Skin rash.

Pruritis without Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

Hepatobiliary disorders
–Cholestasis of pregnancy: Pruritus is most severe in third trimester, ceases after delivery
–Primary biliary cirrhosis: Increased anti-mitochondrial antibodies
–Biliary obstruction: Pruritus not a presenting symptom
Endocrine disorders
–Hypo- and hyperthyroidism

Hematopoietic disorders
–Polycythemia vera: Pruritus classic after emerging from bath, described as severe and prickling
–Hodgkin's lymphoma: Pruritus may present 5 years before diagnosis; pruritus portends a poor prognosis
–Iron deficiency anemia
Chronic renal failure: pruritus begins 6 months after start of dialysis, affects up to 75% of patients during or immediately after dialysis
Malignancies: Adenocarcinoma, squamous cell carcinomas
HIV: Increasing frequency with disease progression
Psychogenic states: May have underlying personality disorder such as OCD
Senescence: Elderly pruritus very common
Drug reactions
Less common etiologies (“zebras”) include multiple myeloma, carcinoid syndrome, Waldenström's macroglobulinemia, parasitic infections (e.g., hookworm, onchocerciasis, ascariasis, trichinosis), hepatitis B and C, diabetes mellitus (results in perianal pruritus)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Pruritis with Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

Infectious causes
–Fungal infections: Dermatophyte infections (tinea), candidiasis (beefy red color with satellite papules), seborrheic dermatitis (from Pityrosporum, common in hair-bearing areas, with scale)
–Bacterial infections: Erythrasma (from Corynebacterium), frequently in axilla
–Viral infections: Chicken pox (Varicella)
–Insect vectors: Scabies, pediculosis or lice (also present on spouse and other family members), flea bites (typically on legs), mosquito bites (central punctum)
–Mixed infections: Intertrigo (present at skin folds or area of friction)
Noninfectious causes
–Contact dermatitis (e.g. rhus dermatitis): May be revealed in contact history, linear vesicular lesions with sharp margins
–Atopic dermatitis: Erythematous rash in flexural areas, patient with seasonal allergies and/or asthma
–Eczematous dermatitis: Stasis dermatitis (hyperpigmented legs of patients with vascular disease), lichen simplex chronicus (anxious patient who chronically scratches), dyshidrotic eczema (on hands and feet with scaling, erythema, and minute vesicles and painful fissures), nummular eczema (round scaly lesions on dry skin, common in the winter)
–Pityriasis rosea: Mostly on trunk in “Christmas tree” pattern, begins as single, larger “herald” patch
–Lichen planus: Koebner reaction (lesions occur with trauma, such as linear lesions from scratching), purple, polygonal, pruritic papules
–Psoriasis: Koebner reaction, pink, silvery scaling plaques, extensor surfaces, nail pits
Less common etiologies (“zebras”) include mycoses fungoides (referred to as Sézary syndrome if erythroderma, lymphadenopathy, and atypical circulating white blood cells are present), dermatitis herpetiformis, miliaria (heat rash)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Rash with Fever: Differential Diagnosis
(In a Page: Signs and Symptoms)

Viral exanthems
–Leading cause of fever and rash in childhood
–Most children present with low-grade fevers, viral prodromal symptoms, and a secondary diffuse exanthem that is usually nonspecific and morbilliform
–Often last only a few days and requires only supportive management
Drug reactions
–Account for a large portion of rashes with associated fever
–Immune complex disease or serum sickness has been reported with many medications
Meningococcemia
–Most common under age 1
–After a brief prodrome; onset is abrupt with spiking fevers, diffuse purpuric lesions, delirium, and death
–DIC and purpura fulminans with secondary necrosis of digits and limbs can occur

Rocky Mountain Spotted Fever
–A fulminant and deadly rickettsial disease transmitted by a tick bite
–Only 60% of patients are aware of tick bite
–Characteristic rash starts acrally on wrists and ankles and spreads toward the trunk
–Initially, pink macules evolve over 10–24 hours into red papules, then purpuric macules and violaceous patches involving most of the body surface area
–Necrosis and DIC may occur
Toxic shock syndrome, Staphylococcus aureus, and streptococcal diseases
–Most cases due to toxin production
–Rapid onset of fever, hypotension with generalized skin (palms and soles common) and mucous membrane erythema (“erythroderma” in case definition), and subsequent multiorgan failure
–Palmar/solar desquamation in 1–3 weeks
–A morbilliform rash and skin “pain” or hyperesthesia is common
–Nonsurgical and surgical wounds are often the source of infection in the more common nonmenstrual variant of TSS

Fifth disease
Measles
Rubella
Parvovirus
Varicella

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Scalp Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

Seborrheic dermatitis (“cradle cap,” “dandruff”)
–The most common scalp condition, it occurs across all age ranges
–May be caused by Pityrosporum ovale
–An inflammatory condition that causes itching and loose, silvery-white scale on scalp, and occasionally blepharitis
–May also affect the eyebrows, nasolabial folds, external auditory canals, chin, anterior chest, upper back, and groin
–Does not cause hair loss
–The scalp is not usually erythematous, but other affected skin areas may be red, greasy, or oily

Tinea capitis
–Most commonly caused by Trichophyton tonsurans or rarely Microsporum canis
–Presents as patches of scale and/or pruritus with broken hairs, patchy hair loss (i.e., “black dot alopecia”)
–May progress to a kerion (see below)

Kerion
–A boggy, tender, subcutaneous fungal infection (dermatophyte)
–Often has associated drainage and hair loss

Scalp folliculitis
–Presents as recurrent, itchy, crusted papules or pustules
–An overgrowth of Staphylococcus aureus

Psoriasis
–Usually presents with plaques of thick, silvery, adherent scalp scale that overlies well-demarcated patches of erythema
–Often occurs at the ears and occipital area
–May be limited to the scalp, but often has skin disease, nail pitting, or nail dystrophy
Dissecting cellulitis of the scalp
–Chronic, tender, boggy, often suppurative subcutaneous fluctuant masses
–Occurs in black patients
–May be associated with acne keloidalis, which can cause a scarring hair loss at the occiput

Discoid lupus
–Presents initially as well-demarcated erythematous plaques of patchy, scarring scalp hair loss, then spreads centrifugally

Contact dermatitis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Hand and Foot Rashes: Differential Diagnosis
(In a Page: Signs and Symptoms)

Dyshidrotic eczema (pompholyx)
–Very common idiopathic skin disease
–Affects one or both hands and/or feet in the thenar eminence, palms and/or soles, and sides of fingers and toes
–Causes itching, scaling, and erythema, and minute vesicles and painful fissures
–Usually chronic and intermittent, and often exquisitely pruritic

Irritant or allergic hand eczema
–Very common
–Difficult to distinguish from dyshidrosis because both are vesicular and very itchy
–Flares occur during work/hobbies, with improvement on vacation when away from the irritant or allergen
Tinea manus (hand) and tinea pedis (foot)
–Presents as itchy, diffuse, light scale, and/or maceration; prominent on palmar, plantar (moccasin distribution), and interdigital surfaces
–Erythema is rarely present
–Often “two hands and one foot” or “two feet and one hand” are affected
Scabies
–Presents as short (a few millimeters), linear burrows and vesicles on the hands and feet (web spaces), belt region, and/or intertriginous spaces
–Intensely pruritic, especially at night
–Often many members of the household unit affected
–Definitive diagnosis made by visualizing the scabies mite in a skin scraping

Psoriasis
–Often affects the hands and/or feet
–Well-demarcated, erythematous plaques
with adherent scale, or can present as a focal or diffuse pustular eruption
–Look for associated nail dystrophy or other skin involvement

Reiter's disease
–Uveitis, urethritis, and arthritis

Pityriasis rubra pilaris
–Well-demarcated bright salmon or red plaques on the palms or soles

Keratoderma
–Focal or diffuse thickening of the skin of the palms or soles

Erythema multiforme

Infection (secondary syphilis, varicella meningococcemia)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Dry Skin (Xerosis): Differential Diagnosis
(In a Page: Signs and Symptoms)

Dry skin is a very common problem
–Low humidity and cold temperatures make winter xerosis and “winter itch” common complaints
–Mild xerosis can cause impaired skin barrier function and allow irritants and allergens to more easily affect the skin
–Most common on the legs, but often affecting the entire skin surface
–Can present with severe pruritus without much evidence of a rash
Severe xerosis is common in the elderly, and can cause eczema craquelé
–Patient's legs often have scale that resembles cracked porcelain
–Secondary erythema and excoriations occur because of the persistent itch
Ichthyoses vulgaris
–Very common cause of dry skin
–A genetic defect in skin barrier function, leading to a higher risk of atopic dermatitis
–Patients often have hyperlinearity of their palmar skin and xerotic fish scale on their legs
Many genetic conditions, such as the large family of ichthyoses (including X-linked ichthyoses, Netherton's disease), lead to severely dry skin in association with other systemic manifestations
Hypothyroidism and hyperthyroidism can also cause marked xerosis and/or itch
Anemia
There is an uncommon association between lymphoma and marked xerosis
HIV
Sarcoidosis
Liver and biliary disease, and renal insufficiency, are commonly associated with xerosis and marked pruritus
Diabetes mellitus
Medications (e.g., niacinamide)
Atopic dermatitis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Skin Pigmentation (Decreased): Differential Diagnosis
(In a Page: Signs and Symptoms)

Vitiligo
–Affects 1% of the population
–Begins as a focal or diffuse (more common) hypopigmented patch that progresses to total loss of pigmentation of the affected skin (chalk white)
–Usually symmetric; often tops of hands, perioral, periorbital skin, knees, elbows

Pityriasis alba
–Very common, especially in black children
–Less distinct borders than in vitiligo, does not result in complete depigmentation
–Plaques may appear lighter than surrounding skin and may be scaly
–Often secondary to mild inflammation, such as tinea versicolor or atopic eczema
–Completely reversible and does not cause permanent hypopigmentation

Piebaldism
–Congenital, permanent, and irreversible
–Newborns often have a patch of white scalp hair and depigmented patches on the trunk with normally pigmented patches within these larger depigmented areas
Chemical leukoderma (depigmentation)
–May be caused by phenols, germicides, and many other caustic chemicals
–Results in confetti-like macules of depigmentation in exposed skin
- Albinism
  –Congenital
  –Disorder of melanin synthesis with several phenotypes, ranging from complete lack of pigmentation (white hair and translucent or “red” iris) to the more common diffuse hypopigmentation or “yellow” albinism that is prevalent in the black population
  –Affects the skin, hair, and eyes
  –Photophobia, decreased visual acuity, strabismus, and risk of skin cancer are the main problems faced by these patients
- Congenital birthmarks (e.g., nevus anemicus, nevus depigmentosis) are isolated patches of hypo- or depigmentation that remain unchanged over time
- Tuberous sclerosis is an inherited systemic disorder that results in hypopigmented macules in the shape of an “ash leaf ” on the trunk, and confetti-type depigmented macules on the arms/legs

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Genital Skin Lesions: Differential Diagnosis
(In a Page: Signs and Symptoms)

Herpes simplex virus (HSV-1 and HSV-2) is the most common cause of genital lesions in the U.S.
–Presents with prodromal tingling and genital discomfort before lesions
–Lesions are always painful and appear as grouped vesicles on an erythematous base
Condyloma acuminatum (“warts,” HPV)
–Etiologic agent is human papilloma virus
–Lesions usually painless and pearly with a smooth surface but may be filiform, fungating, and lobulated

Tinea cruris
–Inguinal erythema with itch or tenderness
–Always spares the scrotum

Candida intertrigo
–Inguinal erythema with itch or tenderness
–Often very red with satellite lesions
–Frequently involves the labia or scrotum

Syphilis
–Primary stage: Painless solitary ulcer (chancre) on labia, penis, or oral mucosa that heals in 2–3 weeks
–Secondary stage: Condyloma lata (moist hypertrophic papules on genital and oral regions)
–Tertiary stage: Cardiac, neurologic, and other systemic effects

Molluscum contagiosum
–Multiple, very small, painless, flesh-colored nodules with umbilicated centers

Chancroid
–Etiologic agent is Haemophilus ducreyi
–Painful, solitary, and erythematous lesions
–May present with dyspareunia and/or dysuria

Erythrasma

Lymphogranuloma venereum

Granuloma inguinale

Behçet syndrome
–Oral and genital ulcers, retinitis, uveitis

Lichen planus

Scabies

Zoon's plasma cell balanitis

Less common etiologies (“zebras”) include inverse psoriasis, seborrheic dermatitis, genital squamous cell carcinoma, extramammary Paget's disease, plaque psoriasis, and fixed drug eruptions

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Papulosquamous Lesions: Differential Diagnosis
(In a Page: Signs and Symptoms)

Allergic and irritant contact reactions and drug-induced rashes are included in the papulosquamous diseases

Psoriasis
–Affects 2% of the U.S. population
–May acutely present as guttate (drop-like), round plaques with minimal scale
–More common is the variant called psoriasis vulgaris: Presents as thick plaques of silvery adherent scale on an erythematous base on the extensor joints
Seborrheic dermatitis
–An inflammatory “dandruff” that manifests as light scale on a greasy and/or erythematous background around the hairline, upper lip, nasolabial creases, chin, external ears, eyebrow areas, scalp
–Due to overgrowth of Pityrosporum ovale
Pityriasis rosea
–A common exanthem that is self-limited; the etiology is unclear
–Presents with initial “herald patch,” with subsequent scaly pink papules/plaques over the trunk in a “Christmas tree” distribution
–May be very itchy and is often confused with guttate psoriasis
Atopic dermatitis
–Common among children with a history of asthma, hay fever, or seasonal allergies
–Manifests as itchy eczematous plaques on the antecubital and popliteal fossae; often becomes secondarily lichenified (i.e., thickened with chronic rubbing changes)
–60% of patients have initial symptoms before 1 year of age
–The disease often lasts 15–20 years

Fungal infections of the skin caused by dermatophytes often present as itchy, scaly papulosquamous rashes that can mimic nummular eczema
Nummular eczema
–An idiopathic disease that affects many patients mostly in the winter months
Lichen planus
–Present with flat topped, polygonal, and purplish papules that may have white streaks or “Wickham's striae”

Eczematous diseases (e.g., eczema craquelé, lichen simplex chronicus)

Infection (e.g., secondary syphilis meningococcemia, RMSF)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Vesicular & Bullous Lesions: Differential Diagnosis
(In a Page: Signs and Symptoms)

Localized

Allergic contact dermatitis (e.g. rhus)
–Localized vesicular and bullous eruptions

Herpes-zoster or shingles
–Due to reactivation of latent virus
–More common in adults
–Presents as painful vesicles on an erythematous base in a dermatomal distribution, beginning with fever, dysesthesia, and/or malaise
Herpes simplex virus
–Herpetic lesions present as painful, recurrent vesicles on an erythematous base
–Type 1 usually affects oral mucosa and vermilion border
–Genital HSV (most commonly HSV-2) may manifest as nonspecific symptoms (e.g., dysuria, urethritis)

Bullous impetigo
–Most common in children
–Presents as flaccid vesicles and bullae with honey-colored crust

Bites from many insects
Many viral infections of childhood can present with focal vesicles, especially hand-foot-andmouth disease

Burns and friction blisters
–Common causes of bullae, especially on hands

Diabetics can develop bullae on the legs
Dyshidrotic eczema (pompholyx)
–Causes itching, scaling, and erythema, and minute vesicles and painful fissures
Diffuse
Polymorphous light eruption
–Common reaction to ultraviolet light
–Presents as itchy vesicles or erythematous papules on sun-exposed areas

Varicella or “chicken pox”
–Presents with vesicles in crops, and in many stages of evolution

Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN)
–Most commonly caused by medications
–TEN is life threatening
Blistering diseases like bullous pemphigoid, pemphigus vulgaris, and porphyria cutanea tarda present with coalescing vesicles and bullae

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Pruritus: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Urticaria
–Hypersensitivity reaction causing edema via mast cell/basophil release of histamine, kinins, prostaglandins, and serotonin, mostly IgE-mediated
–Hives; subcutaneous and mucous membranes
–Angioedema: Most cases acute (resolving within 48 hours); chronic >6 weeks
–Anaphylaxis: May be life-threatening

Atopic dermatitis
–Incidence 2–10%; often begins in infancy
–Most cases improve with age
–Frequent remissions/exacerbations
–Increased risk of infection (herpes, eczema herpeticum; staph, strep)
–Can be exercise-induced

Xerosis (dry skin)
–Idiopathic or due to excessive bathing, low humidity, etc.

Tinea (dermatophytoses, “ringworm”)
–Fungal infection (Trichophyton, Microsporum, Epidermophyton)
–Scalp (tinea capitis), face, trunk, extremities (t. corporis), feet (t. pedis)
–complications: superinfection and kerion
- Scarlet fever (group A strep): “Sandpaper rash,” incubation period 1–7 days; age 5–15 years, 15–20% colonized (oropharyngeal)
- Herpes: Varicella, zoster, herpes simplex
- Lice (pediculosis): Head or pubic area
- Mites (scabies [Sarcoptes scabiei])
- Pinworms (Enterobius vermicularis)
- Cholestasis (TPN, biliary atresia)
- Erythema multiforme (“bull's eye rash”): Stevens-Johnson syndrome
- Drug-induced: Opiates, barbiturates, isoniazid, phenothiazines, erythromycin
- Systemic diseases: Malignancies, renal failure, mastocytosis, SLE, JRA, hypo- and hyperthyroidism, DM
- Prurigo gestationis
- Parasites (“swimmer itch,” trematodes)
- Chronic skin diseases (psoriasis)

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Annular Rashes: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Infectious
–Dermatophytes: Microsporum, Trichophyton, Epidermophyton infections (tinea capitis, corporis, cruris, pedis)
–Tinea versicolor: Superficial infection, caused by Malassezia furfur
–Erythema migrans: Earliest sign in Lyme disease, at the site of the tick bite; typically 7–10 days after bite; initially an erythematous macule that expands to form a large, annular lesion (up to 70 cm, average 15 cm) if left untreated
–Erythema marginatum: In about 10% of the patients with rheumatic fever and occasionally in juvenile rheumatoid arthritis; associated with active carditis
–Pityriasis rosacea
–Secondary syphilis
–African trypanosomiasis: Circinate outline and normal central area
–Larva migrans cutanata: Can present with a serpiginous rash
–Lupus vulgaris (rare, chronic, progressive form of cutaneous tuberculosis)

Numular eczema
Pityriasis alba
Seborrheic dermatitis

Immune mediated
–SLE
–Urticaria
–Erythema multiforme, minor and major (including Stevens-Johnson syndrome): Hypersensitivity syndrome to a variety of etiologies (mostly infectious in children, notably Mycoplasma, and sulfonamides) and presentations; the hallmark is the target lesion (also occasionally seen in erythema annulare centrifugum and Kawasaki disease)
–Toxic epidermal necrolysis (Lyell disease)

Granuloma annulare
Sarcoidosis
Drug eruptions
Cutaneous T-cell lymphoma

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Hand & Foot Rashes: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Infectious

Enterovirus infection (hand-foot-and-mouth disease, Coxsakie virus, other nonpolio enteroviruses)
Kawasaki disease (one of the five criteria)
Scabies
Tinea
Candidal skin infection
Ricketsial rash: Rocky Mountain spotted fever (RMSF), murine typhus
Mononucleosis (EBV)
Measles: Atypical forms start on hands/feet
Scarlet fever, post-streptococcal infection desquamation rash
Infectious endocarditis: Janeway lesions, Osler nodules
Spirochete infection: Secondary syphilis, Lyme disease (acrodermatitis chronica atrophicans)
Congenital toxoplasmosis
Rat-bite fever (Streptobacillus moniliformis, Spirillum minus)
Immune-mediated
- Urticaria: Hands and feet involved in 85% of the cases
- Juvenile rheumatoid arthritis
- Systemic lupus erythematosus
- Raynaud phenomenon (acrocyanosis)
- Acute graft-vs-host disease
  Skin disorders
- Atopic dermatitis (infantile)
- Dyshydrotic eczema, pompholyx
- Chronic allergic contact dermatitis
- Psoriasis
- Lichen simplex
- Papillon-Lefèvre syndrome
- Olmsted syndrome
- Acrodermatitis enteropathica (zinc deficiency) can be presenting sign of cystic fibrosis
- Toxic shock syndrome: Desquamation during the recovery phase; major criteria for staphyloccocal TSS
- Drugs: Ampicillin, especially in patients with infectious mononucleosis
- Chronic liver disease: Cirrhosis, hepatoma
- Metabolic disease: Gangliosidosis
- Malignancy: Acute leukemia, lymphoma

