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ULY CLINIC

14 Septemba 2025, 00:27:08

Papular rash

A papular rash consists of small, solid, raised lesions (papules) usually less than 1 cm in diameter, with red to purple discoloration. It may erupt anywhere on the body in varied configurations and may be acute or chronic. Papular rashes occur in many cutaneous disorders and may also result from allergic, infectious, neoplastic, or systemic causes.

Detection and assessment may vary with skin tone. In darker skin, papules may be less obvious and best appreciated on mucosa, conjunctiva, or by palpation.

Emergency Interventions

Assess for systemic signs suggesting serious illness (fever, hypotension, respiratory distress, altered mental status).
In rapidly spreading, tender, or purpuric rashes, rule out meningococcemia, necrotizing fasciitis, or vasculitis.
Check vital signs, hydration, and perfusion.
Prepare to administer appropriate antibiotics or antivirals if an infectious cause is suspected.
Maintain airway and hemodynamic support in severe cases.

History and Physical Examination

History

Onset, progression, and distribution of the rash.
Character: pruritic, burning, painful, or tender; any discharge or drainage.
Associated symptoms: fever, headache, malaise, GI distress, myalgia, sore throat, lymphadenopathy.
Medical history: allergies, previous skin disorders, infections, childhood exanthems, cancers.
Sexual history, including exposure to sexually transmitted infections.
Environmental exposure: insect/rodent bites, contact with infected individuals, occupational risks (e.g., animals, wool, hides).
Complete drug history: new or recent medications, over-the-counter products, supplements.

Physical Examination

Note color, configuration, size, and distribution of papules.
Examine mucous membranes, scalp, nails, palms, and soles.
Assess for lymphadenopathy, hepatosplenomegaly, joint tenderness, or muscle weakness.
Inspect for ulceration, necrosis, or secondary infection.
Consider dermoscopy or skin scraping if etiology is unclear.

Conditions and lesion type

Table 1: Common Skin Lesions for and types

Lesion	Definition	Size	Contents / Characteristics	Skin Color / Other Notes	Example Conditions
Macule	Flat blemish or discoloration with the same texture as surrounding skin	< 1 cm	None (flat)	Brown, tan, red, or white	Freckles (ephelides), vitiligo patches, measles spots
Papule	Small, solid, raised lesion	< 1 cm	Solid	Red to purple	Warts, lichen planus, insect bites
Nodule	Firm, circumscribed, elevated lesion	1–2 cm	Solid	May have skin discoloration	Dermatofibroma, rheumatoid nodule
Tumor	Solid, raised mass	> 2 cm	Solid	May have skin discoloration	Lipoma, basal cell carcinoma
Vesicle	Thin-walled, raised blister	< 0.5 cm	Clear, serous, purulent, or bloody fluid	—	Chickenpox (varicella), herpes simplex
Bulla	Raised, thin-walled blister	> 0.5 cm	Clear or serous fluid	—	Burns, bullous pemphigoid
Pustule	Circumscribed, elevated lesion	Variable	Pus or lymph (white/yellow)	Firm or soft	Acne, impetigo
Wheal	Slightly raised, firm lesion with surrounding edema	Variable	Edema within dermis	Skin may appear red or pale	Urticaria (hives), insect stings

