Prof. H. Herry Garna, dr., Sp.A(K), Ph.D

Infection – Tropical Disease SubdivisionInfection – Tropical Disease Subdivision

Department of Child Health, Faculty of MedicineDepartment of Child Health, Faculty of Medicine

Padjadjaran University, Hasan Sadikin General Hospital Padjadjaran University, Hasan Sadikin General Hospital BandungBandung

FEVER AND RASH

IntroductionIntroduction

Fever is often the first symptom noted by Fever is often the first symptom noted by parents, common problem in clinicparents, common problem in clinic

Wide range of severity: Wide range of severity:

self limiting disease self limiting disease life-threatening life-threatening Wrong first suspicion Wrong first suspicion fatal outcome fatal outcome It is more likely to be caused by infection, It is more likely to be caused by infection,

but any inflammatory, neoplastic, but any inflammatory, neoplastic, immunologic or traumatic event can immunologic or traumatic event can generate fevergenerate fever

IntroductionIntroduction

Knowledge of differential diagnosis is Knowledge of differential diagnosis is very importantvery important

DiagnosisDiagnosis

- Accurate anamnesis- Accurate anamnesis

-- Physical examination Physical examination

- Supporting examination- Supporting examination

Differential DiagnosisDifferential Diagnosis

Past history of infectious disease and Past history of infectious disease and immunizationimmunization

Type of prodromal periodType of prodromal period Feature of the rashFeature of the rash Presence of pathognomonic or other Presence of pathognomonic or other

diagnostic signsdiagnostic signs Laboratory diagnostic testsLaboratory diagnostic tests

Differential DiagnosisDifferential Diagnosis

Feature of the rashFeature of the rash

* * Category:Category:

- Macular or maculo-papular:- Macular or maculo-papular:

Morbilli, rubella, roseola infantum, Morbilli, rubella, roseola infantum,

scarlatinascarlatina

- Papulo-vesicular:- Papulo-vesicular:

Varicella, herpes zoster, variolaVaricella, herpes zoster, variola

* * Character: Character: discrete or confluentdiscrete or confluent

* Distribution, duration* Distribution, duration

* * The appearance associated with fever?The appearance associated with fever?

Etiologic AgentsEtiologic Agents

Infectious DiseasesInfectious Diseases VirusVirus

Classic viral exanthema: Classic viral exanthema:

Measles, Rubella, Varicella Zoster Virus Measles, Rubella, Varicella Zoster Virus (VZV)(VZV)

Parvovirus, Roseola (HHV 6 and HHV 7) Parvovirus, Roseola (HHV 6 and HHV 7)

Others: HSV, EBV, HBV, Enterovirus, Others: HSV, EBV, HBV, Enterovirus, DengueDengue

BacteriaBacteria

Scarlet fever, Scarlet fever, mmeningococcemia, typhoid fevereningococcemia, typhoid fever

Staphylococcal infection (sepsis, toxic shock Staphylococcal infection (sepsis, toxic shock syndrome)syndrome)

Etiologic AgentsEtiologic Agents

MycoplasmaMycoplasma Rickettsia Rickettsia

Noninfectious DiseasesNoninfectious Diseases AllergicAllergic: food, drugs, toxin, serum : food, drugs, toxin, serum

sicknesssickness

The etiology remains elusiveThe etiology remains elusive: : Kawasaki Kawasaki diseasedisease

AnamnesisAnamnesis

Demographic dataDemographic data Appearance of rashAppearance of rash History of exposureHistory of exposure History of health beforeHistory of health before History of disease in the familyHistory of disease in the family Other complaintOther complaint