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Morbilliform Rashes: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Measles
–Also called rubeola, a highly contagious (>90% exposed patients acquire the disease), moderately severe viral illness
–Characterized by fever and malaise in prodrome, cough, conjunctivitis, Koplick spots on buccal mucosa, and an exanthem on day 3–4
–The exanthem of measles is blotchy, blanching, erythematous maculopapules beginning at the head and spreading distally
–Severe complications, such as pneumonia, DIC, encephalitis, can occur

Viral exanthems
–Adenovirus: Many types can cause a morbilliform rash that is usually generalized when first identified, often accompanied by upper respiratory symptoms
–Rubella (German measles): Without a prodrome in young children, the exanthem is pinkish, fine maculopapules with a distribution similar to that of measles
–Other viruses may also cause this rash

Drug eruptions
–Erythematous, maculopapular rash that may be blanching or fine in nature
–May be generalized, or begin on the trunk or face then spread to the extremities
–Rash usually begins 1–2 weeks into therapy
–May be pruritic
–Drugs commonly resulting in morbilliform reactions are anticonvulsants, cephalosporins, pencillins, and sulfonamides

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Vesicular Rashes: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Infection
–HSV: Primary infection followed by latent infection in sensory ganglia; recurrences triggered by cold, UV light, stress, fever; HSV-2 (genital herpes) in child suspect sexual abuse; transmission by direct contact
–Varicella (chickenpox) and herpes zoster (VZV): Shingles, reactivation of latent virus in sensory ganglia
–Coxsackie virus (CV): Herpangina, “handfoot-and-mouth disease”
–Tinea (“ringworm”): Fungal infection
–Bullous impetigo (BI): Staph, strep
–Scabies (mites)
–Staphylococcal scalded skin syndrome (SSSS): Tender skin, generalized exfoliation

Contact dermatitis (CD): Poison ivy, drugs, foods, jewelry, chemicals

Erythema multiforme (EM)/Stevens-Johnson syndrome (SJS):
–EM: “Bull's eye rash,” central vesicle, bulla or urticaria
–SJS: More severe, two or more mucous membranes involved
–Triggers: Drugs (sulfonamides, NSAIDs, phenytoin), infection (herpes, EM; mycoplasma, SJS), chemicals, malignancies

Toxic epidermal necrolysis (TEN, a.k.a. Lyell syndrome): Sudden-onset erythema, bullae, tender skin; same triggers as EM/SJS

Neonatal
–Erythema toxicum: In up to 60% of newborns, disappears after 1 week
–Miliaria: Obstructed sweat ducts
–Pustular melanosis: Pustule then macule
–Neonatal acne
–Sucking blisters (bullae on hand)
–Acropustulosis
–Eosinophilic pustular folliculitis
–Congenital candidiasis

Folliculitis: Staph and strep infections
Autoimmune: Dermatitis herpetiformis (DH), pemphigus vulgaris (PV), linear IgA disease, bullous pemphigoid (BP)
Hereditary: Incontinentia pigmenti, epidermolysis bullosa (EB)
Others: Mastocytosis, friction, burns

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Papular rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Acne vulgaris

With acne vulgaris, 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, a headache, or a fever may develop.

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 dermatomyositis, 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).

Follicular mucinosis

With follicular mucinosis, perifollicular papules or plaques are accompanied by prominent alopecia.

Fox-Fordyce disease

Fox-Fordyce disease is a chronic disorder that’s 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.

Granuloma annulare

Granuloma annulare is a benign, chronic disorder that 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 a fever, malaise, a sore throat, and a headache. Lymphadenopathy and hepatosplenomegaly may also occur. Most patients don’t recall these symptoms of acute infection.

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.

Multiple variants of Kaposi’s sarcoma are known; most individuals are immunocompromised in some way, especially those with HIV or acquired immunodeficiency syndrome. Human herpes virus-8 has been strongly implicated as a cofactor in the development of Kaposi’s sarcoma.

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 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 mononucleosis in 10% of patients. The rash is typically preceded by a headache, malaise, and fatigue. It may be accompanied by a 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.

Necrotizing vasculitis

With necrotizing vasculitis, crops of purpuric, but otherwise asymptomatic, papules are typical. Some patients also develop a low-grade fever, a headache, myalgia, arthralgia, and abdominal pain.

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, a 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 is a hyperemic disorder 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.

Seborrheic keratosis

With seborrheic keratosis, a 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 of smallpox include a high fever, malaise, prostration, a severe headache, a 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.

Syringoma

With syringoma, 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, a low-grade or spiking fever, chills, lymphadenopathy, anorexia, weight loss, abdominal pain, diarrhea
or constipation, dyspnea, tachycardia, hematuria, a headache, and irritability.

Typhus

Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body lice. Initial symptoms include
a headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of chills, a 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; phenylbutazone; gold salts; allopurinol; isoniazid; and salicylates.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Pustular rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Acne vulgaris

Pustules typify inflammatory lesions of acne vulgaris, which is accompanied by papules, nodules, cysts, open comedones (blackheads), and closed (whiteheads) comedones. Lesions commonly appear on the face, shoulders, back, and chest. Other findings include pain on pressure, pruritus, and burning. Chronic recurrent lesions produce scars.

Blastomycosis

Blastomycosis is a fungal infection that produces small, painless, nonpruritic macules or papules that can enlarge to well-circumscribed, verrucous, crusted, or ulcerated lesions edged by pustules. Localized infection may cause only one lesion; systemic infection may cause many lesions on the hands, feet, face, and wrists. Blastomycosis also produces signs of pulmonary infection, such as pleuritic chest pain and a dry, hacking or productive cough with occasional hemoptysis.

Folliculitis

Folliculitis is a bacterial infection of hair follicles that produces individual pustules, each pierced by a hair and possibly accompanied by pruritus. “Hot tub” folliculitis produces pustules on areas covered by a bathing suit.

Furunculosis

A furuncle is an acute, deep-seated, red, hot, tender abscess that evolves from a staphylococcal folliculitis. Furuncles usually begin as small, tender red pustules at the base of hair follicles. They’re likely to occur on the face, neck, forearm, groin, axillae, buttocks, and legs or areas that are prone to repeated friction. The pustules usually remain tense for 2 to 4 days and then become fluctuant. Rupture discharges pus and necrotic material. Then pain subsides, but erythema and edema may persist.

Impetigo contagiosa

Impetigo contagiosa, a vesiculopustular eruptive disorder that occurs in nonbullous and bullous forms, is usually caused by streptococci or staphylococci. Vesicles form and break, and a crust forms from the exudate: a thick, yellow crust in streptococcal impetigo and a thin, clear crust in staphylococcal impetigo. Both forms usually produce painless itching.

Pustular miliaria

Pustular miliaria is an anhidrotic disorder that causes pustular lesions that begin as tiny erythematous papulovesicles located at sweat pores. Diffuse erythema may radiate from the lesion. The rash and associated burning and pruritus worsen with sweating.

Pustular psoriasis

Small vesicles form and eventually become pustules in pustular psoriasis. The patient may report pruritus, burning, and pain. Localized pustular psoriasis usually affects the hands and feet. Generalized pustular psoriasis may erupt suddenly in a patient with psoriasis, psoriatic arthritis, or exfoliative psoriasis; although rare, this form of psoriasis can occasionally be fatal.

Rosacea

Rosacea is a chronic hyperemic disorder that commonly produces telangiectasia with acute episodes of pustules, papules, and edema. Characterized by persistent erythema, rosacea may begin as a flush covering the forehead, malar region, nose, and chin. Intermittent episodes gradually become more persistent, and the skin — instead of returning to its normal color — develops varying degrees of erythema.

Scabies

Threadlike channels or burrows under the skin characterize scabies, which can also produce pustules, vesicles, and excoriations. The lesions are a few millimeters long, with a swollen nodule or red papule that contains the itch mite.

Gender Cue: In men, crusted lesions commonly develop on the glans, shaft, and scrotum. In women, lesions may form on the nipples. In both genders, these lesions have a predilection for skin folds. Crusty excoriated lesions also develop on wrists, elbows, axillae, waistline, behind the knees, and ankles. Related pruritus worsens with inactivity and warmth.

Smallpox

(variola major). Initial signs and symptoms include a high fever, malaise, prostration, a severe headache, a 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.

Varicella zoster

When immunity to varicella declines, the virus reactivates along a dermatome, producing extremely painful and pruritic vesicles and pustules (herpes zoster, or shingles). Even with resolution of the rash, patients may experience chronic pain (postherpetic neuralgia) that may persist for months.

Other causes

Drugs

Bromides and iodides commonly cause a pustular rash. Other drug causes include corticotropin, corticosteroids, dactinomycin, trimethadione, lithium, phenytoin, phenobarbital, isoniazid, hormonal contraceptives, androgens, and anabolic steroids.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Pruritus: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anemia (iron deficiency)

Iron deficiency anemia occasionally produces pruritus. Initially asymptomatic, anemia can later cause exertional dyspnea, fatigue, listlessness, pallor, irritability, a headache, tachycardia, poor muscle tone and, possibly, murmurs. Chronic anemia causes spoon-shaped (koilonychia) and brittle nails (cheilosis), cracked mouth corners, a smooth tongue (glossitis), and dysphagia.

Anthrax (cutaneous)

Anthrax is an acute infectious disease caused by the gram-positive, spore-forming bacterium Bacillus anthracis. It can occur in humans who are exposed to infected animals, tissue from infected animals, or biological warfare. Cutaneous anthrax occurs when the bacterium enters a cut or an 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, a headache, or a fever may develop.

Conjunctivitis

All forms of conjunctivitis cause eye itching, burning, and pain along with photophobia, conjunctival injection, a foreign-body sensation, excessive tearing, and a feeling of fullness around the eye. Allergic conjunctivitis may also cause milky redness and a stringy eye discharge. Bacterial conjunctivitis typically causes brilliant redness and a mucopurulent discharge that may make the eyelids stick together. Fungal conjunctivitis produces a thick, purulent discharge and crusting and sticking of the eyelid. Viral conjunctivitis may cause copious tearing — but little discharge — and preauricular lymph node enlargement.

Dermatitis

Several types of dermatitis can cause pruritus accompanied by a skin lesion. Atopic dermatitis begins with intense, severe pruritus and an erythematous rash on dry skin at flexion points (antecubital fossa, popliteal area, and neck). During a flare-up, scratching may produce edema, scaling, and pustules. With chronic atopic dermatitis, lesions may progress to dry, scaly skin with white dermatographia, blanching, and lichenification.

Mild irritants and allergies can cause contact dermatitis, with itchy small vesicles that may ooze and scale and are surrounded by redness. A severe reaction can produce marked localized edema.

Dermatitis herpetiformis, most common in men between ages 20 and 50, initially causes intense pruritus and stinging. Between 8 and 12 hours later, symmetrically distributed lesions form on the buttocks, shoulders, elbows, and knees. Sometimes, they also form on the neck, face, and scalp. These lesions are erythematous and papular, bullous, or pustular.

Hepatobiliary disease

An important diagnostic clue to liver and gallbladder disease, pruritus is commonly accompanied by jaundice and may be generalized or localized to the palms and soles. Other characteristics include right upper quadrant pain, clay-colored stools, chills and a fever, flatus, belching and a bloated feeling, epigastric burning, and bitter fluid regurgitation. Later, liver disease may produce mental changes, ascites, bleeding tendencies, spider angiomas, palmar erythema, dry skin, fetor hepaticus, enlarged superficial abdominal veins, bilateral gynecomastia, testicular atrophy or menstrual irregularities, and hepatomegaly.

Herpes zoster

Within 2 to 4 days of a fever and malaise, pruritus, paresthesia or hyperesthesia, and severe, deep pain from cutaneous nerve involvement develop on the trunk or the arms and legs in a dermatome distribution. Up to 2 weeks after initial symptoms, red, nodular skin eruptions appear on the painful areas and become vesicular. About 10 days later, the vesicles rupture and form scabs.

Leukemia (chronic lymphocytic)

Pruritus is an uncommon finding in leukemia. More characteristic signs and symptoms include fatigue, malaise, generalized lymphadenopathy, a fever, hepatomegaly, splenomegaly, weight loss, pallor, bleeding, and palpitations.

Lichen simplex chronicus

Persistent rubbing and scratching cause localized pruritus and a circumscribed scaling patch with sharp margins. Later, the skin thickens and papules form.

Myringitis (chronic)

Myringitis produces pruritus in the affected ear, along with a purulent discharge and gradual hearing loss.

Pediculosis

A prominent symptom, pruritus occurs in the area of infestation. Pediculosis capitis (head lice) may also cause scalp excoriation from scratching, along with matted, foul-smelling, lusterless hair; occipital and cervical lymphadenopathy; and oval, gray-white nits on hair shafts.

Pediculosis corporis (body lice) initially causes small red papules (usually on the shoulders, trunk, or buttocks), which become urticarial from scratching. Later, rashes or wheals may develop. Untreated, pediculosis corporis produces dry, discolored, thickly encrusted, scaly skin with bacterial infection and scarring. In severe cases, it produces a headache, a fever, and malaise.

With pediculosis pubis (pubic lice), scratching commonly produces skin irritation. Nits or adult lice and erythematous, itching papules may appear in pubic hair or in hair around the anus, abdomen, or thighs.

Pityriasis rosea

Pityriasis rosea occasionally produces mild pruritus that’s aggravated by a hot bath or shower. It usually begins with an erythematous herald patch — a slightly raised, oval lesion about 2 to 6 cm in diameter. After a few days or weeks, scaly yellow-tan or erythematous patches erupt on the trunk and extremities and persist for 2 to 6 weeks. Occasionally, these patches are macular, vesicular, or urticarial.

Psoriasis

Pruritus and pain are common in psoriasis. This skin disorder typically begins with small erythematous papules that enlarge or coalesce to form red elevated plaques with silver scales on the scalp, chest, elbows, knees, back, buttocks, and genitals. Nail pitting may occur.

Scabies

Typically, scabies causes localized pruritus that awakens the patient. It may become generalized and persist for up to 2 weeks after treatment. Threadlike lesions several millimeters long appear with a swollen nodule or red papule.

Gender Cue: In males, crusty lesions may form on the glans penis, penile shaft, and scrotum. In females, lesions may also be found on or around the nipples. In both sexes, the lesions have a predilection for skin folds. Crusty excoriated lesions form on the wrists, elbows, axillae, waistline, behind the knees, and ankles. Excoriation from scratching is common.

Tinea pedis

Tinea pedis is a fungal infection that causes severe foot pruritus, pain with walking, scales and blisters between the toes, and a dry, scaly squamous inflammation on the entire sole.

Urticaria

Extreme pruritus and stinging occur as transient, erythematous or whitish wheals form on the skin or mucous membranes. Prickly sensations typically precede the wheals, which may affect any part of the body and may range from pinpoint to palm-sized or larger.

Vaginitis

Vaginitis commonly causes localized pruritus and a foul-smelling vaginal discharge that may be purulent, white or gray, and curdlike. Perineal pain and urinary dysfunction may also occur.

Other causes

Herb Alert

Ingestion of fruit pulp from the ginkgo tree can cause rapid formation of vesicles, resulting in severe itching.

Bedbug bites

Typically, bedbug bites produce itching and burning over the ankles and lower legs, along with clusters of purpuric spots.

Drug hypersensitivity

When mild and localized, an allergic reaction to such drugs as penicillin and sulfonamides can cause pruritus, erythema, an urticarial rash, and edema. However, with a severe drug reaction, anaphylaxis may occur.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Skin, mottled: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Acrocyanosis

With the rare disorder acrocyanosis, anxiety or exposure to cold can cause vasospasm in small cutaneous arterioles. This results in persistent symmetrical blue and red mottling of the affected hands, feet, and nose.

Arterial occlusion (acute)

Initial signs of acute arterial occlusion include temperature and color changes. Pallor may change to blotchy cyanosis and livedo reticularis. Color and temperature demarcation develop at the level of obstruction. Other effects include sudden onset of pain in the extremity and, possibly, paresthesia, paresis, and a sensation of cold in the affected area. Examination reveals diminished or absent pulses, cool extremities, an increased capillary refill time, pallor, and diminished reflexes.

Arteriosclerosis obliterans

Atherosclerotic buildup narrows intra-arterial lumina, resulting in reduced blood flow through the affected artery. Obstructed blood flow to the extremities (most commonly the legs) produces such peripheral signs and symptoms as leg pallor, cyanosis, blotchy erythema, and livedo reticularis. Related findings include intermittent claudication (most common symptom), diminished or absent pedal pulses, and leg coolness. Other symptoms include coldness and paresthesia.

Buerger’s disease

Buerger’s disease, a form of vasculitis, produces unilateral or asymmetrical color changes and mottling, particularly livedo networking in the lower extremities. It also typically causes intermittent claudication and erythema along extremity blood vessels. During exposure to cold, the feet are cold, cyanotic, and numb; later they’re hot, red, and tingling. Other findings include impaired peripheral pulses and peripheral neuropathy. Buerger’s disease is typically exacerbated by smoking.

Cryoglobulinemia

Cryoglobulinemia is a necrotizing disorder that causes patchy livedo reticularis, petechiae, and ecchymoses. Other findings include a fever, chills, urticaria, melena, skin ulcers, epistaxis, Raynaud’s phenomenon, eye hemorrhages, hematuria, and gangrene.

Hypovolemic shock

Vasoconstriction from shock commonly produces skin mottling, initially in the knees and elbows. As shock worsens, mottling becomes generalized. Early signs include a sudden onset of pallor, cool skin, restlessness, thirst, tachypnea, and slight tachycardia. As shock progresses, associated findings include cool, clammy skin; a rapid, thready pulse; hypotension; narrowed pulse pressure; decreased urine output; subnormal temperature; confusion; and a decreased level of consciousness.

Livedo reticularis (idiopathic or primary)

Symmetrical, diffuse mottling can involve the hands, feet, arms, legs, buttocks, and trunk. Initially, networking is intermittent and most pronounced on exposure to cold or stress; eventually, mottling persists even with warming.

Periarteritis nodosa

Skin findings in periarteritis nodosa include asymmetrical, patchy livedo reticularis, palpable nodules along the path of medium-sized arteries, erythema, purpura, muscle wasting, ulcers, gangrene, peripheral neuropathy, a fever, weight loss, and malaise.

Polycythemia vera

Polycythemia vera is a hematologic disorder that produces livedo reticularis, hemangiomas, purpura, rubor, ulcerative nodules, and scleroderma-like lesions. Other symptoms include a headache, a vague feeling of fullness in the head, dizziness, vertigo, vision disturbances, dyspnea, and aquagenic pruritus.

Systemic lupus erythematosus (SLE)

SLE is a connective tissue disorder that can cause livedo reticularis, most commonly on the outer arms. Other signs and symptoms include a butterfly rash, nondeforming joint pain and stiffness, photosensitivity, Raynaud’s phenomenon, patchy alopecia, seizures, a fever, anorexia, weight loss, lymphadenopathy, and emotional lability.

Other causes

Immobility

Prolonged immobility may cause bluish mottling, most noticeably in dependent extremities.

Thermal exposure

Prolonged thermal exposure, as from a heating pad or hot water bottle, may cause erythema Ab Igne — a localized, reticulated, brown-to-red mottling.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Butterfly rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Discoid lupus erythematosus. With discoid lupus erythematosus, a localized form of LE, the patient may come into your facility with a unilateral or butterfly rash that consists of erythematous, raised, sharply demarcated plaques with follicular plugging and central atrophy. The rash may also involve the scalp, ears, chest, or any part of the body exposed to the sun. Telangiectasia, scarring alopecia, and hypopigmentation or hyperpigmentation may occur later. Other accompanying signs include conjunctival redness, dilated capillaries of the nail fold, bilateral parotid gland enlargement, oral lesions, and mottled, reddish blue skin on the legs.

❑ Erysipelas. Erysipelas causes rosy or crimson swollen lesions, mainly on the neck and head and commonly along the nasolabial fold. It may cause hemorrhagic pus-filled blisters. Other signs and symptoms include fever, chills, cervical lymphadenopathy, and malaise.

