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Chapter 27 • Penile Discharge
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319
Is this a local infection or process?
Key Questions
l
Is the tip of your penis red and inamed?
l
Can you describe how you clean yourself?
Red, Inflamed Glans Penis
A beefy-red, inamed glans penis is indicative of a
yeast infection or a xed drug reaction often caused by
tetracycline. Lubricated condoms or spermicidal gel
can cause contact dermatitis.
Hygienic Practices
Poor hygiene or aggressive hygiene with inappropriate
and harsh cleansers can cause local irritation and result
in inammation.
Is this complicated urethritis?
Key Questions
l
Do you have frequency, urgency, or nocturia?
l
Do you have rectal, testicular, or low back pain?
l
Do you have pain in any joints or muscles?
l
Do you have any skin sores or lesions?
Symptoms of Complicated Urethritis
Symptoms of urinary frequency, urgency, and nocturia
may indicate complications of a urethral infection
caused by spreading of the infection to other urinary
tract structures such as the prostate (see Chapter 18).
Symptoms of perirectal, testicular, or low back pain
indicate involvement of the vas deferens and the
epididymis, which can lead to acute epididymitis and/
or the involvement of the testicles and the development
of orchitis.
Symptoms That May Indicate Reiter Syndrome
Reiter syndrome is a complication of NGU that follows
urogenital infection and classically includes arthritis,
conjunctivitis, oral mucosal ulcers, and dermatitis.
More common is the joint and tendon involvement after
C. trachomatis infection. This complication has also
been reported in HIV-positive patients. It is less com-
mon in nonwhite populations, and the incubation period
is usually 1 to 4 weeks after the onset of urethritis.
Symptoms That May Indicate Disseminated
Systemic Urethral Infection
A disseminated gonococcal infection can produce pap-
ules or petechiae that progress to pustules on the skin
surfaces of the hands, arms, and legs.
Is this an upper urinary tract problem?
Key Questions
l
Have you had a fever or chills?
l
Have you noticed any blood in your urine?
l
Are you having any acute pain?
l
Where is the pain?
Fever
The presence of fever indicates an ascending infection
of the upper urinary tract (e.g., pyelonephritis) or a
descending infection of the lower urinary tract (e.g.,
prostatitis, epididymitis). A fever with a temperature of
greater than 1018 F (398 C) should be cause for concern
and requires aggressive treatment.
Hematuria
Blood in the urine signies renal involvement—
specically, pyelonephritis or lithiasis. Painless hematuria in the elderly is characteristic of a bladder
tumor or is a late symptom of carcinoma of the
kidney.
Acute Pain
Abdominal pain, ank pain, and costovertebral angle
(CVA) pain are characteristic of bladder, ureter, and
kidney involvement. Urinary tract pain is usually
perceived locally in the area where sensory bers of
nerves are located. However, pain can be referred to
a site distant from the area that is affected because
sensory nerves of the lower body are concentrated in
the same segments of the spinal cord. Most pain in the
urinary tract is referred pain and may not be perceived by the patient in the site where the problem
actually occurs. A dull ache may be felt at the CVA or
ank. Pain may be elicited by applying tension to the
renal capsule, pelvis, or ureter. Ureter pain may be
perceived in the bladder, penis, scrotum, or perineum.
Testicular pain may be a result of renal calculi. Pain
may vary in intensity from a dull ache to a sharp,
stabbing, colicky pain that is unbearable.
What else could this be?
Key Questions
l
Do you have scrotal pain and/or fever?
l
Have you had recent urinary tract surgery or a
urinary catheter?
l
Have you been treated recently for an STI?
l
Are you or your partner an immigrant or have you
recently engaged in foreign travel?
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Chapter 27 • Penile Discharge
Scrotal Pain or Fever
Epididymitis usually presents with scrotal pain that
developed over a period of several hours. The patient
often is also febrile.
Recent Surgery or Instrumentation
Recent surgery or instrumentation in the urethra results
in a risk of infection. Elderly males are especially at
risk because they often undergo urinary tract surgery or
procedures using instrumentation secondary to benign
prostatic hypertrophy.