AnamnesisAnamnesis

Demographic DataDemographic Data

Age: neonate, infant, older childrenAge: neonate, infant, older children Sex Sex EthnicEthnic//race : Kawasaki disease ?race : Kawasaki disease ? Season: winter or dry season or not Season: winter or dry season or not

specificspecific Certain geographic: endemicCertain geographic: endemic

AnamnesisAnamnesis

Appearance of rashAppearance of rash

Location and distributionLocation and distribution Expansion and evolutionExpansion and evolution Correlation between rash and feverCorrelation between rash and fever

in the period of high fever (morbilli)in the period of high fever (morbilli)

in the period of decreasing fever in the period of decreasing fever (roseola infantum) (roseola infantum)

Pain or itching (drug eruptiPain or itching (drug eruptioon: itching) n: itching)

AnamnesisAnamnesis

History of ExposureHistory of Exposure

Contac t with similar disease (house, Contac t with similar disease (house, others)others)

TravelTravel Pet, insectsPet, insects Medicine or other medical measuresMedicine or other medical measures ImmunizationImmunization

AnamnesisAnamnesis

History of health beforeHistory of health before

History of disease beforeHistory of disease before Growth and developmentGrowth and development History of recurrent diseaseHistory of recurrent disease

History of disease in the familyHistory of disease in the family

Autoimmun ?Autoimmun ?

AnamnesisAnamnesis

Other complaintOther complaint

Local complaint (specific organ) Local complaint (specific organ)

Systemic complaint Systemic complaint (multiorgan/multisystem diseases)(multiorgan/multisystem diseases)

Physical ExaminationPhysical Examination

General condition/severity of diseaseGeneral condition/severity of disease

Characteristic of rashCharacteristic of rash

With enanthemWith enanthemaa

Other physical disordersOther physical disorders

Physical ExaminationPhysical Examination

General condition/severity of diseaseGeneral condition/severity of disease Meningococcemia, Staphylococcal Meningococcemia, Staphylococcal t toxic oxic

syndromesyndrome

Characteristic of rashCharacteristic of rash

Macule, Macule, ppapule, apule, mmaculo-papuleaculo-papule Vesicle, Vesicle, ppustule, ustule, bbullaulla PetechiPetechiaae or purpurae or purpura Erythroderma: diffuse or localErythroderma: diffuse or local

Nonblanching lesionsNonblanching lesions

PPetechietechiaae, purpura, and echymosise, purpura, and echymosis Difference sizeDifference size PetechiPetechiaae diameter <2 mm e diameter <2 mm PPurpura 2 mm–1 cmurpura 2 mm–1 cm EEchymosis diameter >1 cmchymosis diameter >1 cm

Physical ExaminationPhysical Examination

With enanthemWith enanthemaa Mouth: Hand-foot-mouth disease?Mouth: Hand-foot-mouth disease?

Buccal mucosa, Buccal mucosa, ppalatum, pharyngalatum, pharyng,, and and tonsiltonsil

Genital mucosaGenital mucosa

OthersOthers Arthritis, eye disorders, cardiac disordersArthritis, eye disorders, cardiac disorders Hepatomegaly, splenomegaly, Hepatomegaly, splenomegaly,

lymphadenopathylymphadenopathy

Diffential Diagnosis of Fever Diffential Diagnosis of Fever and Rashand Rash

Viruses Bacteria Other

Maculo/papular Measles, rubella, HHV-6, DengueEBV, HBV, HIV, enterovirus

GABHS(scarlet fever)Salmonella, Lyme,Mycoplasma pneumoniae

Rickettsia

Vesicular, bullous

VZV, HSV, EchovirusCoxsackievirus A, B(HFMD)

Impetigo (GAS)

Petechiae Hemorrhagic fever, CMV, EBV, VZVenterovirus

Sepsis (N.men, S.pneu,Hib)Rat bite fever

Rickettsia

Diffuse erythroderma

Dengue GABHS (scarlet fever)TSS

C. albicans

Morbilli (Measles, Rubeola)Morbilli (Measles, Rubeola)

Clinical AppearanceClinical Appearance Incubation period: 10–12 daysIncubation period: 10–12 days Three stadia: prodromal—eruption— convalescentsThree stadia: prodromal—eruption— convalescents ProdromalProdromal: 3–5 days: 3–5 days

