Papular rash

A papular rash consists of small, raised, circumscribed — and perhaps discolored (red to purple) — lesions known as papules. It may erupt anywhere on the body in various configurations and may be acute or chronic. Papular rashes characterize many cutaneous disorders; they may also result from allergy and from infectious, neoplastic, and systemic disorders. (To compare papules with other skin lesions, see Recognizing common skin lesions.)

History and physical examination

Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.

Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

Medical causes

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.

Special considerations

Apply cool compresses or an antipruritic lotion. Administer an antihistamine for allergic reactions and an antibiotic for infection.

Pediatric pointers

Common causes of papular rashes in children are infectious diseases, such as molluscum contagiosum and scarlet fever; scabies; insect bites; allergies and drug reactions; and miliaria, which occurs in three forms, depending on the depth of sweat gland involvement.

Geriatric pointers

In elderly patients who are bedridden, the first sign of pressure ulcers is commonly an erythematous area, sometimes with firm papules. If not properly managed, these lesions progress to deep ulcers and can lead to death.

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Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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