❑ Polymorphous light eruption. Butterfly rash appears as erythema, vesicles, plaques, and multiple small papules that may later become eczematized, lichenified, and excoriated. Provoked by ultraviolet rays, the rash appears on the cheeks and bridge of the nose, the hands and arms, and other areas, beginning a few hours to several days after exposure. It may be accompanied by pruritus.

❑ Rosacea. Initially, butterfly rash may appear as a prominent, nonscaling, intermittent erythema limited to the lower half of the nose or including the chin, cheeks, and central forehead. As rosacea develops, the duration of the rash increases; instead of disappearing after each episode, the rash varies in intensity and is commonly accompanied by telangiectasia. With advanced rosacea, the skin is oily, with papules, pustules, nodules, and telangiectasis restricted to the central oval of the face. In men with severe rosacea, butterfly rash may be accompanied by rhinophyma — a thickened, lobulated overgrowth of sebaceous glands and epithelial connective tissue on the lower half of the nose and, possibly, the adjacent cheeks. This is more common in elderly patients.

❑ Seborrheic dermatitis. Butterfly rash appears as greasy, scaling, slightly yellow macules and papules of varying size on the cheeks and the bridge of the nose, in a “butterfly” pattern. The scalp, beard, eyebrows, portions of the forehead above the bridge of the nose, nasolabial fold, or trunk may also be involved. Associated signs and symptoms include crusts and fissures (particularly when the external ear and scalp are involved), pruritus, redness, blepharitis, styes, severe acne, and oily skin. Severe seborrheic dermatitis of the face occurs in acquired immunodeficiency syndrome.

❑ Systemic lupus erythematosus. Occurring in about 40% of patients with this connective tissue disorder, butterfly rash appears as a red, usually scaly, sharply demarcated macular eruption. The rash may be transient in patients with acute SLE or may progress slowly to include the forehead, the chin, the area around the ears, and other exposed areas. Common associated skin findings include scaling, patchy alopecia, mucous membrane lesions, mottled erythema of the palms and fingers, periungual erythema with edema, reddish purple macular lesions on the volar surfaces of the fingers, telangiectasia of the base of the nails or eyelids, purpura, petechiae, and ecchymoses.

Butterfly rash may also be accompanied by joint pain, stiffness, and deformities, particularly ulnar deviation of the fingers and subluxation of the proximal interphalangeal joints. Related findings include periorbital and facial edema, dyspnea, a low-grade fever, malaise, weakness, fatigue, weight loss, anorexia, nausea, vomiting, lymphadenopathy, photosensitivity, and hepatosplenomegaly.

Other causes

❑ Drugs. Hydralazine and procainamide can cause a lupuslike syndrome.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vesicular rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Burns (second degree)

Thermal burns that affect the epidermis and part of the dermis cause vesicles and bullae, with erythema, swelling, pain, and moistness.

Dermatitis

With contact dermatitis, a hypersensitivity reaction produces an eruption of small vesicles surrounded by redness and marked edema. The vesicles may ooze, scale, and cause severe pruritus.

Dermatitis herpetiformis is a skin disease that’s most common in men between ages 20 and 50 (and is occasionally associated with celiac disease, organ malignancy, or immunoglobulin A immunotherapy) and produces a chronic inflammatory eruption marked by vesicular, papular, bullous, pustular, or erythematous lesions. Usually, the rash is symmetrically distributed on the buttocks, shoulders, extensor surfaces of the elbows and knees, and sometimes the face, scalp, and neck. Other symptoms include severe pruritus, burning, and stinging.

With nummular dermatitis, groups of pinpoint vesicles and papules appear on erythematous or pustular lesions that are nummular (coinlike) or annular (ringlike). Often, the pustular lesions ooze a purulent exudate, itch severely, and rapidly become crusted and scaly. Two or three lesions may develop on the hands, but the lesions typically develop on the extensor surfaces of the limbs and on the buttocks and posterior trunk.

Erythema multiforme

Erythema multiforme is an acute inflammatory skin disease that’s heralded by a sudden eruption of erythematous macules, papules and, occasionally, vesicles and bullae. The characteristic rash appears symmetrically over the hands, arms, feet, legs, face, and neck and tends to reappear. Although vesicles and bullae may also erupt on the eyes and genitalia, vesiculobullous lesions usually appear on the mucous membranes — especially the lips and buccal mucosa — where they rupture and ulcerate, producing a thick, yellow or white exudate. Bloody, painful crusts, a foul-smelling oral discharge, and difficulty chewing may develop. Lymphadenopathy may also occur.

Herpes simplex

Herpes simplex is a common viral infection that produces groups of vesicles on an inflamed base, most commonly on the lips and lower face. In about 25% of cases, the genital region is the site of involvement. Vesicles are preceded by itching, tingling, burning, or pain; develop singly or in groups; are 2 to 3 mm in size; and do not coalesce. Eventually, they rupture, forming a painful ulcer followed by a yellowish crust.

Herpes zoster

With herpes zoster, a vesicular rash is preceded by erythema and, occasionally, by a nodular skin eruption and unilateral, sharp, pain along a dermatome. About 5 days later, the lesions erupt and the pain becomes burning. Vesicles dry and scab about 10 days after eruption. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the involved area. Herpes zoster involving the cranial nerves produces facial palsy, hearing loss, dizziness, loss of taste, eye pain, and impaired vision.

Insect bites

With insect bites, vesicles appear on red hivelike papules and may become hemorrhagic.

Pemphigoid (bullous)

Generalized pruritus or an urticarial or eczematous eruption may precede pemphigoid — a classic bullous rash. Bullae are large, thick-walled, tense, and irregular, typically forming on an erythematous base. They usually appear on the lower abdomen, groin, inner thighs, and forearms.

Pompholyx (dyshidrosis or dyshidrosis eczema)

Pompholyx is a common, recurrent disorder that produces symmetrical vesicular lesions that can become pustular. The pruritic lesions are more common on the palms than on the soles and may be accompanied by minimal erythema.

Porphyria cutanea tarda

Bullae — especially on areas exposed to sun, friction, trauma, or heat — result from abnormal porphyrin metabolism. Photosensitivity is also a common sign. Papulovesicular lesions evolving into erosions or ulcers and scars may appear. Chronic skin changes include hyperpigmentation or hypopigmentation, hypertrichosis, and sclerodermoid lesions. Urine is pink to brown.

Scabies

Small vesicles erupt on an erythematous base and may be at the end of a threadlike burrow. Burrows are a few millimeters long, with a swollen nodule or red papule that contains the mite. Pustules and excoriations may also occur. Men may develop burrows on the glans, shaft, and scrotum; women may develop burrows on the nipples. Both sexes may develop burrows on the webs of the fingers, wrists, elbows, axillae, and waistline. Associated pruritus worsens with inactivity and warmth and at night.

Smallpox

(variola major). Initial signs and symptoms of smallpox 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. Later, the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Tinea pedis

Tinea pedis is a fungal infection that causes vesicles and scaling between the toes and, possibly, scaling over the entire sole. Severe infection causes inflammation, pruritus, and difficulty walking.

Toxic epidermal necrolysis

Toxic epidermal necrolysis is an immune reaction to drugs or other toxins, in which vesicles and bullae are preceded by a diffuse, erythematous rash and followed by large-scale epidermal necrolysis and desquamation. Large, flaccid bullae develop after mucous membrane inflammation, a burning sensation in the conjunctivae, malaise, fever, and generalized skin tenderness. The bullae rupture easily, exposing extensive areas of denuded skin. (See Drugs that cause toxic epidermal necrolysis.)

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Skin turgor, decreased: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Cholera

Cholera is characterized by abrupt watery diarrhea and vomiting, which leads to severe water and electrolyte loss. These imbalances cause the following symptoms: decreased skin turgor, thirst, weakness, muscle cramps, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Dehydration

Decreased skin turgor commonly occurs with moderate to severe dehydration. Associated findings include dry oral mucosa, decreased perspiration, resting tachycardia, orthostatic hypotension, a dry and furrowed tongue, increased thirst, weight loss, oliguria, a fever, and fatigue. As dehydration worsens, other findings include enophthalmos, lethargy, weakness, confusion, delirium or obtundation, anuria, and shock. Hypotension persists even when the patient lies down.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Skin, clammy: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anxiety

An acute anxiety attack commonly produces cold, clammy skin on the forehead, palms, and soles. Other features include pallor, a dry mouth, tachycardia or bradycardia, palpitations, and hypertension or hypotension. The patient may also develop tremors, breathlessness, a headache, muscle tension, nausea, vomiting, abdominal distention, diarrhea, increased urination, and sharp chest pain.

Arrhythmias

Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.

Cardiogenic shock

Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.

Heat exhaustion

In the acute stage of heat exhaustion, generalized cold, clammy skin accompanies an ashen appearance, a headache, confusion, syncope, giddiness and, possibly, a subnormal temperature, with mild heat exhaustion. The patient may exhibit a rapid and thready pulse, nausea, vomiting, tachypnea, oliguria, thirst, muscle cramps, and hypotension.

Hypoglycemia (acute)

Generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, a headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.

Hypovolemic shock

With hypovolemic shock, generalized pale, cold, clammy skin accompanies a subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and a rapid, thready pulse. Other findings are flat neck veins, an increased capillary refill time, decreased urine output, confusion, and a decreased level of consciousness.

Septic shock

The cold shock stage causes generalized cold, clammy skin. Associated findings include a rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Skin, scaly: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Bowen’s disease

Bowen’s disease is a common form of intraepidermal carcinoma that causes painless, erythematous plaques that are raised and indurated with a thick, hyperkeratotic scale and, possibly, ulcerated centers.

Dermatitis

Exfoliative dermatitis begins with rapidly developing generalized erythema. Desquamation with fine scales or thick sheets of all or most of the skin surface may cause life-threatening hypothermia. Other possible complications include cardiac output failure and septicemia. Systemic signs and symptoms include a low-grade fever, chills, malaise, lymphadenopathy, and gynecomastia.

With nummular dermatitis, round, pustular lesions commonly ooze purulent exudate, itch severely, and rapidly become encrusted and scaly. Lesions appear on the extensor surfaces of the limbs, posterior trunk, and buttocks.

Seborrheic dermatitis begins with erythematous, scaly papules that progress to larger, dry or moist, greasy scales with yellowish crusts. This disorder primarily involves the center of the face, the chest and scalp and, possibly, the genitalia, axillae, and perianal regions. Pruritus occurs with scaling.

Dermatophytosis

Tinea capitis produces lesions with reddened, slightly elevated borders and a central area of dense scaling; these lesions may become inflamed and pus-filled (kerions). Patchy alopecia and itching may also occur. Tinea pedis causes scaling and blisters between the toes. The squamous type produces diffuse, fine, branlike scales. Adherent and silvery white, they’re most prominent in skin creases and may affect the entire dorsum of the foot. Tinea corporis produces crusty lesions. As they enlarge, their centers heal, causing the classic ringworm shape.

Lymphoma

Hodgkin’s disease and non-Hodgkin’s lymphoma commonly cause scaly rashes. Hodgkin’s disease may cause pruritic scaling dermatitis that begins in the legs and spreads to the entire body. Remissions and recurrences are common. Small nodules and diffuse pigmentation are related signs. This disease typically produces painless enlargement of the peripheral lymph nodes. Other signs and symptoms include a fever, fatigue, weight loss, malaise, and hepatosplenomegaly.

Non-Hodgkin’s lymphoma initially produces erythematous patches with some scaling that later become interspersed with nodules. Pruritus and discomfort are common; later, tumors and ulcers form. Progression produces nontender lymphadenopathy.

Parapsoriasis (chronic)

Parapsoriasis produces small or moderate-sized maculopapular, erythematous eruptions, with a thin, adherent scale on the trunk, hands, and feet. Removal of the scale reveals a shiny brown surface.

Pityriasis

Pityriasis rosea, an acute, benign, and self-limiting disorder, produces widespread scales. It begins with an erythematous, raised, oval herald patch anywhere on the body. A few days or weeks later, yellow-tan or erythematous patches with scaly edges erupt on the trunk and limbs and sometimes on the face, hands, and feet. Pruritus also occurs.

Pityriasis rubra pilaris, an uncommon disorder, initially produces seborrheic scaling on the scalp, progressing to the face and ears. Later, scaly red patches develop on the palms and soles, becoming diffuse, thick, fissured, hyperkeratotic, and painful. Lesions also appear on the hands, fingers, wrists, and forearms and then on wide areas of the trunk, neck, and limbs.

Psoriasis

Silvery white, micaceous scales cover erythematous plaques that have sharply defined borders. Psoriasis usually appears on the scalp, chest, elbows, knees, back, buttocks, and genitalia. Associated signs and symptoms include nail pitting, pruritus, arthritis, and sometimes pain from dry, cracked, encrusted lesions.

Systemic lupus erythematosus (SLE)

SLE produces a bright-red maculopapular eruption, sometimes with scaling. Patches are sharply defined and involve the nose and malar regions of the face in a butterfly pattern — a primary sign. Similar characteristic rashes appear on other body surfaces; scaling occurs along the lower lip or anterior hair line. Other primary signs and symptoms include photosensitivity and joint pain and stiffness. Vasculitis (leading to infarctive lesions, necrotic leg ulcers, or digital gangrene), Raynaud’s phenomenon, patchy alopecia, and mucous membrane ulcers can also occur.

Tinea versicolor

Tinea versicolor is a benign fungal skin infection that typically produces macular hypopigmented, fawn-colored, or brown patches of varying sizes and shapes. All are slightly scaly. Lesions commonly affect the upper trunk, arms, and lower abdomen; sometimes the neck; and, rarely, the face.

Other causes

Drugs

Many drugs — including penicillins, sulfonamides, barbiturates, quinidine, diazepam, phenytoin, and isoniazid — can produce scaling patches.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Rocky Mountain spotted fever: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

R. rickettsii is transmitted to a human or small animal by the prolonged bite (4 to 6 hours) of an adult tick — the wood tick (Dermacentor andersoni) in the west and by the dog tick (Dermacentor variabilis) in the east. Occasionally, it's acquired through inhalation (it can occur in laboratory settings where aerosolization of blood and specimens may occur) or through the contact of abraded skin with tick excreta or tissue juices. (This explains why people should'nt crush ticks between their fingers when removing them from other people and animals.) In most tick-infested areas, 1% to 5% of the ticks harbor R. rickettsii.

Endemic throughout the continental United States, RMSF is particularly prevalent in the southeast and southwest. Because RMSF is associated with outdoor activities, such as camping and backpacking, the incidence of this illness is usually higher in the spring and summer. Epidemiologic surveillance reports for RMSF indicate that the incidence is also higher in children ages 5 to 9, men and boys, and whites.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Pruritus ani: Causes
(Professional Guide to Diseases (Eighth Edition))

Factors that contribute to pruritus ani include overcleaning of the perianal area (harsh soap, vigorous rubbing with a washcloth or toilet paper); minor trauma caused by straining to defecate; poor hygiene; sensitivity to spicy foods, coffee, alcohol, food preservatives, perfumed or colored toilet paper, detergents, or certain fabrics; specific medications (antibiotics, antihypertensives, or antacids that cause diarrhea); excessive sweating (in occupations associated with physical labor or high stress levels); anal skin tags; systemic disease, especially diabetes; certain skin lesions, such as those associated with squamous cell carcinoma, basal cell carcinoma, Bowen’s disease, Paget’s disease, melanoma, syphilis, and tuberculosis; fungal or parasitic infection; and local anorectal disease (fissure, hemorrhoids, and fistula).

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Staphylococcal scalded skin syndrome: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The causative organism in SSSS is group 2 Staphylococcus aureus, primarily phage type 71, which produces exotoxins that cause detachment of the epidermis. Predisposing factors may include impaired immunity and renal insufficiency — present to some extent in the normal neonate because of immature development of these systems.

SSSS is most prevalent in infants age 1 to 3 months but may develop in children. It’s uncommon in adults.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Papular rash: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

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.

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 (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.

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, 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.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Pustular rash: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acne vulgaris

Pustules typify inflammatory lesions of this disorder, which is accompanied by papules, nodules, cysts, open comedones (blackheads) and closed (whiteheads) comedones. Lesions commonly appear on the face, shoulders, back, and chest. Other findings include pain on pressure, pruritus, and burning. Chronic recurrent lesions produce scars.

Blastomycosis

This fungal infection produces small, painless, nonpruritic macules or papules that can enlarge to well-circumscribed, verrucous, crusted, or ulcerated lesions edged by pustules. Localized infection may cause only one lesion; systemic infection may cause many lesions on the hands, feet, face, and wrists. Blastomycosis also produces signs of pulmonary infection, such as pleuritic chest pain and a dry, hacking or productive cough with occasional hemoptysis.

Folliculitis

This bacterial infection of hair follicles produces individual pustules, each pierced by a hair and possibly accompanied by pruritus. “Hot tub” folliculitis produces pustules on areas covered by a bathing suit.

Furunculosis

A furnicle is an acute, deep-seated, red, hot, tender abscess that evolves from a staphylococcus folliculitis. Furuncles usually begin as small, tender red pustules at the base of hair follicles. They’re likely to occur on the face, neck, forearm, groin, axillae, buttocks, and legs; areas that are prone to repeated friction. The pustules usually remain tense for 2 to 4 days and then become fluctuant. Rupture discharges pus and necrotic material. Then pain subsides, but erythema and edema may persist.

Gonococcemia

This disorder produces a rash of scanty, pinpoint erythematous macules that rapidly become vesiculopustular, maculopapular and, frequently, hemorrhagic. Bullae may form. Mature lesions are elevated, with dirty gray necrotic centers and surrounding erythema. The rash appears on the distal part of the arms and legs, usually during the 1st day that other findings, such as fever and joint pain, occur. The rash disappears after 3 to 4 days but may recur with each episode of fever.

Impetigo contagiosa

This vesiculopustular eruptive disorder, which occurs in nonbullous and bullous forms, is usually caused by streptococci or staphylococci. Vesicles form and break, and a crust forms from the exudate: a thick, yellow crust in streptococcal impetigo and a thin, clear crust in staphylococcal impetigo. Both forms usually produce painless itching.

Nummular or annular dermatitis

With this disorder, numerous coinlike (nummular) or ringed (annular) pustular lesions appear, usually on the extensor surfaces of the extremities, posterior trunk, buttocks, and lower legs; a few lesions may appear on the hands. The lesions commonly ooze a purulent exudate, itch severely, and rapidly become crusted and scaly. A few small, scaling patches may remain for some time.

Pustular miliaria

This anhidrotic disorder causes pustular lesions that begin as tiny erythematous papulovesicles located at sweat pores. Diffuse erythema may radiate from the lesion. The rash and associated burning and pruritus worsen with sweating.

Pustular psoriasis

Small vesicles form and eventually become pustules in this disorder. The patient may report pruritus, burning, and pain. Localized pustular psoriasis usually affects the hands and feet. Generalized pustular psoriasis may erupt suddenly in patients with psoriasis, psoriatic arthritis, or exfoliative psoriasis; although rare, this form of psoriasis can occasionally be fatal.

Rosacea

This chronic hyperemic disorder commonly produces telangiectasia with acute episodes of pustules, papules, and edema. Characterized by persistent erythema, rosacea may begin as a flush covering the forehead, malar region, nose, and chin. Intermittent episodes gradually become more persistent, and the skin—instead of returning to its normal color—develops varying degrees of erythema.

Scabies

Threadlike channels or burrows under the skin characterize this disorder, which can also produce pustules, vesicles, and excoriations. The lesions are a few millimeters long, with a swollen nodule or red papule that contains the itch mite.

Gender Cue: In men, crusted lesions commonly develop on the glans, shaft, and scrotum. In women, lesions may form on the nipples. In both sexes these lesions have a predilection for skin folds. Crusty excoriated lesions also develop on wrists, elbows, axillae, waistline, behind the knees and ankles. Related pruritus worsens with inactivity and warmth.

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.

Varicella zoster

Other causes

Drugs

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Pruritus: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anemia (iron deficiency)

This disorder occasionally produces pruritus. Initially asymptomatic, anemia can later cause exertional dyspnea, fatigue, listlessness, pallor, irritability, headache, tachycardia, poor muscle tone and, possibly, murmurs. Chronic anemia causes spoon-shaped (koilonychia) and brittle nails (cheilosis), cracked mouth corners, a smooth tongue (glossitis), and dysphagia.