3 C3 C ( (Coryza, Conjunctivitis, CoughCoryza, Conjunctivitis, Cough), fever, ), fever, Koplick’s spotsKoplick’s spots

EruptionEruption: high fever (40–40,5°C) : high fever (40–40,5°C) Typical rash: Typical rash:

- Maculo-papular- Maculo-papular erythromatouserythromatous

- Confluence-general- Confluence-general

- Start from backside of ear (head) - Start from backside of ear (head) body and body and upper arm upper arm lower extremities during 3 days lower extremities during 3 days whole of bodywhole of body

MorbilliMorbilli

Endemic in developing countriesEndemic in developing countries Effective immunization programEffective immunization program

cases decreasingcases decreasing

prone to older age groupprone to older age group• Lesion particularly at skin, mucous Lesion particularly at skin, mucous

membrane, conjunctivamembrane, conjunctiva• Serous exudate, mononuclear cell Serous exudate, mononuclear cell

predominantpredominant

DiagnosisDiagnosis

AnamnesisAnamnesis

* Symptoms* Symptoms

* History: contact, immunization* History: contact, immunization Clinical signsClinical signs

* Typical* Typical Laboratory examinationLaboratory examination

* Leukopenia* Leukopenia

* Relative lymphocytosis* Relative lymphocytosis

Clinical Manifestations of Clinical Manifestations of MorbilliMorbilli

Koplick’s spots Conjunctivi

tis

Rash distribution from head to lower extremities

Measles

MorbilliMorbilli

ComplicationsComplications Acute otitis media (10–15%)Acute otitis media (10–15%) Pneumonia interstitialis (50–75% with radiologic Pneumonia interstitialis (50–75% with radiologic

abnormalities) abnormalities) Myocarditis and pericarditisMyocarditis and pericarditis Encephalitis (1/1,000 cases) 7–10 days after rash Encephalitis (1/1,000 cases) 7–10 days after rash

appearance appearance

(1/3 dead, 1/3 physical defect, 1/3 recover )(1/3 dead, 1/3 physical defect, 1/3 recover ) Subacute sclerosing panencephalitis (SSPE)Subacute sclerosing panencephalitis (SSPE)

(0(0,,2–2 /100,000 morbilli, mean2–2 /100,000 morbilli, mean incubation 7 years)incubation 7 years)

CFR almost 100% after 6–9 monthsCFR almost 100% after 6–9 months

ComplicationsComplications

Persistent diarrheaPersistent diarrhea Exaserbation of tuberculosis (TBC)Exaserbation of tuberculosis (TBC) Keratoconjunctivitis Keratoconjunctivitis blindness blindness Secondary bacterial infection of skinSecondary bacterial infection of skin NomaNoma

Rubella (German Measles)Rubella (German Measles)

Clinical ManifestationsClinical Manifestations

Incubation period: 15—21 daysIncubation period: 15—21 days Mild prodromal sign:Mild prodromal sign:

- mild fever- mild fever

- adolescent: more severe- adolescent: more severe Rash: maculopapularRash: maculopapular

face face centrifugal to neck centrifugal to neck trunk, trunk, extremities extremities 24 hours all of body 24 hours all of body resolve in 3resolve in 3rdrd day day

Congenital Rubella Congenital Rubella SyndromeSyndrome

Depend on gestational ageDepend on gestational age

AbortusAbortus

StillbirthStillbirth

Congenital anomalyCongenital anomaly GravidaGravida

1–4 weeks: 61%1–4 weeks: 61%

5–8 weeks: 26%5–8 weeks: 26%

9–12 weeks: 8%9–12 weeks: 8%

Congenital Rubella Congenital Rubella SyndromeSyndrome

Opthalmologic: Cataract - Opthalmologic: Cataract - MicropthalmiaMicropthalmia

Glaucoma - Glaucoma - ChorioretinitisChorioretinitis

Cardiac: Septal defect - PDACardiac: Septal defect - PDA Neurologic: Meningoencephalitis Neurologic: Meningoencephalitis