Recent Treatment for an STI
Recent treatment for an STI may indicate treatment
failure, a coinfection that was not sensitive to the prescribed drug, or recent exposure. The appropriate laboratory test may not have been done or might not have
been available, or treatment may have been empirically
based on presenting symptoms. Infection with more
than one organism indicates coinfection. Urethritis can
also develop from a nongonococcal organism that
has a longer incubation period and was not sensitive
to the drug prescribed. The urethritis episode may also
indicate a recent exposure after treatment. Another
possibility could be a lack of patient compliance with
treatment. The patient might not take the medication
as directed or stop taking the medication when the
symptoms disappear but before the causative organism
is eliminated from the urethra.
Immigrant Patient/Partner or Recent
Foreign Travel
Immigrants, partners of foreigners, and patients with a
history of foreign travel may have exposure to STIs
that are not seen frequently in the United States but
have a higher incidence and prevalence in foreign
countries. Resistant strains of common organisms are
also prevalent in foreign countries. Referral or consultation with urologists, infectious disease departments,
or public health departments may be necessary to
identify and treat patients with unusual STIs.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Note General Appearance
If the patient appears systematically ill, a more aggressive and immediate approach should be taken and an
expanded examination becomes appropriate. An ascending infection is usually limited to the anterior portion of the male urethra and is most likely to cause local
signs and symptoms in the male patient. The patient
who appears to be in acute pain from sites other than
the urethra warrants more than a focused physical
examination.
Examine skin surfaces, exposed orices, eyes,
mucous membranes, and bordering areas around sites
that may have been exposed during sexual activity.
Note eyes for discharge or infection. Check around
nares and lips for signs of infection or lesions. Inspect
the chest, back, palms, and bottoms of the feet for
rashes or lesions. Secondary syphilis produces typical
rashes and lesions in these areas as does Reiter syndrome. Spontaneous greenish-yellow discharge from
the eyes is indicative of gonococcal infections.
Inspect the skin of the abdomen, inguinal areas, and
thighs for lesions or rashes. Disseminated gonococcal
infections may produce papules, petechiae, and pustules on the hands, arms, and feet. Chlamydia may
produce hyperkeratotic lesions on skin surfaces and a
rash on the penis in the uncircumcised male.
Palpate Lymph Nodes
Palpate the cervical, axillary, inguinal, and femoral
lymph nodes for adenopathy. Although a nonspecic
indicator of infection, lymph nodes may enlarge in
response to exposure from several organisms. Virus
exposure may cause lymph node enlargement, or there
may be an extension of bacterial organisms into adjacent lymph chains, indicating regional infections. It is
important to ascertain how long the nodes have been
enlarged and what symptoms have appeared during the
course of enlargement. Assess the state of the nodes
such as any redness, swelling, heat, or pain, and note if
they are rm, mobile, or boggy. Sexually active males
may have some inguinal lymph node enlargement, and
the patient may or may not be aware of the enlargement. Lymph node enlargement should be documented
and described.
Examine Body Hair
Examine hair on the head and in the pubic area, and
inspect underlying skin areas. Hair shafts can be infected with lice and nits. Hair follicles can be irritated
from scratching and from secondary infection by other
organisms.
Examine the Penis and Urethral Meatus
Inspect penile skin surfaces for lesions, especially
the underside of the head of the penis around the area
of the frenulum, where viral lesions may be found.
Palpate the shaft of the penis for tenderness or for
Chapter 27 • Penile Discharge
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321
strictures of the urethra. Retract the foreskin, if present,
and inspect the glans penis, corona, and frenulum for
lesions. Inspect the meatus for redness, discharge, patency, or growths. If there is discharge, note if it is
spontaneous or produced by milking or stripping the
penis. Document a tender urethra and describe the character of any discharge. Note whether the discharge is
profuse and yellow-green, which indicates gonococcal
infection, or scant and mucoid-like, which is characteristic of C. trachomatis and nongonococcal infections.
Examine the Scrotum and Testicles
Inspect and palpate the scrotum for lesions. Palpate the
testicles and epididymis for tenderness and any signs
of inammation. Elevating a tender testicle may alleviate pain and reduce discomfort in epididymitis. The
testicle may not be dened when there is an acute infection present because of examiner-produced pain
with palpation. The borders of the testicle may also be
obliterated by swelling and edema.
Inspect and Examine Other Sites for Lesions
and Discharge
Inspect other sites such as the mouth and pharynx using a
tongue depressor to visualize buccal skinfolds for any lesions. The pharyngeal area may be asymptomatic. Depending on the patient’s sexual practices and preferences,
other sites exposed to sexual contact, such as the rectum,
need to be examined. Rectal bleeding, pus, and mucus
may indicate proctitis and require further anoscopic examination with special cultural and laboratory consideration (see Chapter 29). Examine any joints or tendons that
are inamed or tender or have limited range of motion.