Anthrax (cutaneous)

Anthrax is an acute infectious disease caused by the gram-positive, spore-forming bacterium Bacillus anthracis. It can occur in humans who are 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.

Conjunctivitis

All forms of conjunctivitis cause eye itching, burning, and pain along with photophobia, conjunctival injection, a foreign-body sensation, excessive tearing, and a feeling of fullness around the eye. Allergic conjunctivitis may also cause milky redness and a stringy eye discharge. Bacterial conjunctivitis typically causes brilliant redness and a mucopurulent, discharge that may make the eyelids stick together. Fungal conjunctivitis produces a thick, purulent discharge and crusting and sticking of the eyelid. Viral conjunctivitis may cause copious tearing—but little discharge—and preauricular lymph node enlargement.

Dermatitis

Mild irritants and allergies can cause contact dermatitis, with itchy small vesicles that may ooze and scale and are surrounded by redness. A severe reaction can produce marked localized edema.

Enterobiasis

Also known as pinworm or seatworm, this benign intestinal disease results from infection by Enterobius vermicularis. Adult worms live in the intestine; females migrate to the perianal region to deposit their eggs, causing intense perianal pruritus.

Hemorrhoids

Anal pruritus may occur in patients with hemorrhoids along with rectal pain and constipation. External hemorrhoids may be seen outside the external anal sphincter; internal hemorrhoids are less obvious and less painful but more likely to cause rectal bleeding.

Hepatobiliary disease

An important diagnostic clue to liver and gallbladder disease, pruritus is commonly accompanied by jaundice and may be generalized or localized to the palms and soles. Other characteristics include right-upper-quadrant pain, clay-colored stools, chills and fever, flatus, belching and a bloated feeling, epigastric burning, and bitter fluid regurgitation. Later, liver disease may produce mental changes, ascites, bleeding tendencies, spider angiomas, palmar erythema, dry skin, fetor hepaticus, enlarged superficial abdominal veins, bilateral gynecomastia, testicular atrophy or menstrual irregularities, and hepatomegaly.

Herpes zoster

Within 2 to 4 days of fever and malaise, pruritus, paresthesia or hyperesthesia, and severe, deep pain from cutaneous nerve involvement develop on the trunk or the arms and legs in a dermatome distribution. Up to 2 weeks after initial symptoms, red, nodular skin eruptions appear on the painful areas and become vesicular. About 10 days later, the vesicles rupture and form scabs.

Hodgkin’s disease

This disease, which is most common in young adults, occasionally causes severe and unexplained itching. As the disease progresses, pruritus may become severe and unresponsive to treatment. Early nonspecific findings include persistent fever (occasionally, cyclic fever and chills), night sweats, fatigue, weight loss, malaise, and painless swelling of a cervical lymph node. Other lymph nodes may enlarge rapidly and cause pain, or they may enlarge slowly and be painless. Later findings include retroperitoneal node enlargement, hepatomegaly, splenomegaly, dyspnea, dysphagia, dry cough, hyperpigmentation, jaundice, and pallor.

Leukemia (chronic lymphocytic)

Pruritus is an uncommon finding in this disorder. More characteristic signs and symptoms include fatigue, malaise, generalized lymphadenopathy, fever, hepatomegaly, splenomegaly, weight loss, pallor, bleeding, and palpitations.

Lichen planus

This uncommon skin disease can cause moderate to severe pruritus that’s aggravated by stress. Characteristic oral lesions (white or gray, velvety, lacy, threadlike papules) develop on the buccal mucosa and may cause pain. Violet papules with white lines or spots develop later, usually on the genitalia, lower back, ankles, and shins. Nail distortion and atrophic alopecia may also occur.

Lichen simplex chronicus

Persistent rubbing and scratching cause localized pruritus and a circumscribed scaling patch with sharp margins. Later, the skin thickens and papules form.

Mastocytosis

With this disorder, reddish brown macules or papules (urticaria pigmentosa), along with patchy erythema and telangiectasia occur. Other signs and symptoms include pruritus, flushing, tachycardia, hypotension, and nausea.

Multiple myeloma

Infrequently, this disorder produces pruritus. Other findings include severe, constant back pain that increases with exercise; achiness; joint swelling and tenderness; fever; malaise; slight peripheral neuropathy; and purpura.

Mycosis fungoides

Pruritus may precede other symptoms of this neoplastic disease by 10 years. It may persist into the first, or premycotic, stage, accompanied by erythematous lesions.

Myringitis (chronic)

This disorder produces pruritus in the affected ear, along with a purulent discharge and gradual hearing loss.

Pediculosis

With pediculosis pubis (pubic lice), scratching commonly produces skin irritation. Nits or adult lice and erythematous, itching papules may appear in pubic hair or hair around the anus, abdomen, or thighs.

Pityriasis rosea

This disorder occasionally produces mild pruritus that’s aggravated by a hot bath or shower. It usually begins with an erythematous herald patch—a slightly raised, oval lesion about 2 to 6 cm in diameter. After a few days or weeks, scaly yellow-tan or erythematous patches erupt on the trunk and extremities and persist for 2 to 6 weeks. Occasionally, these patches are macular, vesicular, or urticarial.

Polycythemia vera

This hematologic disorder can produce pruritus that’s generalized or localized to the head, neck, face, and extremities. The itching is typically aggravated by a hot bath or shower and can last from a few minutes to an hour. The patient’s oral mucosa may be deep purplish red, especially on the gingivae and tongue. His engorged gingivae ooze blood with even slight trauma.

Related findings include headache, dizziness, fatigue, dyspnea, paresthesia, impaired mentation, tinnitus, double or blurred vision, scotoma, hypotension, intermittent claudication, urticaria, ruddy cyanosis, and ecchymosis. GI effects include gastric distress, weight loss, and hepatosplenomegaly.

Psoriasis

Psychogenic pruritus

Localized or generalized pruritus occurs without symptoms of dermatologic or systemic disease. Anxiety or emotional lability may be evident.

Renal failure (chronic)

Pruritus may develop gradually or suddenly with this disorder. It may be accompanied by ammonia breath odor, oliguria or anuria, lassitude, fatigue, irritability, decreased mental acuity, convulsions, coarse muscular twitching, muscle cramps, peripheral neuropathies, and coma. Renal failure also causes diverse GI signs and symptoms, such as anorexia, constipation or diarrhea, nausea, and vomiting.

Scabies

Typically, scabies causes localized pruritus that awakens the patient. It may become generalized and persist up to 2 weeks after treatment. Threadlike lesions several millimeters long appear with a swollen nodule or red papule.

Gender Cue: In males, crusty lesions may form on the glans penis, penile shaft, and scrotum. In females, lesions may also be found on or around nipples. In both sexes the lesions have a predilection for skin folds. Crusty excoriated lesions form on the wrists, elbows, axillae, waistline, behind the knees and ankles. Excoriation from scratching is common.

Thyrotoxicosis

Generalized pruritus may precede or accompany the characteristic signs and symptoms of this disorder: tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos.

Tinea pedis

This fungal infection causes severe foot pruritus, pain with walking, scales and blisters between the toes, and a dry, scaly squamous inflammation on the entire sole.

Urticaria

Extreme pruritus and stinging occur as transient erythematous or whitish wheals form on the skin or mucous membranes. Prickly sensations typically precede the wheals, which may affect any part of the body and may range from pinpoint to palm-sized or larger.

Vaginitis

This disorder commonly causes localized pruritus and foul-smelling vaginal discharge that may be purulent, white or gray, and curdlike. Perineal pain and urinary dysfunction may also occur.

Other causes

Bedbug bites

Typically, bedbug bites produce itching and burning over the ankles and lower legs, along with clusters of purpuric spots.

Drug hypersensitivity

Herb alert Ingestion of fruit pulp from the ginkgo tree can cause rapid formation of vesicles, resulting in severe itching.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin, mottled: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acrocyanosis

With this rare disorder, anxiety or exposure to cold can cause vasospasm in small cutaneous arterioles. This results in persistent symmetrical blue and red mottling of the affected hands, feet, and nose.

Arterial occlusion (acute)

Initial signs include temperature and color changes. Pallor may change to blotchy cyanosis and livedo reticularis. Color and temperature demarcation develop at the level of obstruction. Other effects include sudden onset of pain in the extremity and possibly paresthesia, paresis, and a sensation of cold in the affected area. Examination reveals diminished or absent pulses, cool extremities, increased capillary refill time, pallor, and diminished reflexes.

Arteriosclerosis obliterans

Atherosclerotic buildup narrows intra-arterial lumina, resulting in reduced blood flow through the affected artery. Obstructed blood flow to the extremities (most commonly the lower) produces such peripheral signs and symptoms as leg pallor, cyanosis, blotchy erythema, and livedo reticularis. Related findings include intermittent claudication (most common symptom), diminished or absent pedal pulses, and leg coolness. Other symptoms include coldness and paresthesia.

Buerger’s disease

This form of vasculitis produces unilateral or asymmetrical color changes and mottling, particularly livedo networking in the lower extremities. It also typically causes intermittent claudication and erythema along extremity blood vessels. During exposure to cold, the feet are cold, cyanotic, and numb; later they’re hot, red, and tingling. Other findings include impaired peripheral pulses and peripheral neuropathy. Buerger’s disease is typically exacerbated by smoking.

Cryoglobulinemia

This necrotizing disorder causes patchy livedo reticularis, petechiae, and ecchymoses. Other findings include fever, chills, urticaria, melena, skin ulcers, epistaxis, Raynaud’s phenomenon, eye hemorrhages, hematuria, and gangrene.

Hypovolemic shock

Vasoconstriction from shock commonly produces skin mottling, initially in the knees and elbows. As shock worsens, mottling becomes generalized. Early signs include sudden onset of pallor, cool skin, restlessness, thirst, tachypnea, and slight tachycardia. As shock progresses, associated findings include cool, clammy skin; rapid, thready pulse; hypotension; narrowed pulse pressure; decreased urine output; subnormal temperature; confusion; and decreased level of consciousness.

Livedo reticularis (idiopathic or primary)

Periarteritis nodosa

Skin findings include asymmetrical, patchy livedo reticularis, palpable nodules along the path of medium-sized arteries, erythema, purpura, muscle wasting, ulcers, gangrene, peripheral neuropathy, fever, weight loss, and malaise.

Polycythemia vera

This hematologic disorder produces livedo reticularis, hemangiomas, purpura, rubor, ulcerative nodules, and scleroderma-like lesions. Other symptoms include headache, a vague feeling of fullness in the head, dizziness, vertigo, vision disturbances, dyspnea, and aquagenic pruritus.

Rheumatoid arthritis

This disorder may cause skin mottling. Early nonspecific signs and symptoms progress to joint pain and stiffness with subcutaneous nodules, usually on the elbows.

Systemic lupus erythematosus

This connective tissue disorder can cause livedo reticularis, most commonly on the outer arms. Other signs and symptoms include a butterfly rash, nondeforming joint pain and stiffness, photosensitivity, Raynaud’s phenomenon, patchy alopecia, seizures, fever, anorexia, weight loss, lymphadenopathy, and emotional lability.

Other causes

Immobility

Prolonged immobility may cause bluish mottling, most noticeably in dependent extremities.

Thermal exposure

Prolonged thermal exposure, as from a heating pad or hot water bottle, may cause erythema Ab Igne—a localized, reticulated, brown-to-red mottling.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Butterfly rash: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Discoid lupus erythematosus

Discoid lupus erythematosus is a localized form of lupus erythematosus characterized by a rash on one or both sides of the face that consists of erythematous, raised, sharply demarcated plaques with follicular plugging and central atrophy. The rash may also involve the scalp, ears, chest, and any part of the body exposed to the sun. Telangiectasia, scarring alopecia, and hypopigmentation or hyperpigmentation may occur later. Other accompanying signs include conjunctival redness, dilated capillaries of the nail fold, bilateral parotid gland enlargement, oral lesions, and mottled, reddish blue skin on the legs.

Erysipelas

Erysipelas causes rosy or crimson swollen lesions, mainly on the neck and head and commonly along the nasolabial fold. It may cause hemorrhagic pus-filled blisters. Other signs and symptoms include fever, chills, cervical lymphadenopathy, and malaise.

Polymorphous light eruption

A butterfly rash appears as erythema, vesicles, plaques, and multiple small papules that may later become eczematized, lichenified, and excoriated. Provoked by ultraviolet rays, the rash appears on the cheeks and bridge of the nose, the hands and arms, and other areas, beginning a few hours to several days after exposure. It may be accompanied by pruritus.

Rosacea

Initially, the rash may appear as a prominent, nonscaling, intermittent erythema limited to the lower half of the nose or including the chin, cheeks, and central forehead. As rosacea develops, the duration of the rash increases; instead of disappearing after each episode, the rash varies in intensity and is commonly accompanied by telangiectasia. In advanced rosacea, the skin is oily, with papules, pustules, nodules, and telangiectasia restricted to the central oval of the face. In men with severe rosacea, the butterfly rash may be accompanied by rhinophyma—a thickened, lobulated overgrowth of sebaceous glands and epithelial connective tissue on the lower half of the nose and, possibly, the adjacent cheeks. This is more common in elderly patients.

Seborrheic dermatitis

In this disorder, greasy, scaling, slightly yellow macules and papules of varying size appear on the cheeks and the bridge of the nose in a butterfly pattern. The scalp, beard, eyebrows, portions of the forehead above the bridge of the nose, nasolabial fold, or trunk may also be involved. Associated signs and symptoms include crusts and fissures (particularly when the external ear and scalp are involved), pruritus, redness, blepharitis, styes, severe acne, and oily skin. Severe seborrheic dermatitis of the face occurs in acquired immunodeficiency syndrome.

Systemic lupus erythematosus (SLE)

Occurring in about 40% of patients with SLE—a connective tissue disorder—a butterfly rash appears as a red, often scaly, sharply demarcated macular eruption. The rash may be transient in patients with acute SLE or may progress slowly to include the forehead, chin, the area around the ears, and other exposed areas. Common associated skin findings include scaling, patchy alopecia, mucous membrane lesions, mottled erythema of the palms and fingers, periungual erythema with edema, reddish purple macular lesions on the volar surfaces of the fingers, telangiectasia of the base of the nails or eyelids, purpura, petechiae, and ecchymoses.

The rash may be accompanied by joint pain, stiffness, and deformities, particularly ulnar deviation of the fingers and subluxation of the proximal interphalangeal joints. Related findings include periorbital and facial edema, dyspnea, low-grade fever, malaise, weakness, fatigue, weight loss, anorexia, nausea, vomiting, lymphadenopathy, photosensitivity, and hepatosplenomegaly.

Other causes

Drugs

Hydralazine and procainamide can cause a lupuslike syndrome.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Café-au-lait spots: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Albright’s syndrome

In Albright’s syndrome, café-au-lait spots are smaller (about ⅜” [1 cm] in diameter) and more irregularly shaped than those in neurofibromatosis. They may stop abruptly at the midline and seem to follow a dermatomal distribution. Usually, fewer than six spots appear, unilaterally on the forehead, neck, and lower back. When they occur on the scalp, the hair overlying them may be more deeply pigmented. Associated signs include skeletal deformities, frequent fractures and, in females, sexual precocity.

Neurofibromatosis

The most common cause of café-au-lait spots, this disorder (also called von Recklinghausen’s disease) is characterized by six or more large, smooth-bordered spots up to ¼” (6.4 mm) in diameter in prepubertal children and more than ⅝” (15 mm) in diameter in postpubertal children. Associated signs include axillary and inguinal freckling; irregular, hyperpigmented, and mottled skin; and multiple skin-colored pedunculated nodules clustered along nerve sheaths. The nodules develop during childhood, growing larger than ¼”. They proliferate throughout life, affecting all body tissues and causing marked deformity. They grow to ⅝” or larger in adults. Mental impairment, seizures, hearing loss, exophthalmos, decreased visual acuity, and GI bleeding can eventually occur.

Tuberous sclerosis

Mental retardation and seizures characteristically appear first, followed several years later by cutaneous facial lesions—multiple café-au-lait spots, spherical areas of rough skin, and areas of yellow-red or depigmented nevi.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vesicular rash: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Burns (second-degree)

Thermal burns that affect the epidermis and part of the dermis cause vesicles and bullae along with erythema, swelling, pain, and moistness.

Dermatitis

In contact dermatitis, a hypersensitivity reaction produces an eruption of small vesicles surrounded by redness and marked edema. The vesicles may ooze, scale, and cause severe pruritus.

Dermatitis herpetiformis, a skin disease that is most common in men between ages 20 and 50 (and is occasionally associated with celiac disease, organ malignancy, or immunoglobulin A immunotherapy), produces a chronic inflammatory eruption marked by vesicular, papular, bullous, pustular, or erythematous lesions. The rash is usually distributed symmetrically on the buttocks, shoulders, and extensor surfaces of the elbows and knees, but it may sometimes appear on the face, scalp, and neck. Other symptoms include severe pruritus, burning, and stinging.

In nummular dermatitis, groups of pinpoint vesicles and papules appear on erythematous or pustular lesions that are nummular (coinlike) or annular (ringlike). The pustular lesions commonly ooze a purulent exudate, itch severely, and rapidly become crusted and scaly. Two or three lesions may develop on the hands, but the lesions typically develop on the extensor surfaces of the limbs and on the buttocks and posterior trunk.

Dermatophytid

This allergic reaction to a fungal infection produces vesicular lesions on the hands, usually in response to tinea pedis. The lesions are extremely pruritic and tender and may be accompanied by fever, anorexia, generalized adenopathy, and splenomegaly.

Erythema multiforme

This acute inflammatory skin disease is heralded by a sudden eruption of erythematous macules, papules and, occasionally, vesicles and bullae. The characteristic rash appears symmetrically over the hands, arms, feet, legs, face, and neck and tends to reappear. Although vesicles and bullae may also erupt on the eyes and genitalia, vesiculobullous lesions usually appear on the mucous membranes—especially the lips and buccal mucosa—where they rupture and ulcerate, producing a thick, yellow or white exudate. Bloody, painful crusts, a foul-smelling oral discharge, and difficulty chewing may develop. Lymphadenopathy may also occur.

Herpes simplex

This common viral infection produces groups of vesicles on an inflamed base, most commonly on the lips and lower face. In about 25% of cases, the genital region is involved. Vesicles are preceded by itching, tingling, burning, or pain; develop singly or in groups; are 2 to 3 mm in diameter; and don’t coalesce. Eventually, they rupture, forming a painful ulcer followed by a yellowish crust.

Herpes zoster

A vesicular rash is preceded by erythema and, occasionally, by a nodular skin eruption and unilateral, sharp pain along a dermatome. About 5 days later, the lesions erupt and the pain becomes burning. Vesicles dry and scab about 10 days after eruption. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the involved area. Herpes zoster involving the cranial nerves produces facial palsy, hearing loss, dizziness, loss of taste, eye pain, and impaired vision.

Pemphigoid (bullous)

Generalized pruritus or an urticarial or eczematous eruption may precede the classic bullous rash. Bullae are large, thick walled, tense, and irregular, typically forming on an erythematous base. They usually appear on the lower abdomen, groin, inner thighs, and forearms.

Pemphigus

In chronic familial pemphigus, groups of tiny vesicles erupt on normal skin or mucous membranes. The vesicles are thin walled, flaccid, and easily broken, producing small denuded areas that become covered with crust and typically itch and burn. The eruption remits spontaneously but recurs.

Pemphigus foliaceus usually develops slowly and may begin with bullous lesions, commonly on the head and trunk. As these lesions spread to other areas, they become moist, scaly, and foul smelling. Nikolsky’s sign is present, and denudation of lesions results in extensive erythema, with large, loose scales and crusts. Pruritus and burning are common.

Pemphigus vulgaris may be acute and rapidly progressive or chronic. The typically flaccid bullae may be tender or painful and large or small. When they rupture, denuded skin exudes a clear, bloody, or purulent discharge. Commonly, the bullae first erupt in a specific location, such as the mouth or scalp, and eventually become widespread. Nikolsky’s sign and pruritus may be present.

Pompholyx (dyshidrosis or dyshidrotic eczema)

This common, recurrent disorder produces symmetrical vesicular lesions that can become pustular. The pruritic lesions are more common on the palms than on the soles and may be accompanied by minimal erythema.

Porphyria cutanea tarda

This disorder, resulting from abnormal porphyrin metabolism, produces bullae—especially on areas exposed to sun, friction, trauma, or heat—and photosensitivity. Papulovesicular lesions may evolve into erosions or ulcers and scars. Chronic skin changes include hyperpigmentation or hypopigmentation, hypertrichosis, and sclerodermoid lesions. Urine is pink to brown.