Microcephaly Microcephaly

Mental retardation Mental retardation Auditoric: Sensorineural deafnessAuditoric: Sensorineural deafness

Exanthema Subitum Exanthema Subitum (Roseola Infantum)(Roseola Infantum)

Acute infection caused by human herpes Acute infection caused by human herpes virus 6 (some HHV 7)virus 6 (some HHV 7)

Mostly in infantMostly in infant Sporadic (sometimes epidemic)Sporadic (sometimes epidemic) Typical feature:Typical feature:

- Severity of clinical sign unproportionally- Severity of clinical sign unproportionally

with degree of feverwith degree of fever

- Simultaniously resolve of rash and - Simultaniously resolve of rash and clinical signclinical sign

Clinical ManifestationClinical Manifestation

Incubation period: 7–17 days (mean 10 days)Incubation period: 7–17 days (mean 10 days) Most common in 6–18 months oldMost common in 6–18 months old FeverFever

- abruptly high: 39,4–41,2°C- abruptly high: 39,4–41,2°C

- duration: 1–5 days (mostly 3–4 days)- duration: 1–5 days (mostly 3–4 days)

- convulsion can occur- convulsion can occur Mild clinical sign: mild pharyngitis and coryzaMild clinical sign: mild pharyngitis and coryza Rash: not specific: macule/maculopapular, rose color Rash: not specific: macule/maculopapular, rose color

chest chest extremities and neck extremities and neck face face Appear while temperature has return to normalAppear while temperature has return to normal Disappear on 1–2 days with normal skinDisappear on 1–2 days with normal skin

PrognosisPrognosis

Particularly good prognosisParticularly good prognosis Bad prognosis:Bad prognosis:

Hyperpyrexia with persistent Hyperpyrexia with persistent convulsionconvulsion

Scarlet Fever - ScarlatinaScarlet Fever - Scarlatina

Clinical manifestationClinical manifestation Incubation period: 1–7 days (mean: 3 Incubation period: 1–7 days (mean: 3

days)days) Acute symptoms: high fever—Acute symptoms: high fever—

headache— vomiting—chillsheadache— vomiting—chills Signs: severe pharyngitis Signs: severe pharyngitis

hyperemia— edema— exudate—hyperemia— edema— exudate—dysphagiadysphagia

Sometimes abdominal painSometimes abdominal pain Enlargement of lymph nodeEnlargement of lymph node

SScarlet Fevercarlet Fever - Scarlatina- Scarlatina

Typical rashTypical rash Erythroderma diffuse (red sandpaper)Erythroderma diffuse (red sandpaper) Reddish macule/papule Reddish macule/papule blanching on pressure blanching on pressure Firstly on axilla, groin, and neck Firstly on axilla, groin, and neck 24 hours all of 24 hours all of

bodybody Petechiae can occurPetechiae can occur Rash at chin and forehead (confluence): Rash at chin and forehead (confluence):

circumoral palorcircumoral palor Usually: Usually: palms and soles of feetpalms and soles of feet

Scarlet FeverScarlet Fever - Scarlatina- Scarlatina

Tongue: white thick membrane Tongue: white thick membrane

(white strawberry tongue)(white strawberry tongue)

After several days : peeled off After several days : peeled off papule papule (red strawberry tongue)(red strawberry tongue)

Pintpoint petechiae in the flexures Pintpoint petechiae in the flexures

produce a linear purpuric pattern produce a linear purpuric pattern

(pathognomonic)(pathognomonic)(Pastia’s lines)(Pastia’s lines)

Scarlet Fever (Scarlatina)Scarlet Fever (Scarlatina)

A beta-hemolytic Streptococcus group A beta-hemolytic Streptococcus group pyrogenic toxin (erythrogenic toxin)pyrogenic toxin (erythrogenic toxin)