Medical causes

Table 2: Medical causes of skin rash

Cause	Key Features / Associated Findings
Acne vulgaris	Inflamed papules, pustules, nodules, or cysts on face, chest, back; rupture of comedones may cause tenderness or pruritus.
Anthrax (cutaneous)	Pruritic macule or papule → vesicle → painless ulcer with black necrotic center; ± lymphadenopathy, malaise, headache, fever.
Dermatomyositis	Gottron’s papules (flat, violet lesions on finger joints); heliotrope edema; malar rash; proximal muscle weakness or soreness.
Follicular mucinosis	Perifollicular papules or plaques with alopecia.
Fox–Fordyce disease	Pruritic papules in axillae, pubic area, areolae; linked to apocrine gland inflammation; sparse hair growth.
Granuloma annulare	Papules forming annular plaques with central clearing; often on hands, feet, legs; may be pruritic or asymptomatic.
HIV infection (acute)	Generalized maculopapular rash; fever, sore throat, headache, lymphadenopathy, hepatosplenomegaly.
Kaposi’s sarcoma	Purple/blue papules or macules of vascular origin; blanch then refill slowly; may ulcerate or bleed; common in immunocompromised patients.
Kawasaki disease	Erythematous maculopapular rash on trunk/extremities; fever, irritability, conjunctivitis, red cracked lips, strawberry tongue, edema, peeling fingers/toes, lymphadenopathy; risk of coronary artery lesions.
Lichen planus	Flat, polygonal, violet papules with white lines (Wickham striae); often on wrists, lumbar area, genitalia; buccal mucosa lesions common.
Mononucleosis	Rubella-like maculopapular rash (10%); headache, malaise, fatigue, sore throat, lymphadenopathy, fever; ± splenomegaly or hepatitis.
Necrotizing vasculitis	Purpuric papules; ± low-grade fever, headache, myalgia, arthralgia, abdominal pain.
Pityriasis rosea	“Herald patch” (2–6 cm) followed by scaly yellow/tan or erythematous patches on trunk/limbs in “Christmas tree” pattern; mild itch.
Polymorphic light eruption	Papular/vesicular/nodular rash on sun-exposed skin; ± pruritus, headache, malaise.
Psoriasis	Erythematous papules → plaques with silvery scale (except in moist sites); ± nail pitting, arthralgia.
Rosacea	Persistent erythema, telangiectasia, papules/pustules on face; rhinophyma in severe cases.
Seborrheic keratosis	Benign tumors; yellow–brown papules (face/chest/back); in Black skin, small lesions on malar area (dermatosis papulosa nigra).
Smallpox (variola)	Fever, malaise, severe headache/backache → maculopapular rash on mouth, face, forearms → vesicles/pustules in sync; crust → pitted scar.
Syringoma	Sweat gland adenoma; yellowish/erythematous papules on eyelids, face, neck, upper chest.
Systemic lupus erythematosus (SLE)	Butterfly rash (malar), discoid plaques, photosensitivity; ± alopecia, oral ulcers, arthritis, fever, lymphadenopathy, serositis, renal or neuro symptoms.
Typhus	Headache, myalgia, arthralgia, fever, nausea, vomiting; maculopapular rash (not always).

Other Causes

Drug eruptions: Transient maculopapular rashes on trunk due to antibiotics (ampicillin, tetracycline, cephalosporins, sulfonamides), benzodiazepines, lithium, gold salts, allopurinol, isoniazid, salicylates.

Special considerations

Apply cool compresses or antipruritic lotions for comfort.
Prescribe antihistamines for allergic reactions; antibiotics for bacterial infection.
For uncertain etiology, consider skin biopsy, serology, or patch testing.
Evaluate immunocompromised patients promptly (e.g., HIV, transplant recipients).
Advise avoidance of irritants, allergens, or triggers.

Patient counseling

Teach gentle skin care: mild cleansers, moisturizers, avoid scratching.
Explain signs that require urgent review: sudden spread, high fever, mucosal involvement, or purpura.
Emphasize adherence to prescribed therapy (e.g., topical steroids, antivirals).
Counsel on sun protection in photosensitive conditions.

Pediatric pointers

Common causes in children: molluscum contagiosum, scarlet fever, scabies, insect bites, allergic or drug reactions, miliaria.
Assess vaccination history and exposure to exanthematous illnesses (measles, rubella, varicella).
Infants: monitor for dehydration or sepsis with widespread rashes.

Geriatric pointers

Bedridden older adults may develop papules as early signs of pressure ulcers; prompt pressure relief prevents progression to deep ulcers or death.
Drug reactions are more common due to polypharmacy.
Chronic papular eruptions (e.g., seborrheic keratosis, lichen planus) are frequent.

References

Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St Louis, MO: Mosby Elsevier; 2008:444-447.
Lehne RA. Pharmacology for Nursing Care. 7th ed. St Louis, MO: Saunders Elsevier; 2010.
McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.
Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.
Wolff K, Johnson RA. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. 6th ed. New York, NY: McGraw Hill Medical; 2009.