Scabies

In this disorder, mites that burrow under the skin cause small vesicles to erupt on the webs of the fingers, wrists, elbows, axillae, and waistline; the glans, shaft, and scrotum in males; and the nipples in females. The lesions are a few millimeters long, with a swollen nodule or red papule that contains the mite. Pustules and excoriations may also occur. Associated pruritus worsens at night and with inactivity and warmth.

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, which later separates from the skin leaving a pitted scar. Death may result from encephalitis, extensive bleeding, or secondary infection.

Tinea pedis

This fungal infection causes vesicles and scaling between the toes and possibly scaling over the entire sole. Severe infection causes inflammation, pruritus, and difficulty walking.

Toxic epidermal necrolysis

In this immune reaction to drugs or other toxins, vesicles and bullae are preceded by a diffuse, erythematous rash and followed by large-scale epidermal necrolysis and desquamation. Large, flaccid bullae develop after mucous membrane inflammation, a burning sensation in the conjunctivae, malaise, fever, and generalized skin tenderness. The bullae rupture easily, exposing extensive areas of denuded skin. (See Drugs that cause toxic epidermal necrolysis.)

Other causes

Insect bites

Vesicles appear on red hivelike papules and may become hemorrhagic.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin turgor, decreased: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Cholera

This infection is characterized by abrupt watery diarrhea and vomiting, which leads to severe water and electrolyte loss. These imbalances cause the following symptoms: decreased skin turgor, thirst, weakness, muscle cramps, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Dehydration

Decreased skin turgor commonly occurs with moderate to severe dehydration. Associated findings include dry oral mucosa, decreased perspiration, resting tachycardia, orthostatic hypotension, dry and furrowed tongue, increased thirst, weight loss, oliguria, fever, and fatigue. As dehydration worsens, other findings include enophthalmos, lethargy, weakness, confusion, delirium or obtundation, anuria, and shock. Hypotension persists even when the patient lies down.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin, bronze: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Adrenal hyperplasia

The skin assumes a dark bronze tone within a few months. Other findings include visual field deficits and headache (from an expanding pituitary lesion), and signs of masculinization in females.

Biliary cirrhosis

This disorder causes bronze skin from melanosis of exposed areas of jaundiced skin: eyelids, palms, neck, and chest or back. The patient may also experience generalized pruritus, weakness, fatigue, jaundice, dark urine, pale stools with steatorrhea, decreased appetite with weight loss, and hepatomegaly.

Chronic renal failure

The skin becomes pallid, yellowish bronze, dry, and scaly. Other findings include ammonia breath odor, oliguria, fatigue, decreased mental acuity, seizures, muscle cramps, peripheral neuropathy, bleeding tendencies, pruritus and, occasionally, uremic frost and hypertension.

Hemochromatosis

An early sign is progressive, generalized bronzing accentuated by metallic gray-bronze skin on sun-exposed areas, genitalia, and scars. Mucous membranes are affected less often. Early associated effects include weakness, lethargy, weight loss, abdominal pain, loss of libido, polydipsia, and polyuria.

Malnutrition

As weight loss depletes body nutrients, bronzing develops along with apathy, lethargy, anorexia, weakness, and slow pulse and respiratory rates. Patients may develop paresthesia in the extremities; dull, sparse, dry hair; brittle nails; dark, swollen cheeks; dry, flaky skin; red, swollen lips; muscle wasting; and gonadal atrophy in males.

Primary adrenal insufficiency

Bronze skin is a classic sign. Other findings include axillary and pubic hair loss, vitiligo, progressive fatigue, weakness, anorexia, nausea and vomiting, weight loss, orthostatic hypotension, weak and irregular pulse, abdominal pain, irritability, diarrhea or constipation, amenorrhea, and syncope.

Wilson’s disease

Kayser-Fleischer rings—rusty brown rings of pigment around the corneas—characterize this disease, which may cause skin bronzing. Other effects include incoordination, dysarthria, chorea, ataxia, muscle spasms and rigidity, abdominal distress, fatigue, personality changes, hypotension, syncope, and seizures.

Other causes

Drugs

Prolonged therapy with high doses of a phenothiazine may cause gradual bronzing of the skin.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin, clammy: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anxiety

An acute anxiety attack commonly produces cold, clammy skin on the forehead, palms, and soles. Other features include pallor, dry mouth, tachycardia or bradycardia, palpitations, and hypertension or hypotension. The patient may also develop tremors, breathlessness, headache, muscle tension, nausea, vomiting, abdominal distention, diarrhea, increased urination, and sharp chest pain.

Arrhythmias

Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.

Cardiogenic shock

Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.

Heat exhaustion

In the acute stage of heat exhaustion, generalized cold, clammy skin accompanies an ashen appearance, headache, confusion, syncope, giddiness and, possibly, a subnormal temperature, with mild heat exhaustion. The patient may exhibit a rapid and thready pulse, nausea, vomiting, tachypnea, oliguria, thirst, muscle cramps, and hypotension.

Hypoglycemia (acute)

Generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.

Hypovolemic shock

With this common form of shock, generalized pale, cold, clammy skin accompanies subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and rapid, thready pulse. Other findings are flat neck veins, increased capillary refill time, decreased urine output, confusion, and decreased level of consciousness.

Septic shock

The cold shock stage causes generalized cold, clammy skin. Associated findings include rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin, scaly: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Bowen’s disease

This common form of intraepidermal carcinoma causes painless, erythematous plaques that are raised and indurated with a thick, hyperkeratotic scale and, possibly, ulcerated centers.

Dermatitis

Exfoliative dermatitis begins with rapidly developing generalized erythema. Desquamation with fine scales or thick sheets of all or most of the skin surface may cause life-threatening hypothermia. Other possible complications include cardiac output failure and septicemia. Systemic signs and symptoms include low-grade fever, chills, malaise, lymphadenopathy, and gynecomastia.

Dermatophytosis

Discoid lupus erythematosus

This cutaneous form of lupus may occur without systemic signs and symptoms. Separate or coalescing lesions (macules, papules, or plaques), ranging from pink to purple, are covered with a yellow or brown crust. Enlarged hair follicles are filled with scales, and telangiectasia may be present. After this inflammatory stage, the lesions heal and hypopigmentation or hyperpigmentation and noncontractile scarring and atrophy may occur. Discoid lupus commonly involves the face or sun-exposed areas of the neck, ears, scalp, lips, and oral mucosa. Alopecia may also occur.

Lichen planus

With this disorder, small, flat, violet lesions with a fine scale and gray lines on the surface usually affect the lumbar region, genitalia, wrists, ankles, and anterior lower legs.

Lymphoma

Hodgkin’s disease and non-Hodgkin’s lymphoma commonly cause scaly rashes. Hodgkin’s disease may cause pruritic scaling dermatitis that begins in the legs and spreads to the entire body. Remissions and recurrences are common. Small nodules and diffuse pigmentation are related signs. This disease typically produces painless enlargement of the peripheral lymph nodes. Other signs and symptoms include fever, fatigue, weight loss, malaise, and hepatosplenomegaly.

Parapsoriasis (chronic)

This disorder produces small or moderate-sized maculopapular, erythematous eruption, with a thin, adherent scale on the trunk, hands, and feet. Removal of the scale reveals a shiny brown surface.

Pityriasis

Psoriasis

Syphilis (secondary)

Papulosquamous, slightly scaly eruptions characterize this disorder. A ring-shaped pattern of copper-red papules usually forms on the face, arms, palms, soles, chest, back, and abdomen. Annular papules may occur. Systemic findings include lymphadenopathy, malaise, weight loss, anorexia, nausea, vomiting, headache, sore throat, and low-grade fever.

Systemic lupus erythematosus

This disorder produces a bright-red maculopapular eruption, sometimes with scaling. Patches are sharply defined and involve the nose and malar regions of the face in a butterfly pattern—a primary sign. Similar characteristic rashes appear on other body surfaces; scaling occurs along the lower lip or anterior hair line. Other primary signs and symptoms include photosensitivity and joint pain and stiffness. Vasculitis (leading to infarctive lesions, necrotic leg ulcers, or digital gangrene), Raynaud’s phenomenon, patchy alopecia, and mucous membrane ulcers also can occur.

Tinea versicolor

This benign fungal skin infection typically produces macular hypopigmented, fawn-colored, or brown patches of varying sizes and shapes. All are slightly scaly. Lesions commonly affect the upper trunk, arms, and lower abdomen, sometimes the neck and, rarely, the face.

Other causes

Drugs

Many drugs—including penicillins, sulfonamides, barbiturates, quinidine, diazepam, phenytoin, and isoniazid—can produce scaling patches.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Scaling Rash: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Eczema

❑ Atopic dermatitis

❑ Seborrheic dermatitis

❑ Tinea versicolor

❑ Pityriasis rosea

❑ Psoriasis

❑ Contact dermatitis

❑ Tinea corporis

❑ Tinea manuum

❑ Stasis dermatitis

❑ Drugs

❑ Lichen planus

❑ Secondary syphilis

❑ Reiter

❑ Bowen disease

❑ Cutaneous T-cell lymphoma

Clinical Findings

Eczema Red, poorly defined patches appear on the neck and flexor surfaces and thicken with excoriations caused by excessive scratching. Coinlike (num-mular) lesions are common on the lower legs.

Atopic dermatitis Pruritus/scratching lead to eczematous lesions. A personal or family history of atopy (asthma, allergic rhinitis) is elicited. An extra fold of skin below the lower eyelid is a common finding.

Seborrheic dermatitis Pink-red scaly patches with an indistinct outline develop in the scalp, eyebrows, nasolabial crease, behind the ears, in the ear canal, over the sternum, and in intertriginous areas. New-onset severe seborrheic dermatitis may be the first sign of HIV infection.

Tinea versicolor A finely scaled macular eruption appears over the trunk. Hypopigmented macules may occur on dark skin; hyperpigmented macules occur on light skin.

Pityriasis rosea Salmon-pink oval lesions have their long axis following the cleavage lines of the skin. Lesions have a collarette of fine scale around the perimeter. They are distributed on the trunk and proximal extremities, sparing the palms (involved in secondary syphilis). There is usually a herald patch, which is the initial and largest lesion.

Psoriasis Pink-red sharply demarcated plaques have a silvery micaceous scale. They occur on the elbows, knees, scalp, and gluteal crease. There is often nail dystrophy with pitting, onycholysis, and yellow discoloration. Guttate psoriasis—a widespread eruption of small, scaling lesions—may be brought on by streptococcal infection, lithium, beta-blockers, rapid steroid taper, or acute HIV infection. It spares the face, palms, and soles.

Contact dermatitis Well-demarcated lesions develop in areas of thin, exposed skin. Lesions are in a localized distribution, reflecting the contact exposure. Common precipitants include poison ivy, nickel jewelry, formaldehyde (in clothing and nail polish), fragrances, perservatives, topical antibiotic cream, rubber, and tanning chemicals. Latex exposure can cause type I hypersensitivity reactions in addition to allergic contact dermatitis.

Tinea corporis Red annular lesions have an active scaling border with central clearing. The inner thigh is a typical location.

Tinea manuum One hand is gray-red with scaling within the palmar creases, associated with scaling and nail dystrophy on both feet.

Stasis dermatitis The lower extremities are edematous, red, and scaling. A brownish discoloration develops due to hemosiderin; it occurs especially over the medial ankle.

Drugs Pityriasis rosea-like lesions may be seen with beta-blockers, captopril, clonidine, gold, griseofulvin, isotretinoin, metronidazole, and penicillin. Lichenoid eruptions can be produced by gold, antimalarials, thiazides, quinidine, phenothiazines, sulfonylureas, furosemide, methyldopa, griseofulvin, beta-blockers, and captopril.

Lichen planus Lesions appear as violet-colored, polygonal, and flat-topped papules, traversed by a network of thin gray-white lines (Wickham striae). They occur in the flexor aspects of the wrists, ankles, and glans penis. The oral mucosa also has lacy white plaques or erosions. The plaques are only scaly on the legs.

Secondary syphilis Scattered red-brown papules with thin scale often involve the palms or soles. Associated findings that assist diagnosis are systemic symptoms such as fever, malaise, and lymphadenopathy; recent (4 to 8 weeks previously) chancre; annular plaques on the face; alopecia; or broad-based and moist condyloma lata.

Reiter Psoriasiform lesions occur in a patient with arthritis, urethritis, and/or uveitis.

Bowen disease A single, well-demarcated plaque with variable scale develops in a patient with a known history of arsenic exposure, or exposure manifest as palmar hyperkeratosis.

Cutaneous T-cell lymphoma Retiform (net-like) psoriatic lesions appear without the typical distribution, with an increase in palpability, and do not respond to topical steroids. The earliest lesions are macular, scaly, and red, admixed with yellow (poikiloderma).

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Source: Field Guide to Bedside Diagnosis, 2007

Staphylococcal scalded skin syndrome: Causes
(Handbook of Diseases)

The causative organism in SSSS is Group 2 Staphylococcus aureus, primarily phage type 71. Predisposing factors may include impaired immunity and renal insufficiency — present to some extent in the normal neonate because of immature development of these systems.

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Source: Handbook of Diseases, 2003

Skin, mottled: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Acrocyanosis

. With acrocyanosis, a rare disorder, anxiety or exposure to cold can cause vasospasm in small cutaneous arterioles. This results in persistent symmetrical blue and red mottling of the affected hands, feet, and nose.

Arterial occlusion (acute)

Initial signs include temperature and color changes. Pallor may change to blotchy cyanosis and livedo reticularis. Color and temperature demarcation develop at the level of the obstruction. Other effects include a sudden onset of pain in the extremity and possibly paresthesia, paresis, and a sensation of cold in the affected area. Examination reveals diminished or absent pulses, cool extremities, increased capillary refill time, pallor, and diminished reflexes.

Arteriosclerosis obliterans

Atherosclerotic buildup narrows intra-arterial lumina, resulting in reduced blood flow through the affected artery. Obstructed blood flow to the extremities (most commonly the lower) produces such peripheral signs and symptoms as leg pallor, cyanosis, blotchy erythema, and livedo reticularis. Related findings include intermittent claudication (most common symptom), diminished or absent pedal pulses, and leg coolness. Other symptoms include coldness and paresthesia.

Buerger’s disease

A form of vasculitis, Buerger’s disease produces unilateral or asymmetrical color changes and mottling, particularly livedo networking in the lower extremities. It also typically causes intermittent claudication and erythema along extremity blood vessels. During exposure to cold, the feet are cold, cyanotic, and numb; later, they’re hot, red, and tingling. Other findings include impaired peripheral pulses and peripheral neuropathy. Buerger’s disease is typically exacerbated by smoking.

Cryoglobulinemia

A necrotizing disorder, cryoglobulinemia causes patchy livedo reticularis, petechiae, and ecchymoses. Other findings include fever, chills, urticaria, melena, skin ulcers, epistaxis, Raynaud’s phenomenon, eye hemorrhage, hematuria, and gangrene.

Hypovolemic shock

Vasoconstriction from shock commonly produces skin mottling, initially in the knees and elbows. As shock worsens, mottling becomes generalized. Early signs include a sudden onset of pallor, cool skin, restlessness, thirst, tachypnea, and slight tachycardia. As shock progresses, associated findings include cool, clammy skin as well as a rapid, thready pulse accompanied by hypotension, narrowed pulse pressure, decreased urine output, subnormal temperature, confusion, and a decreased level of consciousness.

Livedo reticularis (idiopathic or primary)

Periarteritis nodosa

Polycythemia vera

A hematologic disorder, polycythemia vera produces livedo reticularis, hemangiomas, purpura, rubor, ulcerative nodules, and scleroderma-like lesions. Other symptoms include headache, a vague feeling of fullness in the head, dizziness, vertigo, vision disturbances, dyspnea, aquagenic pruritus, and night sweats.

Rheumatoid arthritis (RA)

RA may cause skin mottling. Early nonspecific signs and symptoms progress to joint pain and stiffness with subcutaneous nodules, usually on the elbows.

Systemic lupus erythematosus (SLE)

A connective tissue disorder, SLE can cause livedo reticularis, most commonly on the outer arms. Other signs and symptoms include a butterfly rash, nondeforming joint pain and stiffness, photosensitivity, Raynaud’s phenomenon, patchy alopecia, seizures, fever, anorexia, weight loss, lymphadenopathy, and emotional lability.

Other causes

Immobility

Prolonged immobility may cause bluish mottling, most noticeably in dependent extremities.

Thermal exposure

Prolonged thermal exposure, such as from a heating pad or hot water bottle, may cause erythema ab igne —a localized, reticulated, brown-to-red mottling.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Skin, clammy: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Anxiety

Arrhythmias

Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.

Cardiogenic shock

Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.

Heat exhaustion

Hypoglycemia (acute)

Hypovolemic shock

With this common form of shock, generalized pale, cold, clammy skin accompanies subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and a rapid, thready pulse. Other findings are flat neck veins, increased capillary refill time, decreased urine output, confusion, and a decreased level of consciousness.

Septic shock

The cold shock stage causes generalized cold, clammy skin. Associated findings include a rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Papular rash: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

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

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

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

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

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.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Pustular rash: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Acne vulgaris

Pustules typify inflammatory lesions of acne vulgaris and are accompanied by papules, nodules, cysts, open comedones (blackheads) and closed comedones (whiteheads). Lesions commonly appear on the face, shoulders, back, and chest. Other findings include pain on pressure, pruritus, and burning. Chronic recurrent lesions produce scars.

Blastomycosis

Blastomycosis, a fungal infection, produces small, painless, nonpruritic macules or papules that can enlarge to well-circumscribed, verrucous, crusted, or ulcerated lesions edged by pustules. Localized infection may cause only one lesion; systemic infection may cause many lesions on the hands, feet, face, and wrists. Blastomycosis also produces signs of pulmonary infection, such as pleuritic chest pain and a dry, hacking or productive cough with occasional hemoptysis.

CULTURAL CUE:Blastomycosis is generally found in North America (where the fungus Blastomyces dermatitidis inhabits the soil) and is endemic to the southeastern United States. Sporadic cases have also been reported in Africa.

Folliculitis

This bacterial infection of hair follicles produces individual pustules, each pierced by a hair and possibly accompanied by pruritus. Folliculitis might progress to the hard painful nodules of furunculosis. “Hot tub” folliculitis produces pustules on areas covered by a bathing suit.

Furunculosis

A furuncle is an acute, deep-seated, red, hot, tender abscess that evolves from a staphylococcus folliculitis. Furuncles usually begin as small, tender red pustules at the base of hair follicles. They’re likely to occur on the face, neck, forearm, groin, axillae, buttocks, and legs — areas that are prone to repeated friction. The pustules usually remain tense for 2 to 4 days and then become fluctuant. Rupture discharges pus and necrotic material. Then pain subsides, but erythema and edema may persist.

Gonococcemia

Gonococcemia produces a rash of scanty, pinpoint erythematous macules that rapidly become vesiculopustular, maculopapular and, frequently, hemorrhagic. Bullae may form. Mature lesions are elevated, with dirty gray necrotic centers and surrounding erythema. The rash appears on the distal part of the arms and legs, usually during the 1st day that other findings, such as fever and joint pain, occur. The rash disappears after 3 to 4 days but may recur with each episode of fever.

Impetigo contagiosa

Impetigo contagiosa is a vesiculopustular eruptive disorder, which occurs in nonbullous and bullous forms, that’s usually caused by streptococci or staphylococci. Vesicles form and break, and a crust forms from the exudate: a thick, yellow crust in streptococcal impetigo and a thin, clear crust in staphylococcal impetigo. Both forms usually produce painless itching.

Nummular or annular dermatitis

With nummular or annular dermatitis, numerous coinlike (nummular) or ringed (annular) pustular lesions appear, usually on the extensor surfaces of the extremities, posterior trunk, buttocks, and lower legs; a few lesions may appear on the hands. The lesions commonly ooze a purulent exudate, itch severely, and rapidly become crusted and scaly. A few small, scaling patches may remain for some time.

Pustular miliaria

Pustular miliaria, an anhidrotic disorder, causes pustular lesions that begin as tiny erythematous papulovesicles located at sweat pores. Diffuse erythema may radiate from the lesion. The rash and associated burning and pruritus worsen with sweating.