Desquamation occur from end of 1Desquamation occur from end of 1stst week to week to 66thth week of disease week of disease

Diagnosis: History and physical examinationDiagnosis: History and physical examination

Pharyngeal swab: bacterial culturePharyngeal swab: bacterial culture

Serologic: ASTO/ASLO/ASOSerologic: ASTO/ASLO/ASO

Complete blood count: leukocytosisComplete blood count: leukocytosis

CRP increased or +: not specificCRP increased or +: not specific

Scarlet FeverScarlet Fever - Scarlatina- Scarlatina

Desquamation of rash after 1 week, Desquamation of rash after 1 week,

especially in hand and footespecially in hand and foot

ComplicationsComplications

Local spread/per continuitatum:Local spread/per continuitatum:

- Sinusitis – otitis media – mastoiditis- Sinusitis – otitis media – mastoiditis

- Retro/parapharyngeal abcess- Retro/parapharyngeal abcess

- Brochopneumonia- Brochopneumonia

- Servical adenitis- Servical adenitis Hematogenic spreadHematogenic spread - Meningitis – osteomyelitis – arthritis (septic)- Meningitis – osteomyelitis – arthritis (septic) Non suppurative (late) complicationsNon suppurative (late) complications

- Acute rheumatic fever- Acute rheumatic fever

- Acute- Acute glomerulonephritisglomerulonephritis

• Incubation period: 3–14 days

• Fever: suddenly high disappear: day-3 or 4 recover or dicrease: day-3 atau 4 , and appear again after 1–3 days camel saddle Long of fever: 5–7 days

• Incubation period: 3–14 days

• Fever: suddenly high disappear: day-3 or 4 recover or dicrease: day-3 atau 4 , and appear again after 1–3 days camel saddle Long of fever: 5–7 days

Dengue Fever (1)Dengue Fever (1)

Other complaint

• Headache, retro orbital pain

• Joint pain, back pain (backborne fever)

• Weakness, malaise

• Flushing: face, neck

• Photophobia, cough

Other complaint

• Headache, retro orbital pain

• Joint pain, back pain (backborne fever)

• Weakness, malaise

• Flushing: face, neck

• Photophobia, cough

Dengue Fever (2)Dengue Fever (2)

Skin rash

Primary rash

Rash: morbilliform (maculopapule):

chest and joint fold

Secondary rash

After day-4, especially day-6 or day-7

Maculopapule/petechiae /purpura/mixed

Confluence: usually hand and foot

Sometimes itching

Skin rash

Primary rash

Rash: morbilliform (maculopapule):

chest and joint fold

Secondary rash

After day-4, especially day-6 or day-7

Maculopapule/petechiae /purpura/mixed

Confluence: usually hand and foot

Sometimes itching

Dengue Fever (3)Dengue Fever (3)

• Hemorrhage ?

• Although not usual hemorrhage - petechiae (skin) - epistaxis - gum bleeding, vomiting/with blood - menorrhage

• Hemorrhage ?

• Although not usual hemorrhage - petechiae (skin) - epistaxis - gum bleeding, vomiting/with blood - menorrhage

Dengue Fever (4)Dengue Fever (4)

I VIV VII VIIIIIIII IV

36 oC

39 oC

40 oC

38 oC

37 oC

Pattern of Fever in Dengue Infection Pattern of Fever in Dengue Infection

Primary rash Primary rash Secondary rash Secondary rash

Dengue Virus Infection

FlushingPetechia

Secondary rash (convalescent rash)Secondary rash (convalescent rash)

MeningococcemiaMeningococcemia

Etiology: Neisseria meningitidis Etiology: Neisseria meningitidis (meningococcus)(meningococcus)

Clinical manifestationsClinical manifestations

– Acute fever, suddenly highAcute fever, suddenly high

– Hemorrhagic manifestations: petechiHemorrhagic manifestations: petechiaa, , purpura (fulminant)purpura (fulminant)