LABORATORY AND DIAGNOSTIC STUDIES
To improve the probability of identifying the causative
organism, the patient should be examined and specimens obtained at least 1 hour after the last voiding
and ideally up to 4 hours after voiding. Manufacturer
directions should be followed for all materials used to
collect specimens, and policies and procedures should
be followed to obtain valid and reliable results from
laboratory and diagnostic tests.
Urine Dipstick
Urine dipstick is used as a screening test for urethritis.
A positive leukocyte esterase (LE) result is indicative
of urethritis (75% to 90% sensitivity, 95% specicity).
A positive nitrite signies bacterial infection. Urine
that tests positive for leukocyte esterase and nitrites
should be cultured for bacteria. However, note that
some organisms that cause UTIs do not convert nitrate
to nitrites (e.g., staphylococci and streptococci).
Urinalysis With Microscopic Examination
Look for proteinuria and glycosuria, which suggest kid-
ney involvement. The presence of casts, red blood cells
(RBCs), and bacteria is also important. Casts indicate
hemorrhage or pathological conditions of the nephrons.
RBCs indicate acute inammatory or vascular disorders
of the glomerulus. More than 1 or 2 RBCs/high-power
eld (HPF) is abnormal and may indicate renal or sys-
temic disease or kidney trauma. Microscopic examination
of the urine resulting in 20 or more organisms/HPF indi-
cates urinary tract infection. Fewer than 20 organisms/
HPF merits further study such as culture and sensitivity.
Segmented Urine Collection for Culture
and Sensitivity
Obtaining segmented urine specimens is a procedure
used to identify the site along the urinary tract where
the colonization of organisms occurs and is useful in
diagnosing prostatitis (see Chapter 18).
Gram Stain of Specimens
The Gram stain has 95% specicity in gonococcal
urethritis. Sensitivity in urethritis is nearly 100%. A
Gram stain of urethral discharge should be performed
to determine inammation (WBCs) and the presence
of either gram-negative or gram-positive bacteria.
If the stain is positive for polymorphonuclear neutrophils (PMNs), then the smear is examined for gramnegative intracellular diplococci (GNICDCs). If diplococci are found, the smear is considered positive for
gonococcal urethritis. A smear that is equivocal or
atypical indicates a mixed gonococcal and NGU. If
there are no GNICDCs, then an NGU is indicated.
Culture and Sensitivity
Culture and sensitivity should be performed on specimens to conrm the identity of the causative organism
and its sensitivity to antibiotics. This is especially important in populations with resistant organisms. A urethral
swab and cultures are necessary in cases of suspected
rectal or pharyngeal infection.
DNA Testing for Infectious Organisms
DNA testing using a rst-void sample or a sample taken
from the urethra or rectum provides rapid, sensitive,
and specic results. DNA tests include DNA probes, nucleic acid amplication tests (NAATs), and polymerase
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Chapter 27 • Penile Discharge
chain reaction (PCR) assays. Tests are available for
C. trachomatis, N. gonorrhoeae, U. urealyticum, and
other organisms.
Doppler Blood Flow
Doppler blood ow studies can be performed to support
the diagnoses of testicular torsion and epididymitis.
Testicular torsion results in a lack of blood ow to the
testicle, whereas in epididymitis the blood ow is intact. Color Doppler ow studies also provide information concerning blood ow to the testicles and identify
hot areas of infection.
Complete Blood Count
A complete blood count with differential can be performed to indicate a systemic response to infection.
Syphilis Testing
Serological tests are used for screening and diagnosing
syphilis and are recommended if other STIs are found
or suspected. The screening tests are nontreponemal
and include Venereal Disease Research Laboratory
(VDRL), rapid plasma reagin (RPR), and enzyme immunoassay (EIA) tests. Diagnostic tests are Treponema
pallidum–specic IgM hemagglutination test (TPIgM-HA), uorescent treponemal antibody absorption
test (FTA-ABS), and the Treponema pallidum particle
agglutination assay (TPPA). Detection of T. pallidum
can also be done using DNA testing.
severity. Discharge may range from copious amounts
of greenish-yellow discharge to scant mucoid-like
discharge that may only be visible before the rst
voiding of the day. The patient may report symptoms
such as urinary frequency, urgency, and/or burning
with urination, as well as penile discharge. Patients
may also report a known sexual partner or indicate
that the public health department has informed them
to get checked for an STI. If you are unable to make
a diagnosis based on history and physical ndings,
diagnostic testing is necessary for specic organism
identication.