Rosacea

Scabies

Threadlike channels or burrows under the skin characterize scabies, which can also produce pustules, vesicles, and excoriations. The lesions are a few millimeters long with a swollen nodule or red papule that contains the itch mite.

Smallpox

Initial signs and symptoms of smallpox (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.

Varicella zoster

Other causes

Drugs

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Pruritus: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Anemia (iron deficiency)

Anemia occasionally produces pruritus. Initially asymptomatic, anemia can later cause exertional dyspnea, fatigue, listlessness, pallor, irritability, headache, tachycardia, poor muscle tone and, possibly, murmurs. Chronic anemia causes spoon-shaped (koilonychia) and brittle nails (cheilosis), cracked mouth corners, a smooth tongue (glossitis), and dysphagia.

Anthrax (cutaneous)

A cutaneous anthrax 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.

Conjunctivitis

Dermatitis

Mild irritants and allergies can cause contact dermatitis, with itchy, small vesicles that may ooze and scale and are surrounded by redness. A severe reaction can produce marked localized edema.

Enterobiasis

Also known as pinworm or seatworm, this helminthic infection produces intense perianal pruritus, especially at night, when the female worm leaves the anus to deposit ova. Pruritus causes irritability, scratching, skin irritation and, sometimes, vaginitis.

Hemorrhoids

Hepatobiliary disease

An important diagnostic clue to liver and gallbladder disease, pruritus is commonly accompanied by jaundice and may be generalized or localized to the palms and soles. Other characteristics include right-upper-quadrant pain, clay-colored stools, chills and fever, flatus, belching and a bloated feeling, epigastric burning, and bitter fluid regurgitation. Later, liver disease may produce mental changes, ascites, bleeding tendencies, spider angiomas, palmar erythema, dry skin, fetor hepaticus, enlarged superficial abdominal veins, bilateral gynecomastia, testicular atrophy or menstrual irregularities, and hepatomegaly.

Herpes zoster

In herpes zoster, within 4 days of fever and malaise, pruritus, paresthesia or hyperesthesia, and severe, deep pain from cutaneous nerve involvement develop on the trunk or the arms and legs in a dermatome distribution. Up to 2 weeks after initial symptoms, red, nodular skin eruptions appear on the painful areas and become vesicular. About 10 days later, the vesicles rupture and form scabs.

Hodgkin’s disease

Hodgkin’s disease occasionally causes severe and unexplained itching. As the disease progresses, pruritus may become severe and unresponsive to treatment. Early nonspecific findings include persistent fever (occasionally, cyclic fever and chills), night sweats, fatigue, weight loss, malaise, and painless swelling of a cervical lymph node. Other lymph nodes may enlarge rapidly and cause pain, or they may enlarge slowly and be painless. Later findings include retroperitoneal node enlargement, hepatomegaly, splenomegaly, dyspnea, dysphagia, dry cough, hyperpigmentation, jaundice, and pallor.

Lichen simplex chronicus

Lichen simplex chronicus is due to persistent rubbing and scratching of the skin, causing localized pruritus and a circumscribed scaling patch with sharp margins. Later, the skin thickens and papules form. This condition usually affects areas easily reached, such as ankles, lower legs, anogenital area, back of neck, and ears.

Pediculosis

A prominent symptom of pediculosis, pruritus occurs in the area of infestation. Pediculosis capitis (head lice) may also cause scalp excoriation from scratching, along with matted, foul-smelling, lusterless hair; occipital and cervical lymphadenopathy; and oval, gray-white nits on hair shafts.

Pediculosis corporis (body lice) initially causes small red papules (usually on the shoulders, trunk, or buttocks), which become urticarial from scratching. Later, rashes or wheals may develop. Left untreated, pediculosis corporis produces dry, discolored, thickly encrusted, scaly skin with bacterial infection and scarring. In severe cases, it produces headache, fever, and malaise.

Pityriasis rosea

Pityriasis rosea occasionally produces mild pruritus that’s aggravated by a hot bath or shower. It usually begins with an erythematous herald patch — a slightly raised, oval lesion about 2 to 6 cm in diameter. After a few days or weeks, scaly yellow-tanor erythematous patches erupt on the trunk and extremities and persist for 2 to 6 weeks. Occasionally, these patches are macular, vesicular, or urticarial.

Polycythemia vera

Polycythemia vera, a hematologic disorder, can produce pruritus that’s generalized or localized to the head, neck, face, and extremities. The itching is typically aggravated by a hot bath or shower and can last from a few minutes to an hour. The patient’s oral mucosa may be deep purplish red, especially on the gingivae and tongue. His engorged gingivae ooze blood with even slight trauma.

Psoriasis

Pruritus and pain are common in psoriasis. This skin disorder typically begins with small erythematous papules that enlarge or coalesce to form red, elevated plaques with silver scales on the scalp, chest, elbows, knees, back, buttocks, and genitals. Nail pitting may occur.

Renal failure (chronic)

Pruritus may develop gradually or suddenly with chronic renal failure. It may be accompanied by ammonia breath odor, oliguria or anuria, lassitude, fatigue, irritability, decreased mental acuity, convulsions, coarse muscular twitching, muscle cramps, peripheral neuropathies,and coma. Renal failure also causes diverse GI signs and symptoms, such as anorexia, constipation or diarrhea, nausea, and vomiting.

Scabies

Thyrotoxicosis

Generalized pruritus may precede or accompany the characteristic signs and symptoms of thyrotoxicosis: tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos.

Tinea pedis

Tinea pedis, also called athlete’s foot, is a fungal infection that causes severe foot pruritus, pain with walking, scales and blisters between the toes, and a dry, scaly squamous inflammation on the entire sole. The affected skin may appear red and inflamed.

Urticaria

With urticaria, extreme pruritus and stinging occur as transient erythematous or whitish wheals form on the skin or mucous membranes. Prickly sensations typically precede the wheals, which may affect any part of the body and may range from pinpoint to palm-sized or larger.

Vaginitis

Vaginitis commonly causes localized pruritus and foul-smelling vaginal discharge that may be purulent, white or gray, and curdlike. Perineal pain and urinary symptoms, such as burning and frequency, may also occur.

Other causes

Bedbug bites

Typically, bedbug bites produce itching and burning over the ankles and lower legs, along with clusters of purpuric spots.

Drug hypersensitivity

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, mottled: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Arterial occlusion (acute)

Initial signs of acute arterial occlusion include temperature and color changes. Pallor may change to blotchy cyanosis and livedo reticularis. Color and temperature demarcation develop at the level of obstruction. Other effects include sudden onset of pain in the extremity and possibly paresthesia, paresis, and a sensation of cold in the affected area. Examination reveals diminished or absent pulses, cool extremities, increased capillary refill time, pallor, and diminished reflexes.

Arteriosclerosis obliterans

Atherosclerotic buildup narrows intra-arterial lumina, resulting in reduced blood flow through the affected artery. Obstructed blood flow to the extremities (most commonly the lower) produces such peripheral signs and symptoms as leg pallor, cyanosis, blotchy erythema, and livedo reticularis. Related findings include intermittent claudication (most common symptom), diminished or absent pedal pulses, and leg coolness. Other symptoms include coldness and paresthesia.

Buerger’s disease

Buerger’s disease is a form of vasculitis that produces unilateral or asymmetrical color changes and mottling, particularly livedo networking in the lower extremities. It also typically causes intermittent claudication and erythema along extremity blood vessels. During exposure to cold, the feet are cold, cyanotic, and numb; later they’re hot, red, and tingling. Other findings include impaired peripheral pulses and peripheral neuropathy. Buerger’s disease is typically exacerbated by smoking.

Hypovolemic shock

Vasoconstriction from hypovolemic shock commonly produces skin mottling, initially in the knees and elbows. As shock worsens, mottling becomes generalized. Early signs include sudden onset of pallor, cool skin, restlessness, thirst, tachypnea, and slight tachycardia. As shock progresses, associated findings include cool, clammy skin; rapid, thready pulse; hypotension; narrowed pulse pressure; decreased urine output; subnormal temperature; confusion; and decreased level of consciousness.

Livedo reticularis (idiopathic or primary)

With livedo reticularis, symmetrical, diffuse mottling can involve the hands, feet, arms, legs, buttocks, and trunk. Initially, networking is intermittent and most pronounced on exposure to cold or stress; eventually, mottling persists even with warming.

Polycythemia vera

Polycythemia vera, a hematologic disorder, produces livedo reticularis, hemangiomas, purpura, rubor, ulcerative nodules, and scleroderma-like lesions. Other symptoms include headache, a vague feeling of fullness in the head, dizziness, vertigo, vision disturbances, dyspnea, and aquagenic pruritus.

Rheumatoid arthritis

Rheumatoid arthritis may cause skin mottling. Early nonspecific signs and symptoms progress to joint pain and stiffness with subcutaneous nodules, usually on the elbows. The patient may report morning stiffness.

Systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a connective tissue disorder that can cause livedo reticularis, most commonly on the outer arms. Other signs and symptoms include a butterfly rash, nondeforming joint pain and stiffness, photosensitivity, Raynaud’s phenomenon, patchy alopecia, seizures, fever, anorexia, weight loss, lymphadenopathy, and emotional lability.

Other causes

Immobility

Prolonged immobility may cause bluish mottling, most noticeably in dependent extremities.

Thermal exposure

Prolonged thermal exposure, such as from a heating pad or hot water bottle, may cause erythema Ab Igne — a localized, reticulated, brown-to-red mottling.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Butterfly rash: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Discoid lupus erythematosus

With discoid lupus erythematosus, a localized form of lupus erythematosus, the patient may have a unilateral or butterfly rash that consists of erythematous, raised, sharply demarcated plaques with follicular plugging and central atrophy. The rash may also involve the scalp, ears, chest, or any part of the body exposed to the sun. Telangiectasia, scarring alopecia, and hypopigmentation or hyperpigmentation may occur later. Other accompanying signs include conjunctival redness, dilated capillaries of the nail fold, bilateral parotid gland enlargement, oral lesions, and mottled, reddish blue skin on the legs.

Erysipelas

Occurring primarily in infants and adults older than age 30 following a streptococcal infection, erysipelas causes rosy or crimson swollen lesions, mainly on the neck and head and commonly along the nasolabial fold. It may cause hemorrhagic pus-filled blisters. Other signs and symptoms include fever, chills, cervical lymphadenopathy, and malaise.

Rosacea

Initially, with rosacea, butterfly rash may appear as a prominent, nonscaling, intermittent erythema limited to the lower half of the nose or including the chin, cheeks, and central forehead. As rosacea develops, the duration of the rash increases; instead of disappearing after each episode, the rash varies in intensity and is commonly accompanied by telangiectasia. With advanced rosacea, the skin is oily, with papules, pustules, nodules, and telangiectasis restricted to the central oval of the face. In men with severe rosacea, butterfly rash may be accompanied by rhinophyma — a thickened, lobulated overgrowth of sebaceous glands and epithelial connective tissue on the lower half of the nose and, possibly, the adjacent cheeks. This is more common in elderly patients.

Seborrheic dermatitis

With seborrheic dermatitis, butterfly rash appears as greasy, scaling, slightly yellow macules and papules of varying size on the cheeks and the bridge of the nose, in a “butterfly” pattern. The scalp, beard, eyebrows, portions of the forehead above the bridge of the nose, nasolabial fold, or trunk may also be involved. Associated signs and symptoms include crusts and fissures (particularly when the external ear and scalp are involved), pruritus, redness, blepharitis, styes, severe acne, and oily skin. Severe seborrheic dermatitis of the face occurs in acquired immunodeficiency syndrome.

Systemic lupus erythematosus

Occurring in about 40% of patients with SLE (a connective tissue disorder), butterfly rash appears as a red, commonly scaly, sharply demarcated macular eruption. The rash may be transient in patients with acute SLE or may progress slowly to include the forehead, chin, the area around the ears, and other exposed areas. Common associated skin findings include scaling, patchy alopecia, mucous membrane lesions, mottled erythema of the palms and fingers, periungual erythema with edema, reddish purple macular lesions on the volar surfaces of the fingers, telangiectasia of the base of the nails or eyelids, purpura, petechiae, and ecchymoses.

Butterfly rash may also be accompanied by joint pain, stiffness, and deformities, particularly ulnar deviation of the fingers and subluxation of the proximal interphalangeal joints. Related findings include periorbital and facial edema, dyspnea, low-grade fever, malaise, weakness, fatigue, weight loss, anorexia, nausea, vomiting, lymphadenopathy, photosensitivity, and hepatosplenomegaly. (See Associated disorder: Lupus.)

Other causes

Drugs

The drugs hydralazine and procainamide can cause a lupus-like syndrome, which is evidenced by the butterfly rash.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Vesicular rash: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Burns (second degree)

Second-degree burns include thermal burns that affect the epidermis and part of the dermis, which cause vesicles and bullae, erythema, swelling, pain, and moistness.

Dermatitis

With contact dermatitis, a hypersensitivity reaction produces an eruption of small vesicles surrounded by redness and marked edema. The vesicles may ooze, scale, and cause severe pruritus.

Dermatitis herpetiformis produces a chronic inflammatory eruption marked by vesicular, papular, bullous, pustular, or erythematous lesions. Usually, the rash is symmetrically distributed on the buttocks, shoulders, extensor surfaces of the elbows and knees, and sometimes the face, scalp, and neck. Other symptoms include severe pruritus, burning, and stinging.

CULTURAL CUE:Dermatitis herpetiformis is more common in people of Northern European descent; it rarely occurs in Asians and Blacks.

With nummular dermatitis, groups of pinpoint vesicles and papules appear on erythematous or pustular lesions that are nummular (coinlike) or annular (ringlike). Often, the pustular lesions ooze a purulent exudate, itch severely, and rapidly become crusted and scaly. Two or three lesions may develop on the hands, but the lesions typically develop on the extensor surfaces of the limbs and on the buttocks and posterior trunk.

Dermatophytid

Dermatophytid, also known as ringworm, is an allergic reaction to fungal infection. It produces vesicular lesions on the hands, usually in response to tinea pedis. The lesions are extremely pruritic and tender and may be accompanied by fever, anorexia, generalized adenopathy, and splenomegaly.

Herpes simplex

Herpes simplex is a common viral infection that produces groups of vesicles on an inflamed base, most commonly on the lips and lower face. In about 25% of cases of herpes simplex, the genital region is the site of involvement. Vesicles are preceded by itching, tingling, burning, or pain; develop singly or in groups; are 2 to 3 mm in size; and do not coalesce. Eventually, they rupture, forming a painful ulcer followed by a yellowish crust.

Herpes zoster

Insect bites

With insect bites, vesicles appear on red hivelike papules and may become hemorrhagic. Nonspecific signs and symptoms may also occur, such as fever, myalgia, headache, lymphadenopathy, nausea, and vomiting.

Pompholyx (dyshidrosis or dyshidrosis eczema)

Scabies

With scabies, small vesicles erupt on an erythematous base and may be at the end of a threadlike burrow. Burrows are a few millimeters long, with a swollen nodule or red papule that contains the mite. Pustules and excoriations may also occur. Men may develop burrows on the glans, shaft, and scrotum; women may develop burrows on the nipples. Both sexes may develop burrows on the webs of the fingers, wrists, elbows, axillae, and waistline. Associated pruritus worsens with inactivity and warmth and at night.

Smallpox

Initial signs and symptoms of smallpox (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. Later, the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Tinea pedis

Tinea pedis, a fungal infection, causes vesicles and scaling between the toes and, possibly, scaling over the entire sole. Severe infection causes inflammation, pruritus, and difficulty walking.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, bronze: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Adrenal hyperplasia

With adrenal hyperplasia, the skin assumes a dark bronze tone within a few months. Other findings include visual field deficits and headache (from an expanding pituitary lesion), and signs of masculinization in females such as clitoral enlargement, and male distribution of hair, fat, and muscle mass.

Biliary cirrhosis

Biliary cirrhosis causes bronze skin from melanosis of exposed areas of jaundiced skin: eyelids, palms, neck, and chest or back. The patient may also experience generalized pruritus, weakness, fatigue, jaundice, dark urine, pale stools with steatorrhea, decreased appetite with weight loss, and hepatomegaly.

Hemochromatosis

An early sign of hemochromatosis is progressive, generalized bronzing accentuated by metallic gray-bronze skin on sun-exposed areas, genitalia, and scars. Mucous membranes are affected less often. Early associated effects include weakness, lethargy, weight loss, abdominal pain, loss of libido, polydipsia, and polyuria.

CULTURAL CUE:Hereditary hemochromatosis is the most common genetic disorder in whites, affecting 1 in 200 to 300 people of Northern European descent.

Malnutrition

As weight loss, which occurs from malnutrition, depletes body nutrients, bronzing develops along with apathy, lethargy, anorexia, weakness, and slow pulse and respiratory rates. Patients may develop paresthesia in the extremities; dull, sparse, dry hair; brittle nails; dark, swollen cheeks; dry, flaky skin; red, swollen lips; muscle wasting; and gonadal atrophy in males.

Primary adrenal insufficiency

Bronze skin is a classic sign of primary adrenal insufficiency. Other findings include axillary and pubic hair loss, vitiligo, progressive fatigue, weakness, anorexia, nausea and vomiting, weight loss, orthostatic hypotension, weak and irregular pulse, abdominal pain, irritability, diarrhea or constipation, amenorrhea, and syncope.

Renal failure (chronic)

With chronic renal failure, the skin becomes pallid, yellowish bronze, dry, and scaly. Other findings include ammonia breath odor, oliguria, fatigue, decreased mental acuity, seizures, muscle cramps, peripheral neuropathy, bleeding tendencies, pruritus and, occasionally, uremic frost and hypertension.

Other causes

Drugs

Prolonged therapy with high doses of a phenothiazine may cause gradual bronzing of the skin.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, clammy: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Anxiety

Cardiac arrhythmias

Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension. The pulse rate may be rapid, slow, or irregular. The patient may report palpitations, chest pain, diaphoresis, light-headedness, and weakness.

Cardiogenic shock

With cardiogenic shock, generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria. Associated signs and symptoms include anginal pain, dyspnea, jugular vein distention, ventricular gallop, and a weak, rapid pulse.

Heat exhaustion

Hypoglycemia (acute)

With acute hypoglycemia, generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.

Hypovolemic shock

With hypovolemic shock, generalized pale, cold, clammy skin accompanies subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and rapid, thready pulse. Other findings are flat neck veins, increased capillary refill time, decreased urine output, confusion, and decreased level of consciousness.

Septic shock

The cold shock stage of septic shock causes generalized cold, clammy skin. Associated findings include rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, scaly: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Bowen’s disease

Bowen’s disease, a common form of intraepidermal carcinoma, causes painless, erythematous plaques that are raised and indurated with a thick, hyperkeratotic scale and, possibly, ulcerated centers. The head and neck are the most commonly affected sites.

Dermatitis

Exfoliative dermatitis begins with rapidly developing generalized erythema. Desquamation with fine scales or thick sheets of all or most of the skin surface may cause life-threatening hypothermia. Other possible complications include cardiac output failure and septicemia. Systemic signs and symptoms include low-grade fever, chills, malaise, lymphadenopathy, and gynecomastia.

Dermatophytosis

Discoid lupus erythematosus

Discoid lupus erythematosus is a cutaneous form of lupus that may occur without systemic signs and symptoms. Separate or coalescing lesions (macules, papules, or plaques), ranging from pink to purple, are covered with a yellow or brown crust. Enlarged hair follicles are filled with scales, and telangiectasia may be present. After this inflammatory stage, the lesions heal and hypopigmentation or hyperpigmentation and noncontractile scarring and atrophy may occur. Discoid lupus commonly involves the face or sun-exposed areas of the neck, ears, scalp, lips, and oral mucosa. Alopecia may also occur.

Lymphoma

Hodgkin’s disease and non-Hodgkin’s lymphoma commonly cause scaly rashes. Hodgkin’s disease may cause pruritic scaling dermatitis that begins in the legs and spreads to the entire body. Remissions and recurrences are common. Small nodules and diffuse pigmentation are related signs. This disease typically produces painless enlargement of the peripheral lymph nodes. Other signs and symptoms include fever, fatigue, weight loss, malaise, and hepatosplenomegaly.