– Progressive severe Progressive severe meningitis, sepsis, meningitis, sepsis, septic shockseptic shock

Meningococcemia

VaricellaVaricella//ChickenpoxChickenpox Clinical manifestationsClinical manifestations Prodromal:Prodromal: 1–2 days,1–2 days, mild fever mild fever Papular erythromatous Papular erythromatous vvesicle esicle ppustule ustule crusta crusta Distribution of rash from body to faceDistribution of rash from body to face neck and extremitiesneck and extremities Pruritus +++Pruritus +++ Mucous membraneMucous membrane Spesific: several kinds of rash inSpesific: several kinds of rash in the same timethe same time

Varicella/ChickenpoxVaricella/Chickenpox

ComplicationComplication PneumoniaPneumonia (rare in children(rare in children, , high mortality inhigh mortality in immunocompromised hostsimmunocompromised hosts CeCerebelrebelllarar ataxia ataxia (1/4 (1/4..000000: : age age <15 yr) <15 yr) (Develops 7 to 10 days into the disease, (Develops 7 to 10 days into the disease, excellent prognosis)excellent prognosis) Transvere myelitis, Transvere myelitis, Guillain-Barre Guillain-Barre syndrome syndrome Hemorrhagic: thrombocytopeniaHemorrhagic: thrombocytopenia

Varicella/ChickenpoxVaricella/Chickenpox

ComplicationComplication SuperinfectionSuperinfection

- loc- localal: S. aureus: S. aureus or GABHS: cellulitisor GABHS: cellulitis

- systemic: GABHS: sepsis, necrotizing fasciitis, - systemic: GABHS: sepsis, necrotizing fasciitis, streptococcal streptococcal ttoxic oxic sshock hock ssyndromeyndrome

Reye Syndrome Reye Syndrome

PersistPersisteent vomiting, decreased mental status, nt vomiting, decreased mental status, liverliver

dysfunctiondysfunction

Associated with salicylate-containing productsAssociated with salicylate-containing products

Avoid aspirin in varicella !!!Avoid aspirin in varicella !!!

Hand-foot-mouth DiseaseHand-foot-mouth Disease

Etiologi Etiologi

- - CCoxackie virus typeoxackie virus type 16 (A 16)16 (A 16) >>>>

- - EEnterovirus 71nterovirus 71 encephalitis encephalitis

- Others: - Others: A5, A7, A9, A10, B2, B5 A5, A7, A9, A10, B2, B5

Fever, pharyngitis, salivationFever, pharyngitis, salivation

Self-limiting, simpSelf-limiting, simpttomatic therapy omatic therapy

HFMDHFMD HFMD

KKawasaki diseaseawasaki disease

First described in 1967First described in 1967 Incidence: 67 cases /100Incidence: 67 cases /100,,000 in Japan000 in Japan

5.6 cases/1005.6 cases/100,,000 in USA000 in USA 85% in children < 5 years (peak 18–24 mo)85% in children < 5 years (peak 18–24 mo)

Rarely occurs in adolescent, adults or children < Rarely occurs in adolescent, adults or children < 6 mo 6 mo

M/F ratio 1.4:1M/F ratio 1.4:1 Occurs often in late winter and springOccurs often in late winter and spring Etiology: UEtiology: Unknownnknown Pathophysiology: « Superantigen theory » causing Pathophysiology: « Superantigen theory » causing

an intense vasculitisan intense vasculitis

KKawasakiawasaki Disease Disease

Diagnosis: Diagnosis: fever lasting more than 5 daysfever lasting more than 5 days, plus , plus 4 of the following 5 criteria (other illnesses 4 of the following 5 criteria (other illnesses with similar clinical signs must be excluded):with similar clinical signs must be excluded):