N. gonorrhoeae and NGU caused by C. trachomatis
are the two most common infectious causes of urethritis. A coinfection with both organisms is found in up to
25% of cases.
Gonococcal Urethritis
Gonococcal STIs are usually the easiest to diagnose
because the patient often presents with complaints of
a yellow-green discharge and burning on urination.
Unprotected sexual relations increase the risk for contracting this STI. Gonococcal infection often becomes
symptomatic 2 to 6 days after exposure and produces
the classic yellow-green, profuse, spontaneous drainage. On examination, the penis will be normal in
appearance except for the copious discharge. Diagnosis is established by DNA testing and is conrmed by
Gram staining and urethral culture.
DIFFERENTIAL DIAGNOSIS
Urethritis
Urethritis presents with itching, burning, or pain
around the urethral opening. Symptoms vary in
EVIDENCE-BASED PRACTICE
Partner notification is a process in which sexual partners
of patients with an STI are informed of their exposure and
the need to receive treatment. This systematic review covers
four partner notification strategies: (1) Patient referral (the
patient tells their sexual partners that they need to be
treated, either with [enhanced] or without [simple] additional
support); (2) Expedited partner therapy (the patient delivers
medication or a prescription for medication to their partner(s)
without the need for a medical examination of the partner;
(3) Provider referral (health service personnel notify the partners); (4) Contract referral (the patient is encouraged to notify partners, but health service personnel will contact them
Data from Ferreira A, Young T, Mathews C, et al: Strategies for partner notification for sexually transmitted infections, including HIV, Cochrane Database
of Systematic Reviews
2013. Epub 2013 Oct 3.
Nongonococcal Urethritis
NGU can produce penile discharge, although on examination, discharge may not be present. NGU typically
develops over a longer incubation period of 8 to 21 days,
and 75% of patients have a clear or mucoid discharge.
Partner Notication for STIs
if they do not visit the health service by a certain date). In
this review, expedited partner therapy was more successful
than simple patient referral in reducing repeat infection in
patients with gonorrhea, chlamydia, or nongonococcal urethritis (six trials). Expedited partner therapy and enhanced
patient referral resulted in similar levels of repeat infection
(three trials). There were too few trials to allow consistent
conclusions about the relative effects of provider, contract, or
other patient referral methods for different STIs. The authors
concluded that the evidence assessed in this review does not
identify a single optimal strategy for partner referral for any
particular STI.
Chapter 27 • Penile Discharge
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323
Chlamydia is the most common nongonococcal
causative organism. The resulting urethritis is characterized by a scant mucoid discharge visible before the
rst urination of the day. The patient may complain of
irritation around the meatus of the urethra and have
vague symptoms. On examination, stripping the penis
may produce scant mucoid discharge. DNA testing is
used to diagnose Chlamydia. Gram staining is used to
rule out or conrm nongonococcal disease, which is
usually a chlamydial infection. Urine screening tests
can be used to identify DNA chlamydial particles.
Complicated Urethritis
Periurethritis may progress to urethral stricture in untreated cases, causing banding of the penile urethra in
the shaft of the penis. Prostatitis can develop and progress to a systemic inammatory response, causing chills
and fever. Extension of inammation to other structures
of the urinary tract may result in acute infection of the
epididymis and testicles. Orchitis, a testicular inammation, presents with a swollen and tender testicle.
Disseminated systemic urethral infection produces
small tender papules or petechiae on the skin surfaces
of the hands, arms, and legs. They may further develop
into pustules and become hemorrhagic or necrotic.
Joints may become involved, with tenosynovitis and
arthritis with synovial effusion indicating reactive arthritis (Reiter syndrome). Monarticular joint or tendon
involvement should be investigated further.
Prostatitis
Patients with acute bacterial prostatitis likely look and
feel ill and be febrile. They usually complain of dysuria,
burning, frequency, and nocturia (see Chapter 18).
Prostatic massage is contraindicated in acute bacterial
prostatitis.
Patients with chronic prostatitis do not appear
acutely ill but have a history of prostate problems.
A causative organism may not be identied (see
Chapter 18).