Pityriasis rosea

Psoriasis

Syphilis (secondary)

Papulosquamous, slightly scaly eruptions characterize secondary syphilis. A ring-shaped pattern of copper-red papules usually forms on the face, arms, palms, soles, chest, back, and abdomen. Annular papules may occur. Systemic findings include lymphadenopathy, malaise, weight loss, anorexia, nausea, vomiting, headache, sore throat, and low-grade fever.

Systemic lupus erythematosus

Systemic lupus erythematosus (SLE) produces a bright-red maculopapular eruption, sometimes with scaling. Patches are sharply defined and involve the nose and malar regions of the face in a butterfly pattern — a primary sign. Similar characteristic rashes appear on other body surfaces; scaling occurs along the lower lip or anterior hair line. Other primary signs and symptoms include photosensitivity and joint pain and stiffness. Vasculitis (leading to infarctive lesions, necrotic leg ulcers, or digital gangrene), Raynaud’s phenomenon, patchy alopecia, and mucous membrane ulcers also can occur.

Tinea versicolor

Tinea versicolor, a benign fungal skin infection, typically produces macular hypopigmented, fawn-colored, or brown patches of varying sizes and shapes. All are slightly scaly. Lesions commonly affect the upper trunk, arms, and lower abdomen, sometimes the neck and, rarely, the face.

Other causes

Drugs

Many drugs — including penicillins, sulfonamides, barbiturates, quinidine, diazepam, phenytoin, and isoniazid — can produce scaling patches.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin Lesions and Rashes: Principal Causes of Skin Lesions and Rashes
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Blistering(vesiculobullous) lesions
1. Miliaria
2. Allergic contact dermatitis
3. Chemical and thermal burns
4. Friction blisters
5. Frostbite
6. Bullous impetigo
7. Papular urticaria (insect bites)
8. Hand-foot-mouth disease
9. Varicella-zoster virus infections
10. Herpes simplex virus infections
11. Erythema multiforme
12. Staphylococcal scalded skin syndrome
13. Epidermolysis bullosa
14. Chronic bullous dermatitis of childhood(linear immunoglobulin A dermatosis)
15. Dermatitis herpetiformis
16. Bullous pemphigoid
17. Incontinentia pigmenti
Pustular lesions
1. Erythematoxicum
2. Transient neonatal pustular melanosis
3. Acne
4. Folliculitis
5. Eosinophilic pustular folliculitis
6. Infantile acropustulosis
7. Miliaria
8. Candidiasis
9. Herpes simplex virus infections
10. Local bacterial infections (Staphylococcusaureus)
11. Scabies
Skin-colored papules and nodules
1. Smoothsurface
  1. Milia
  2. Molluscum contagiosum
  3. Acne
  4. Epidermal cyst
  5. Granuloma annulare
  6. Lipoma
  7. Juvenile xanthogranuloma
  8. Xanthoma
  9. Neurofibroma
2. Rough surface
  1. Epidermal nevi
  2. Warts
  3. Corns and calluses
  4. Keratosis pilaris
White lesions
1. Flat lesions
  1. Postinflammatory hypopigmentation
  2. Pityriasis alba
  3. Tinea versicolor
  4. Vitiligo
  5. Piebaldism
  6. Ash-leaf macules
  7. Hypomelanosis of Ito
  8. Chediak-Higashi syndrome
  9. Waardenburg syndrome
2. Raised lesions
  1. Milia
  2. Acne
  3. Keratosis pilaris
  4. Molluscum contagiosum
Brown, blue-black, or black lesions
1. Flat lesions
  1. Freckles(ephelides)
  2. Mongolian spots (dermal melanosis)
  3. Café au lait spots
  4. Lentigines
  5. Nevi of Ota and of Ito
  6. Congenital nevocellular nevi
  7. Acquired nevocellular nevi
  8. Nevus spilus (speckled lentiginousnevus)
  9. Spitz nevi (spindle epithelioid nevi)
  10. Epidermal nevi
2. Raised lesions
  1. Postinflammatoryhyperpigmentation
  2. Mastocytoma and urticaria pigmentosa
  3. Pyogenic granuloma
  4. Dysplastic melanocytic nevi
  5. Melanoma
Yellow lesions
1. Jaundice
2. Carotenemia
3. Sebaceous gland hyperplasia
4. Nevus sebaceous of Jadassohn
Inflammatory papules and nodules
1. Insectbites
2. Acne
3. Roseola (exanthem subitum)
4. Enteroviruses (coxsackie A and B viruses,echoviruses)
5. Epstein-Barr virus
6. Parvovirus B19 (fifth disease)
7. Postnatal rubella
8. Measles (rubeola)
9. Scarlet fever
10. Cellulitis
11. Furuncle
12. Candidiasis
13. Kawasaki disease
14. Mycoplasma infections
15. Erythema marginatum
16. Panniculitis
17. Erythema chronicum migrans
18. Cutaneous larva migrans
19. Urticaria (hives)
Vascular reactions
1. Blanching
  1. Mottling(cutis marmorata)
  2. Salmon patch
  3. Spider angioma
  4. Port-wine stains
  5. Hemangiomas
  6. Drug hypersensitivity reactions
  7. Erythema toxicum
  8. Urticaria
  9. Viral infections (exanthems)
  10. Scarlet fever
  11. Erythema multiforme
  12. Kawasaki disease
  13. Toxic shock syndrome
  14. Erythema chronicum migrans
  15. Syphilis
  16. Pyogenic granuloma
  17. Pityriasis rosea (early lesions)
  18. Guttate psoriasis (early lesions)
2. Nonblanching (purpuric rashes)
  1. Meningococcemia
  2. Toxic shock syndrome
  3. Rocky Mountain spotted fever
  4. Other
Papulosquamous disorders
1. Diaperdermatitis (irritant dermatitis)
2. Atopic dermatitis
3. Nummular eczematous dermatitis
4. Juvenile plantar dermatosis (foot eczema)
5. Seborrheic dermatitis (infantile)
6. Contact dermatitis
7. Tinea corporis
8. Tinea pedis
9. Candidiasis
10. Sunburn
11. Pityriasis rosea
12. Drug eruptions
13. Scabies
14. Polymorphous light eruption
15. Psoriasis
16. Parapsoriasis
17. Lichen nitidis
18. Lichen striatus
19. Lichen planus
20. Lupus erythematosus
21. Dermatomyositis
22. Langerhans cell histiocytosis
23. Acrodermatitis enteropathica
24. Human immunodeficiency virus infection
25. Secondary syphilis
26. Ichthyoses
  1. Ichthyosis vulgaris
  2. X-linked ichthyosis
  3. Classic lamellar ichthyosis and congenitalnonbullous ichthyosiform erythroderma
  4. Congenital bullous ichthyosiform erythroderma(epidermolytic hyperkeratosis)

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Papular rash: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acne vulgaris.With acne vulgaris, 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 begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 1 or 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.

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 dermatomyositis, 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).

Follicular mucinosis.With follicular mucinosis, perifollicular papules or plaques are accompanied by prominent alopecia.

Fox-Fordyce disease.Fox-Fordyce disease 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.

Granuloma annulare.Granuloma annulare 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.

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 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 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 commonly blisterlike and can follow these stages: vesiculation, postulation, umbilication, and crusting. Typically 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.

Mononucleosis (infectious).A maculopapular rash that resembles rubella is an early sign of 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.

Necrotizing vasculitis.With necrotizing vasculitis, crops of purpuric, but otherwise asymptomatic, papules are typical. Some patients also develop low-grade fever, headache, myalgia, arthralgia, and abdominal pain.

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 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 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.

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 (variola major).Initial signs and symptoms of smallpox include a high fever, malaise, prostration, severe headache, a 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 or 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.

Syringoma.With syringoma, 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.Initial symptoms of typhus include headache, myalgia, arthralgia, and malaise, 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; phenylbutazone; gold salts; allopurinol; isoniazid; and salicylates.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Pustular rash: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acne vulgaris.Pustules typify inflammatory lesions of acne vulgaris, which is accompanied by papules, nodules, cysts, open comedones (blackheads), and closed comedones (whiteheads). Lesions commonly appear on the face, shoulders, back, and chest. Other findings include pain on pressure, pruritus, and burning. Chronic recurrent lesions produce scars.

Blastomycosis.Blastomycosis is a fungal infection that produces small, painless, nonpruritic macules or papules that can enlarge to well-circumscribed, verrucous, crusted, or ulcerated lesions edged by pustules. Localized infection may cause only one lesion; systemic infection may cause many lesions on the hands, feet, face, and wrists. Blastomycosis also produces signs of pulmonary infection, such as pleuritic chest pain and a dry, hacking or productive cough with occasional hemoptysis.

Folliculitis.Folliculitis is a bacterial infection of hair follicles that produces individual pustules, each pierced by a hair and possibly accompanied by pruritus. “Hot tub” folliculitis produces pustules on areas covered by a bathing suit.

Furunculosis.A furuncle is an acute, deep-seated, red, hot, tender abscess that evolves from a staphylococcal folliculitis. Furuncles usually begin as small, tender red pustules at the base of hair follicles. They're likely to occur on the face, neck, forearm, groin, axillae, buttocks, and legs or areas that are prone to repeated friction. The pustules usually remain tense for 2 to 4 days and then become fluctuant. Rupture discharges pus and necrotic material. Then pain subsides, but erythema and edema may persist.

Impetigo contagiosa.Impetigo contagiosa, a vesiculopustular eruptive disorder that occurs in nonbullous and bullous forms, is usually caused by streptococci or staphylococci. Vesicles form and break, and a crust forms from the exudate: a thick, yellow crust in streptococcal impetigo and a thin, clear crust in staphylococcal impetigo. Both forms usually produce painless itching.

Pustular miliaria.Pustular miliaria causes pustular lesions that begin as tiny erythematous papulovesicles located at sweat pores. Diffuse erythema may radiate from the lesion. The rash and associated burning and pruritus worsen with sweating.

Pustular psoriasis.Small vesicles form and eventually become pustules with pustular psoriasis. The patient may report pruritus, burning, and pain. Localized pustular psoriasis usually affects the hands and feet. Generalized pustular psoriasis may erupt suddenly in a patient with psoriasis, psoriatic arthritis, or exfoliative psoriasis; although rare, this form of psoriasis can occasionally be fatal.

Rosacea.Rosacea commonly produces telangiectasia with acute episodes of pustules, papules, and edema. Characterized by persistent erythema, rosacea may begin as a flush covering the forehead, malar region, nose, and chin. Intermittent episodes gradually become more persistent, and the skin—instead of returning to its normal color—develops varying degrees of erythema.

Scabies.Threadlike channels or burrows under the skin characterize scabies, which can also produce pustules, vesicles, and excoriations. The lesions are a few millimeters long, with a swollen nodule or red papule that contains the itch mite.

Smallpox (variola major).Initial signs and symptoms of smallpox 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 or 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.

Varicella zoster.When immunity to varicella declines, the virus reactivates along a dermatome, producing extremely painful and pruritic vesicles and pustules (herpes zoster, or shingles). Even with resolution of the rash, patients may experience chronic pain (postherpetic neuralgia) that may persist for months.

Other causes

Drugs.Bromides and iodides commonly cause a pustular rash. Other drug causes include corticotropin, corticosteroids, dactinomycin, trimethadione, lithium, phenytoin, phenobarbital, isoniazid, hormonal contraceptives, androgens, and anabolic steroids.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Pruritus: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anemia (iron deficiency).Iron deficiency anemia occasionally produces pruritus. Initially producing no symptoms, anemia can later cause exertional dyspnea, fatigue, listlessness, pallor, irritability, headache, tachycardia, poor muscle tone and, possibly, murmurs. Chronic anemia causes spoon-shaped (koilonychia) and brittle nails, cracked mouth corners (cheilosis), a smooth tongue (glossitis), and dysphagia.

Anthrax (cutaneous).Anthrax infection begins as a small, painless or pruritic macular or papular lesion resembling an insect bite. Within 1 or 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.

Conjunctivitis.All forms of conjunctivitis cause eye itching, burning, and pain along with photophobia, conjunctival injection, a foreign-body sensation, excessive tearing, and a feeling of fullness around the eye. Allergic conjunctivitis may also cause milky redness and a stringy eye discharge. Bacterial conjunctivitis typically causes brilliant redness and a mucopurulent discharge that may make the eyelids stick together. Fungal conjunctivitis produces a thick, purulent discharge and crusting and sticking of the eyelid. Viral conjunctivitis may cause copious tearing—but little discharge—and preauricular lymph node enlargement.

Dermatitis.Several types of dermatitis can cause pruritus accompanied by a skin lesion. Atopic dermatitis begins with intense, severe pruritus and an erythematous rash on dry skin at flexion points (antecubital fossa, popliteal area, and neck). During a flare-up, scratching may produce edema, scaling, and pustules. With chronic atopic dermatitis, lesions may progress to dry, scaly skin with white dermatographia, blanching, and lichenification.

Mild irritants and allergies can cause contact dermatitis, with itchy small vesicles that may ooze and scale and are surrounded by redness. A severe reaction can produce marked localized edema.

Dermatitis herpetiformis, initially causes intense pruritus and stinging. Between 8 and 12 hours later, symmetrically distributed lesions form on the buttocks, shoulders, elbows, and knees. Sometimes, they also form on the neck, face, and scalp. These lesions are erythematous and papular, bullous, or pustular.

Hepatobiliary disease.An important diagnostic clue to liver and gallbladder disease, pruritus is commonly accompanied by jaundice and may be generalized or localized to the palms and soles. Other characteristics include right upper quadrant pain, clay-colored stools, chills and fever, flatus, belching and a bloated feeling, epigastric burning, and bitter fluid regurgitation. Later, liver disease may produce mental changes, ascites, bleeding tendencies, spider angiomas, palmar erythema, dry skin, fetor hepaticus, enlarged superficial abdominal veins, bilateral gynecomastia, testicular atrophy or menstrual irregularities, and hepatomegaly.

Herpes zoster.With herpes zoster, within 2 to 4 days of a fever and malaise, pruritus, paresthesia or hyperesthesia, and severe, deep pain from cutaneous nerve involvement develop on the trunk or the arms and legs in a dermatome distribution. Up to 2 weeks after initial symptoms, red, nodular skin eruptions appear on the painful areas and become vesicular. About 10 days later, the vesicles rupture and form scabs.

Leukemia (chronic lymphocytic).Pruritus is an uncommon finding in leukemia. More characteristic signs and symptoms include fatigue, malaise, generalized lymphadenopathy, fever, hepatomegaly, splenomegaly, weight loss, pallor, bleeding, and palpitations.

Lichen simplex chronicus.Persistent rubbing and scratching cause localized pruritus and a circumscribed scaling patch with sharp margins. Later, the skin thickens and papules form.

Myringitis (chronic).Myringitis produces pruritus in the affected ear, along with a purulent discharge and gradual hearing loss.

Pediculosis.A prominent symptom of pediculosis, pruritus occurs in the area of infestation. Pediculosis capitis (head lice) may also cause scalp excoriation from scratching, along with matted, foul-smelling, lusterless hair; occipital and cervical lymphadenopathy; and oval, gray-white nits on hair shafts.

With pediculosis pubis(pubic lice), scratching commonly produces skin irritation. Nits or adult lice and erythematous, itching papules may appear in pubic hair or in hair around the anus, abdomen, or thighs.

Pityriasis rosea.Pityriasis rosea occasionally produces mild pruritus that's aggravated by a hot bath or shower. It usually begins with an erythematous herald patch—a slightly raised, oval lesion about 2 to 6 cm in diameter. After a few days or weeks, scaly yellow-tan or erythematous patches erupt on the trunk and extremities and persist for 2 to 6 weeks. Occasionally, these patches are macular, vesicular, or urticarial.

Psoriasis.Pruritus and pain are common in psoriasis. This skin disorder typically begins with small erythematous papules that enlarge or coalesce to form red elevated plaques with silver scales on the scalp, chest, elbows, knees, back, buttocks, and genitals. Nail pitting may occur.

Scabies.Typically, scabies causes localized pruritus that awakens the patient. It may become generalized and persist for up to 2 weeks after treatment. Threadlike lesions several millimeters long appear with a swollen nodule or red papule.

Tinea pedis.Tinea pedis is a fungal infection that causes severe foot pruritus, pain with walking, scales and blisters between the toes, and a dry, scaly squamous inflammation on the entire sole.

Urticaria.With urticaria, extreme pruritus and stinging occur as transient, erythematous or whitish wheals form on the skin or mucous membranes. Prickly sensations typically precede the wheals, which may affect any part of the body and may range from pinpoint to palm-size or larger.

Vaginitis.Vaginitis commonly causes localized pruritus and a foul-smelling vaginal discharge that may be purulent, white or gray, and curdlike. Perineal pain and urinary dysfunction may also occur.

Other causes

Bedbug bites.Typically, bedbug bites produce itching and burning over the ankles and lower legs, along with clusters of purpuric spots.

Drug hypersensitivity.When mild and localized, an allergic reaction to such drugs as penicillin and sulfonamides can cause pruritus, erythema, an urticarial rash, and edema. However, with a severe drug reaction, anaphylaxis may occur.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Skin, mottled: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acrocyanosis.With acrocyanosis, anxiety or exposure to cold can cause vasospasm in small cutaneous arterioles. This results in persistent symmetrical blue and red mottling of the affected hands, feet, and nose.

Arterial occlusion (acute).Initial signs of acute arterial occlusion include skin temperature and color changes. Pallor may change to blotchy cyanosis and livedo reticularis. Color and temperature demarcation develop at the level of obstruction. Other effects include sudden onset of pain in the extremity and, possibly, paresthesia, paresis, and a sensation of cold in the affected area. Examination reveals diminished or absent pulses, cool extremities, an increased capillary refill time, pallor, and diminished reflexes.

Arteriosclerosis obliterans.Atherosclerotic buildup narrows intra-arterial lumina, resulting in reduced blood flow through the affected artery. Obstructed blood flow to the extremities (most commonly the legs) produces such peripheral signs and symptoms as leg pallor, cyanosis, blotchy erythema, and livedo reticularis. Related findings include intermittent claudication (most common symptom), diminished or absent pedal pulses, and leg coolness. Other symptoms include coldness and paresthesia.

Buerger's disease.Buerger's disease produces unilateral or asymmetrical color changes and mottling, particularly livedo networking in the lower extremities. It also typically causes intermittent claudication and erythema along extremity blood vessels. During exposure to cold, the feet are cold, cyanotic, and numb; later they're hot, red, and tingling. Other findings include impaired peripheral pulses and peripheral neuropathy. Buerger's disease is typically exacerbated by smoking.

Cryoglobulinemia.Cryoglobulinemia causes patchy livedo reticularis, petechiae, and ecchymoses. Other findings include fever, chills, urticaria, melena, skin ulcers, epistaxis, Raynaud's phenomenon, eye hemorrhages, hematuria, and gangrene.

Hypovolemic shock.Vasoconstriction from hypovolemic shock commonly produces skin mottling, initially in the knees and elbows. As shock worsens, mottling becomes generalized. Early signs include a sudden onset of pallor, cool skin, restlessness, thirst, tachypnea, and slight tachycardia. As shock progresses, associated findings include cool, clammy skin; a rapid, thready pulse; hypotension; narrowed pulse pressure; decreased urine output; subnormal temperature; confusion; and decreased level of consciousness.

Livedo reticularis (idiopathic or primary).With livedo reticularis, symmetrical, diffuse mottling can involve the hands, feet, arms, legs, buttocks, and trunk. Initially, networking is intermittent and most pronounced on exposure to cold or stress; eventually, mottling persists even with warming.

Periarteritis nodosa.Skin findings in periarteritis nodosa include asymmetrical, patchy livedo reticularis, palpable nodules along the path of medium-sized arteries, erythema, purpura, muscle wasting, ulcers, gangrene, peripheral neuropathy, fever, weight loss, and malaise.

Polycythemia vera.Polycythemia vera produces livedo reticularis, hemangiomas, purpura, rubor, ulcerative nodules, and scleroderma-like lesions. Other symptoms include headache, a vague feeling of fullness in the head, dizziness, vertigo, vision disturbances, dyspnea, and aquagenic pruritus.

Systemic lupus erythematosus (SLE).SLE can cause livedo reticularis, most commonly on the outer arms. Other signs and symptoms include a butterfly rash, nondeforming joint pain and stiffness, photosensitivity, Raynaud's phenomenon, patchy alopecia, seizures, fever, anorexia, weight loss, lymphadenopathy, and emotional lability.