1.1. Polymorphous rashPolymorphous rash

2.2. Bilateral conjunctival injectionBilateral conjunctival injection

3.3. One or more of the following mucous One or more of the following mucous membrane changes:membrane changes:

- Diffuse injection of oral and pharyngeal - Diffuse injection of oral and pharyngeal mucosamucosa

- Erythema or fissuring of the lips- Erythema or fissuring of the lips

- Strawberry tongue- Strawberry tongue

KKawasakiawasaki Disease Disease

4.4. Acute, nonpurulent cervical Acute, nonpurulent cervical lymphadenopathy (one lymph node must lymphadenopathy (one lymph node must be >1.5 cm)be >1.5 cm)

5. One or more of the following extremity 5. One or more of the following extremity changes:changes:

- Erythema of palms and/or soles- Erythema of palms and/or soles

- Indurative edema of hands and/or feet- Indurative edema of hands and/or feet

- Membranous desquamation of the - Membranous desquamation of the fingertipsfingertips

Polymorphous rash

Kawasaki Disease

One or more of the following One or more of the following extremity changesextremity changes

Erythema of palms and/ or soles

Indurative edema of hands and/or feet

Membranous desquamation of the fingertips

Bilateral conjunctival

injection

Strawberry tongue

Erythema or fissuring of the

lips

Nonpurulent cervical

lymphadenopathy

ConclusionsConclusions

Children Who Present Fever Children Who Present Fever and Rashand Rash

Group 1Group 1 : children with symptoms of serious illness who : children with symptoms of serious illness who require require

immediate intervention immediate intervention

Group 2Group 2 : children with a clearly recognizable-and usually : children with a clearly recognizable-and usually benign-benign-

viral syndromeviral syndrome

Group 3Group 3 : children who present early in the course of the : children who present early in the course of the disease, disease,

when the clinical picture and physical findings are when the clinical picture and physical findings are

nonspecific, and those with undifferentiated rashes nonspecific, and those with undifferentiated rashes with with

feverfever

Key Questions

Acute or Chronic (Recurrent)?

When did it start?

Pattern of Spread?

Sick or Well?

Pruritic?

Medications?

Exposures?

Describe What You See Pattern/Distribution

Diffuse or Localized? Mucous Membranes?

Palms & Soles? Exposed vs. Unexposed Areas?

Individual Lesions Color Size

Blanches? Characteristics

Other Physical Findings

Common Primary Skin Common Primary Skin LesionsLesions

MaculeMacule : Circumscribed area of change in normal skin color, : Circumscribed area of change in normal skin color, with no skin elevation or depression; may be any with no skin elevation or depression; may be any

sizesize

Papule Papule : Solid, raised lesion up to 0.5 cm in greatest : Solid, raised lesion up to 0.5 cm in greatest diameterdiameter

NoduleNodule : Similar to papule but located deeper in the dermis : Similar to papule but located deeper in the dermis or or

subcutaneous tissue; differentiated from papule by subcutaneous tissue; differentiated from papule by palpability and depth, rather than sizepalpability and depth, rather than size

PlaquePlaque : Elevation of skin occupying a relatively large area in : Elevation of skin occupying a relatively large area in relation to height; often formed by confluence of relation to height; often formed by confluence of papulespapules

Common Primary Skin Common Primary Skin LesionsLesions

Vesicle Vesicle : Circumscribed, elevated, fluid-containing lesion : Circumscribed, elevated, fluid-containing lesion less less

than 0.5 cm in greatest diameter; may be than 0.5 cm in greatest diameter; may be intraepidermal or subepidermal in originintraepidermal or subepidermal in origin

BullaBulla : Same as vesicle, except lesion is more than 0.5 : Same as vesicle, except lesion is more than 0.5 cm cm

in diameterin diameter

PustulePustule : Circumscribed elevation of skin containing : Circumscribed elevation of skin containing purulent purulent

fluid of variable character (i.e., fluid may be fluid of variable character (i.e., fluid may be white, white,

yellow, greenish or hemorrhagic)yellow, greenish or hemorrhagic)