Epididymitis and Orchitis
The patient with epididymitis/orchitis is usually a
sexually active young male, and pain is likely the presenting symptom. The patient may also have a urethral
discharge and be febrile. The history usually indicates
a slower onset of discomfort over hours or days
compared to testicular torsion, which has a rapid onset
of symptoms. Elevation of the affected testicle may
reduce the discomfort. Swelling of the scrotum and
testicle may be present. Doppler ow studies with
color can locate hot spots and identify intact blood
ow (see Chapter 18). Urethral Gram staining, urinalysis and culture, and DNA testing for C. trachomatis
and N. gonorrhoeae may be indicated.
Balanitis
Balanitis is inammation of the glans penis. Balanitis
involving the foreskin or prepuce is called balanoposthitis. Uncircumcised men with poor personal hygiene are most affected by balanitis. Lack of aeration
and irritation from smegma and discharge surrounding the glans penis cause inammation and edema.
The most common complication of balanitis is phimosis or inability to retract the foreskin from the
glans penis.
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Balanitis Not circumcised; poor hygiene
URETHRITIS
Gonococcal
urethritis
Common Causes of Penile Discharge
practices
Unprotected sexual activity; abrupt
onset of symptoms 3-5 days after
exposure; yellow-green discharge;
classic symptoms reported by
males: frequency, urgency,
dysuria; dysuria may be worse
at beginning of urine flow
Localized erythema and
edema; presence of
smegma
Yellow-green discharge;
spontaneous or copious
amounts with stripping
of penis
None; history and physical
examination
Collect specimens at least
1 hr, preferably 4 hr, after
last voiding; Gram stain,
culture; urine DNA testing
for gonococcus
Continued
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Chapter 27 • Penile Discharge
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Penile Discharge—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
URETHRITIS—cont’d
Nongonococcal
urethritis
COMPLICATED URETHRITIS
Acute bacterial
prostatitis
Epididymitis/orchitis Abrupt onset over several hours;
DNA, Deoxyribonucleic acid.
References and Readings
Baron EJ, Miller JM, Weinstein MP, et al: Testicular ultrasound,
Emerg Med Clin North Am 22:723, 2004.
Bremnor JD, Sadovsky R: Evaluation of dysuria in adults, Am Fam
Physician 65:1589, 2002.
Brill J: Diagnosis and treatment of urethritis in men, Am Fam Physician
81:873, 2010.
Diaz-Parker C, Bratslavsky G: Male genitourinary disease: Urethritis,
epididymitis, and prostatitis, Clin Rev 15:40, 2005.
Forbes BA, Patel R, Rosenblatt JE, et al: A guide to utilization of the
microbiology laboratory for diagnosis of infectious diseases:
2013 recommendations by the Infectious Diseases Society of
America (IDSA) and the American Society for Microbiology
(ASM), Clin Infect Dis 57:e22, 2013.
McGrath N, Howell J, Davis J: Pediatric genitourinary emergencies,
Emerg Med Clin of North Am 29:3, 2011.
Unprotected sexual activity; longer
incubation period (8-21 days);
meatal itching or irritation;
scant mucoid-like discharge,
if present, before first voiding
of day; symptoms vary and range
in severity for urgency, frequency,
and dysuria
Chills, fever; 30-50 yr of age; onset
of symptoms over days; pain in
rectal, perianal area, low back,
and abdomen
febrile, pain in scrotum and/or
testicles
Thin mucoid discharge may
be absent or minimal
with penile milking or
stripping
May have fever; painful
prostate; do not massage
Tender, swollen epididymis
and/or testicles; elevation
of affected testicle may
lessen discomfort; may
have fever
Miller KE: Diagnosis and treatment of Neisseria gonorrhoeae
infections, Am Fam Physician 73:1779, 2006.
Richens J: Main presentations of sexually transmitted infections in
men, BMJ 328:1251, 2004.
Sharp VJ, Takacs EB, Powell CR: Prostatitis: Diagnosis and treat-
ment, Am Fam Physician 82:397, 2010.
Simpson T, Oh MK: Urethritis and cervicitis in adolescents, Adolesc
Med Clin 15:253, 2004.
Trojian TH, Lishnak TS, Heiman D: Epididymitis and orchitis:
An overview, Am Fam Physician 79:583, 2009.
Walker NA, Challacombe B: Managing epididymo-orchitis in
general practice, Practitioner 257:21, 2013.
Wren T: Penile and testicular disorders, Nurs Clin North Am 39:319,
2004.