Other causes

Drugs.Vasoconstrictors administered at a high dose can cause mottling of the extremities.

Immobility.Prolonged immobility may cause bluish mottling, most noticeably in dependent extremities.

Thermal exposure.Prolonged thermal exposure, as from a heating pad or hot water bottle, may cause erythema ab igne—a localized, reticulated, brown-to-red mottling.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Butterfly rash: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Discoid lupus erythematosus.With discoid lupus erythematosus, the patient may have a unilateral or butterfly rash that consists of erythematous, raised, sharply demarcated plaques with follicular plugging and central atrophy. The rash may also involve the scalp, ears, chest, or any part of the body exposed to the sun. Telangiectasia, scarring alopecia, and hypopigmentation or hyperpigmentation may occur later. Other accompanying signs include conjunctival redness, dilated capillaries of the nail fold, bilateral parotid gland enlargement, oral lesions, and mottled, reddish blue skin on the legs.

Erysipelas.Erysipelas causes rosy or crimson swollen lesions, mainly on the neck and head and commonly along the nasolabial fold. It may cause hemorrhagic pus-filled blisters. Other signs and symptoms include fever, chills, cervical lymphadenopathy, and malaise.

Polymorphous light eruption.A butterfly rash appears as erythema, vesicles, plaques, and multiple small papules that may later become eczematized, lichenified, and excoriated. Provoked by ultraviolet rays, the rash appears on the cheeks and bridge of the nose, the hands and arms, and other areas, beginning a few hours to several days after exposure. It may be accompanied by pruritus.

Rosacea.Initially, a butterfly rash may appear as a prominent, nonscaling, intermittent erythema limited to the lower half of the nose or including the chin, cheeks, and central forehead. As rosacea develops, the duration of the rash increases; instead of disappearing after each episode, the rash varies in intensity and is commonly accompanied by telangiectasia. With advanced rosacea, the skin is oily, with papules, pustules, nodules, and telangiectasis restricted to the central oval of the face. In men with severe rosacea, butterfly rash may be accompanied by rhinophyma—a thickened, lobulated overgrowth of sebaceous glands and epithelial connective tissue on the lower half of the nose and, possibly, the adjacent cheeks. This is more common in elderly patients.

Seborrheic dermatitis.A butterfly rash appears as greasy, scaling, slightly yellow macules and papules of varying size on the cheeks and the bridge of the nose, in a “butterfly” pattern. The scalp, beard, eyebrows, portions of the forehead above the bridge of the nose, nasolabial fold, or trunk may also be involved. Associated signs and symptoms include crusts and fissures (particularly when the external ear and scalp are involved), pruritus, redness, blepharitis, styes, severe acne, and oily skin. Severe seborrheic dermatitis of the face occurs in acquired immunodeficiency syndrome.

Systemic lupus erythematosus.Occurring in about 40% of patients with this connective tissue disorder, a butterfly rash appears as a red, usually scaly, sharply demarcated macular eruption. The rash may be transient in patients with acute SLE or may progress slowly to include the forehead, the chin, the area around the ears, and other exposed areas. Common associated skin findings include scaling, patchy alopecia, mucous membrane lesions, mottled erythema of the palms and fingers, periungual erythema with edema, reddish purple macular lesions on the volar surfaces of the fingers, telangiectasia of the base of the nails or eyelids, purpura, petechiae, and ecchymoses.

A butterfly rash may also be accompanied by joint pain, stiffness, and deformities, particularly ulnar deviation of the fingers and subluxation of the proximal interphalangeal joints. Related findings include periorbital and facial edema, dyspnea, a low-grade fever, malaise, weakness, fatigue, weight loss, anorexia, nausea, vomiting, lymphadenopathy, photosensitivity, and hepatosplenomegaly.

Other causes

Drugs.Hydralazine and procainamide can cause a lupuslike syndrome, producing a butterfly rash.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Vesicular rash: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Burns (second degree).Thermal burns that affect the epidermis and part of the dermis cause vesicles and bullae, with erythema, swelling, pain, and moistness.

Dermatitis.With contact dermatitis, a hypersensitivity reaction produces an eruption of small vesicles surrounded by redness and marked edema. The vesicles may ooze, scale, and cause severe pruritus.

Dermatitis herpetiformis produces a chronic inflammatory eruption marked by vesicular, papular, bullous, pustular, or erythematous lesions. Usually, the rash is symmetrically distributed on the buttocks, shoulders, extensor surfaces of the elbows and knees, and sometimes on the face, scalp, and neck. Other symptoms include severe pruritus, burning, and stinging.

Erythema multiforme.Erythema multiforme is heralded by a sudden eruption of erythematous macules, papules and, occasionally, vesicles and bullae. The characteristic rash appears symmetrically over the hands, arms, feet, legs, face, and neck and tends to reappear. Although vesicles and bullae may also erupt on the eyes and genitalia, vesiculobullous lesions usually appear on the mucous membranes—especially the lips and buccal mucosa—where they rupture and ulcerate, producing a thick, yellow or white exudate. Bloody, painful crusts, a foul-smelling oral discharge, and difficulty chewing may develop. Lymphadenopathy may also occur.

Herpes simplex.Herpes simplex produces groups of vesicles on an inflamed base, most commonly on the lips and lower face. In about 25% of cases, the genital region is the site of involvement. Vesicles are preceded by itching, tingling, burning, or pain; develop singly or in groups; are 2 to 3 mm in size; and don't coalesce. Eventually, they rupture, forming a painful ulcer followed by a yellowish crust.

Herpes zoster.With herpes zoster, a vesicular rash is preceded by erythema and, occasionally, by a nodular skin eruption and unilateral, sharp, pain along a dermatome. About 5 days later, the lesions erupt and the pain becomes burning. Vesicles dry and scab approximately 10 days after eruption. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the involved area. Herpes zoster involving the cranial nerves produces facial palsy, hearing loss, dizziness, loss of taste, eye pain, and impaired vision.

Insect bites.With insect bites, vesicles appear on red hivelike papules and may become hemorrhagic.

Pemphigoid (bullous).Generalized pruritus or an urticarial or eczematous eruption may precede pemphigoid—a classic bullous rash. Bullae are large, thick-walled, tense, and irregular, typically forming on an erythematous base. They usually appear on the lower abdomen, groin, inner thighs, and forearms.

Pompholyx (dyshidrosis or dyshidrosis eczema).Pompholyx is a common, recurrent disorder that produces symmetrical vesicular lesions that can become pustular. The pruritic lesions are more common on the palms than on the soles and may be accompanied by minimal erythema.

Porphyria cutanea tarda.Bullae—especially on areas exposed to sun, friction, trauma, or heat—result from abnormal porphyrin metabolism. Photosensitivity is also a common sign. Papulovesicular lesions evolving into erosions or ulcers and scars may appear. Chronic skin changes include hyperpigmentation or hypopigmentation, hypertrichosis, and sclerodermoid lesions. Urine is pink to brown.

Scabies.With scabies, small vesicles erupt on an erythematous base and may be at the end of a threadlike burrow. Burrows are a few millimeters long, with a swollen nodule or red papule that contains the mite. Pustules and excoriations may also occur. Men may develop burrows on the glans, shaft, and scrotum; women may develop burrows on the nipples. Both sexes may develop burrows on the webs of the fingers, wrists, elbows, axillae, and waistline. Associated pruritus worsens with inactivity and warmth and at night.

Smallpox (variola major).Initial signs and symptoms of smallpox 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. Later, the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Tinea pedis.Tinea pedis causes vesicles and scaling between the toes and, possibly, scaling over the entire sole. Severe infection causes inflammation, pruritus, and difficulty walking.

Toxic epidermal necrolysis.Toxic epidermal necrolysis is an immune reaction to drugs or other toxins, in which vesicles and bullae are preceded by a diffuse, erythematous rash and followed by large-scale epidermal necrolysis and desquamation. Large, flaccid bullae develop after mucous membrane inflammation, a burning sensation in the conjunctivae, malaise, fever, and generalized skin tenderness. The bullae rupture easily, exposing extensive areas of denuded skin. (See Drugs that cause toxic epidermal necrolysis.)

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Skin turgor, decreased: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Cholera.Cholera is characterized by abrupt watery diarrhea and vomiting, which leads to severe water and electrolyte loss. These imbalances cause the following symptoms: decreased skin turgor, thirst, weakness, muscle cramps, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Dehydration.Decreased skin turgor commonly occurs with moderate to severe dehydration. Associated findings include dry oral mucosa, decreased perspiration, resting tachycardia, orthostatic hypotension, a dry and furrowed tongue, increased thirst, weight loss, oliguria, fever, and fatigue. As dehydration worsens, other findings include enophthalmos, lethargy, weakness, confusion, delirium or obtundation, anuria, and shock. Hypotension persists even when the patient lies down.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Skin, clammy: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anxiety.An acute anxiety attack commonly produces cold, clammy skin on the forehead, palms, and soles. Other features include pallor, a dry mouth, tachycardia or bradycardia, palpitations, and hypertension or hypotension. The patient may also develop tremors, breathlessness, headache, muscle tension, nausea, vomiting, abdominal distention, diarrhea, increased urination, and sharp chest pain.

Arrhythmias.Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.

Cardiogenic shock.Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.

Heat exhaustion.In the acute stage of heat exhaustion, generalized cold, clammy skin accompanies an ashen appearance, headache, confusion, syncope, giddiness and, possibly, a subnormal temperature, with mild heat exhaustion. The patient may exhibit a rapid and thready pulse, nausea, vomiting, tachypnea, oliguria, thirst, muscle cramps, and hypotension.

Hypoglycemia (acute).Generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.

Hypovolemic shock.With hypovolemic shock, generalized pale, cold, clammy skin accompanies a subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and a rapid, thready pulse. Other findings are flat neck veins, an increased capillary refill time, decreased urine output, confusion, and decreased level of consciousness.

Septic shock.The cold shock stage causes generalized cold, clammy skin. Associated findings include a rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Skin, scaly: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Bowen's disease.Bowen's disease causes painless, erythematous plaques that are raised and indurated with a thick, hyperkeratotic scale and, possibly, ulcerated centers.

Dermatitis.Exfoliative dermatitis begins with rapidly developing generalized erythema. Desquamation with fine scales or thick sheets of all or most of the skin surface may cause life-threatening hypothermia. Other possible complications include cardiac output failure and septicemia. Systemic signs and symptoms include a low-grade fever, chills, malaise, lymphadenopathy, and gynecomastia.

Dermatophytosis.Tinea capitis produces lesions with reddened, slightly elevated borders and a central area of dense scaling; these lesions may become inflamed and pus-filled (kerions). Patchy alopecia and itching may also occur. Tinea pedis causes scaling and blisters between the toes. The squamous type produces diffuse, fine, branlike scales. Adherent and silvery white, they're most prominent in skin creases and may affect the entire dorsum of the foot. Tinea corporis produces crusty lesions. As they enlarge, their centers heal, causing the classic ringworm shape.

Lymphoma.Hodgkin's disease and non-Hodgkin's lymphoma commonly cause scaly rashes. Hodgkin's disease may cause pruritic scaling dermatitis that begins in the legs and spreads to the entire body. Remissions and recurrences are common. Small nodules and diffuse pigmentation are related signs. This disease typically produces painless enlargement of the peripheral lymph nodes. Other signs and symptoms include fever, fatigue, weight loss, malaise, and hepatosplenomegaly.

Non-Hodgkin's lymphoma initially produces erythematous patches with some scaling that later become interspersed with nodules. Pruritus and discomfort are common; later, tumors and ulcers form. Progression produces nontender lymphadenopathy.

Parapsoriasis (chronic).Parapsoriasisproduces small or moderate-sized maculopapular, erythematous eruptions, with a thin, adherent scale on the trunk, hands, and feet. Removal of the scale reveals a shiny brown surface.

Pityriasis.Pityriasis rosea, an acute, benign, and self-limiting disorder, produces widespread scales. It begins with an erythematous, raised, oval herald patch anywhere on the body. A few days or weeks later, yellow-tan or erythematous patches with scaly edges erupt on the trunk and limbs and sometimes on the face, hands, and feet. Pruritus also occurs.

Psoriasis.Silvery white, micaceous scales cover erythematous plaques that have sharply defined borders. Psoriasis usually appears on the scalp, chest, elbows, knees, back, buttocks, and genitalia. Associated signs and symptoms include nail pitting, pruritus, arthritis, and sometimes pain from dry, cracked, encrusted lesions.

Systemic lupus erythematosus (SLE).SLE produces a bright-red maculopapular eruption, sometimes with scaling. Patches are sharply defined and involve the nose and malar regions of the face in a butterfly pattern—a primary sign. Similar characteristic rashes appear on other body surfaces; scaling occurs along the lower lip or anterior hair line. Other primary signs and symptoms include photosensitivity and joint pain and stiffness. Vasculitis (leading to infarctive lesions, necrotic leg ulcers, or digital gangrene), Raynaud's phenomenon, patchy alopecia, and mucous membrane ulcers can also occur.

Tinea versicolor.Tinea versicolor typically produces macular hypopigmented, fawn-colored, or brown patches of varying sizes and shapes. All are slightly scaly. Lesions commonly affect the upper trunk, arms, and lower abdomen; sometimes the neck; and, rarely, the face.

Other causes

Drugs.Many drugs—including penicillins, sulfonamides, barbiturates, quinidine, diazepam, phenytoin, and isoniazid—can produce scaling patches.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Rash - Case 9-2: 7-Week-Old Girl: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

Bruising caused clinicians to consider hematologic causes primarily. The initial workup was done to evaluate for von Willebrand 's disease, which causes decreased platelet adhesiveness, impaired agglutination of platelets in the presence of ristocetin, and prolonged bleeding time. The usual presentation is mild to moderate bleeding involving mucous membranes, including easy bruising, epistaxis, and prolonged bleeding after dental procedures. In boys, hemophilia (factor VIII and IX deficiency) should be considered. These children have bruising with a firm or nodular consistency because of deep soft-tissue bleeding. Vitamin K deficiency can be seen in patients with fat malabsorption syndromes, and hemorrhagic disease of the newborn may be seen in those not given vitamin K at delivery. In these infants, signs and symptoms typically occur within the first few days of life and include diffuse bruising and, rarely, catastrophic central nervous system bleeding. However, the timing in this case was not consistent with vitamin K deficiency. ITP, an acute and self-limited illness that causes bruising and petechiae 2 to 4 weeks after a minor illness, could be considered. This infant did not have any preceding illness, and her platelet count was normal. The peak age for presentation with ITP is 2 to 5 years, and infants who are diagnosed before 1 year of age have a high likelihood of developing chronic symptoms. Leukemia was considered less likely on the basis of a normal complete blood count in the context of significant bruising and bleeding. Anticoagulant ingestions from medications or commercial rat poison have been seen in older children and in cases of Munchausen syndrome by proxy, but this child had normal PT and PTT times, which would not have been the case after ingestion of anticoagulants.

Dermatologic considerations include Mongolian spots, which are rare in Caucasian children and do not progress through the color changes indicative of a healing bruise. These slate-blue patches of skin are commonly seen in pigmented skin. Phytophotodermatitis is a skin reaction to psoralens (a chemical compound in citrus fruits such as limes). After contact with psoralens and on exposure to sunlight, this manifests as red marks that appear as bruises or burns. The locations of the lesions, as well as the child 's age and lack of contact with psoralens, made such a diagnosis unlikely. Hemangioma was considered. Unlike this child 's lesions, hemangiomas undergo a typical growth pattern of rapid growth for the first 6 months of life, then a slowing of growth until 3 years. This child 's lesions resolved and then new ones appeared. Approximately 85% of hemangiomas spontaneously involute or partially regress, but not until later childhood.

Collagen vascular diseases should be considered. Ehlers-Danlos syndrome (EDS) is a congenital defect in collagen synthesis that may lead to easy bruising. Many forms have been identified that involve a variety of basic defects and inheritance patterns. This child did not display the clinical triad seen in these patients: skin hyperextensibility, joint hypermobility, and skin fragility. Osteogenesis imperfecta is a congenital abnormality of quality or quantity of type I collagen synthesis. Of the four subtypes, type I is associated with easy bruising and fractures as seen in this child, but this child did not display other signs, such as blue sclera, hearing impairment, osteopenia, bony deformities, and excessive laxity of joints. Should a question have persisted, a punch biopsy of skin for analysis of collagen synthesis would confirm the diagnosis. Infectious causes were unlikely given the timing of the child 's lesions. Child abuse remains the most alarming cause of unexplained bruising in children.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

» Next page: Risk Factors for Skin rash

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Causes of Skin rash

Causes of Skin rash (Diseases Database):

Skin rash Causes: Book Excerpts

Skin rash as a complication of other conditions:

Skin rash as a symptom:

Medications or substances causing Skin rash:

Drug interactions causing Skin rash:

Medical news summaries relating to Skin rash:

Related information on causes of Skin rash:

Causes of Skin rash: Online Medical Books

Pruritis without Rash: Differential Diagnosis (In a Page: Signs and Symptoms)

Pruritis with Rash: Differential Diagnosis (In a Page: Signs and Symptoms)

Rash with Fever: Differential Diagnosis (In a Page: Signs and Symptoms)

Scalp Rash: Differential Diagnosis (In a Page: Signs and Symptoms)

Hand and Foot Rashes: Differential Diagnosis (In a Page: Signs and Symptoms)

Dry Skin (Xerosis): Differential Diagnosis (In a Page: Signs and Symptoms)

Skin Pigmentation (Decreased): Differential Diagnosis (In a Page: Signs and Symptoms)

Genital Skin Lesions: Differential Diagnosis (In a Page: Signs and Symptoms)

Papulosquamous Lesions: Differential Diagnosis (In a Page: Signs and Symptoms)

Vesicular & Bullous Lesions: Differential Diagnosis (In a Page: Signs and Symptoms)

Pruritus: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Annular Rashes: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Hand & Foot Rashes: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Morbilliform Rashes: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Vesicular Rashes: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Papular rash: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Acne vulgaris

Anthrax (cutaneous)

Dermatomyositis

Follicular mucinosis

Fox-Fordyce disease

Granuloma annulare

Human immunodeficiency virus (HIV) infection

Kaposi’s sarcoma

Lichen planus

Mononucleosis (infectious)

Necrotizing vasculitis

Pityriasis rosea

Polymorphic light eruption

Psoriasis

Rosacea

Seborrheic keratosis

Smallpox

Syringoma

Systemic lupus erythematosus (SLE)

Typhus

Other causes

Drugs

Pustular rash: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Acne vulgaris

Blastomycosis

Folliculitis

Furunculosis

Impetigo contagiosa

Pustular miliaria

Pustular psoriasis

Rosacea

Scabies

Smallpox

Varicella zoster

Other causes

Drugs

Pruritus: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Anemia (iron deficiency)

Anthrax (cutaneous)

Conjunctivitis

Dermatitis

Hepatobiliary disease

Herpes zoster

Leukemia (chronic lymphocytic)

Lichen simplex chronicus

Myringitis (chronic)

Pediculosis

Pityriasis rosea

Psoriasis

Scabies

Tinea pedis

Urticaria

TREATMENTS &
RESEARCH

Dr. Huntley's
Diagnosis
Checklist

Pruritis without Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

Pruritis with Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

Rash with Fever: Differential Diagnosis
(In a Page: Signs and Symptoms)

Scalp Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

Hand and Foot Rashes: Differential Diagnosis
(In a Page: Signs and Symptoms)

Dry Skin (Xerosis): Differential Diagnosis
(In a Page: Signs and Symptoms)

Skin Pigmentation (Decreased): Differential Diagnosis
(In a Page: Signs and Symptoms)

Genital Skin Lesions: Differential Diagnosis
(In a Page: Signs and Symptoms)

Papulosquamous Lesions: Differential Diagnosis
(In a Page: Signs and Symptoms)

Vesicular & Bullous Lesions: Differential Diagnosis
(In a Page: Signs and Symptoms)

Pruritus: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Annular Rashes: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Hand & Foot Rashes: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Morbilliform Rashes: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Vesicular Rashes: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Papular rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Pustular rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Pruritus: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Skin, mottled: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Butterfly rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Vesicular rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Skin turgor, decreased: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Skin, clammy: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Skin, scaly: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Rocky Mountain spotted fever: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Pruritus ani: Causes
(Professional Guide to Diseases (Eighth Edition))

Staphylococcal scalded skin syndrome: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Papular rash: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))