Vesicular rash
A vesicular rash is a scattered or linear distribution of blisterlike lesions — sharply circumscribed and filled with clear, cloudy, or bloody fluid. The lesions, which are usually less than 0.5 cm in diameter, may occur singly or in groups. (See Recognizing common skin lesions, pages 488 and 489.) They sometimes occur with bullae — fluid-filled lesions larger than 0.5 cm in diameter.
A vesicular rash may be mild or severe and temporary or permanent. It can result from infection, inflammation, or allergic reactions.
History
Ask your patient when the rash began, how it spread, and whether it has appeared before. Did other skin lesions precede eruption of the vesicles? Obtain a thorough drug history. If the patient has used a topical medication, what type did he use and when was it last applied? Also, ask about associated signs and symptoms. Find out if he has a family history of skin disorders, and ask about allergies, recent infections, insect bites, and exposure to allergens.
Physical assessment
Examine the patient’s skin, noting if it’s dry, oily, or moist. Observe the general distribution of the lesions and record their exact location. Note the color, shape, and size of the lesions, and check for crusts, scales, scars, macules, papules, or wheals. Palpate the vesicles or bullae to determine if they’re flaccid or tense. Slide your finger across the skin to see if the outer layer of epidermis separates easily from the basal layer (Nikolsky’s sign).
Medical causes
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
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. Nonspecific signs and symptoms may also occur, such as fever, myalgia, headache, lymphadenopathy, nausea, and vomiting.
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.
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.
Special considerations
Any skin eruption that covers a large area may cause substantial fluid loss through the vesicles, bullae, or other weeping lesions. If necessary, start an I.V. line to replace fluids and electrolytes. Keep the patient’s environment warm and free from drafts, cover him with sheets or blankets as necessary, and take his rectal temperature every 4 hours because increased fluid loss and increased blood flow to inflamed skin may lead to hyperthermia.
Obtain cultures to determine the standard causative organism. Use precautions until infection is ruled out. Be alert for signs of secondary infection. Give the patient an antibiotic and apply corticosteroid or antimicrobial ointment to the lesions.
Pediatric pointers
Vesicular rashes in children are caused by staphylococcal infections (staphylococcal scalded skin syndrome is a life-threatening infection occurring in infants), varicella, hand-foot-and-mouth disease, contact dermatitis, and miliaria rubra.
Patient counseling
Tell the patient to wash his hands often and not to touch the lesions. Tell the patient not to scratch the rash to avoid infection and scarring. Suggest a tepid bath using little soap and rinsing thoroughly to help relieve itching. Cold compresses may also relieve itching.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Blisters
Read excerpts from these other book chapters related to Blisters:
Medical Books Excerpts
- Pustular rash
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Skin, scaly
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Skin, scaly
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Blisters
» Next page: Pustular rash (Nursing: Interpreting Signs and Symptoms)
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