Gram stain; culture; urine
DNA testing for Chlamydia
Segmental urine specimens;
culture and sensitivity
Doppler flow studies with
color; urethral Gram
stain, urinalysis and
culture, and DNA testing
for C. trachomatis and
N. gonorrhoeae
CHAPTER
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28
ermatological problems result from a number of
D
mechanisms, including inammatory, infectious,
immunological, and environmental (traumatic and
exposure-induced). At times, the mechanism may be
readily identied, such as the infectious bacterial etiology in impetigo. However, some dermatological lesions
may be classied in more than one way. Most insect
bites, for example, involve both environmental (the
bite) and inammatory (the response) mechanisms.
Awareness of the potential mechanism of any skin
disorder is most helpful in identifying the risk a person
may have for other illnesses. For example, people with
eczema are also frequently at risk for other atopic
conditions, notably asthma and/or allergic rhinitis. Thousands of skin disorders have been described, but only a
small number account for the majority of patient visits.
Evaluation of rashes and skin lesions depends on a
carefully focused history and physical examination. The
provider needs to be familiar with the characteristics of
various skin lesions; anatomy, physiology, and pathophysiology of the skin; clinical appearance of the basic
lesion; arrangement and distribution of the lesion; and
associated pathological conditions. It is also important
to know common symptoms associated with specic
lesions such as itching or fever. It is necessary to quickly
identify life-threatening diseases and those that are highly
contagious. Ultimately, competence in dermatological
assessment involves recognition through repetition.
Rashes and Skin Lesions
DIAGNOSTIC REASONING: INITIAL FOCUSED
PHYSICAL EXAMINATION
Initial Inspection
Dermatological assessment is similar to the assessment
of most other body systems in that it depends on patient history and physical assessment. However, sometimes a brief physical assessment preceding the history
can assist in the development of the initial differential
diagnoses, followed by a focused history and further
physical examination.
Morphological Criteria
Examination involves the classication of the lesion
based on a number of morphological features (examples are listed in Tables 28-1 and 28-2 and illustrated
in Figures 28-1 and 28-2). Evaluation should be systematic. Generally, morphological features should be
analyzed as follows:
l
Identify the location of the lesion(s).
l
Identify the distribution of the lesions as localized,
regional, or generalized.
l
Identify whether the lesion is primary (appearing
initially) or secondary (resulting from a change in a
primary lesion).
l
Identify the shape of the lesion and any arrangement
if numerous lesions are present.
l
Assess the margins (borders).
l
Assess the pigmentation, including variations.
l
Palpate to assess texture and consistency.
l
Measure the size of an individual lesion or estimate
the size if lesions are numerous or widespread.
Perform a systematic physical examination before obtaining the majority of the history to provide greater
relevance to the information given by the patient.
Gloves are not necessary unless there are open, draining, or exudative lesions.
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is the rash associated with an immediate life-threatening
condition?
Key Questions
l
Do you have a fever?
l
Are you short of breath?
l
Do you have difculty swallowing?
l
Is the rash tender and does it involve mucous
membranes?
Text continued on p. 331
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Chapter 28 • Rashes and Skin Lesions
Table 28-1
Morphological Criteria of Rashes and Skin Lesions
NATURE OF LESION DESCRIPTION EXAMPLES
PRIMARY LESIONS (DEVELOP INITIALLY IN RESPONSE TO CHANGE IN INTERNAL OR EXTERNAL ENVIRONMENT OF SKIN)
Macule
Patch Discrete flat lesion (large macule);
Papule Discrete palpable elevation of skin;
Nodule Discrete palpable elevation of skin;
Plaque Slightly raised lesion, typically with
Wheal Transient pink/red swelling of skin; often
Tumor
Pustule
Vesicle
Bulla
Cyst Semi-solid lesion; varies in size
Discrete flat change in color of skin;
usually ,1.5-cm diameter
usually .1.5-cm diameter
,1-cm diameter; origin may be
epidermal, dermal, or both
may evolve from papule; may involve
any level of skin from epidermis to
subcutis
flat surface; .1-cm diameter; scaling
frequently present
displaying central clearing; various
shapes and sizes; usually pruritic and
lasts ,24 hr
Large papule or nodule; usually .1-cm
diameter
Raised lesion ,0.5-cm diameter
containing yellow cloudy fluid
(usually infected)
Raised lesion ,0.5-cm diameter
containing clear fluid
Vesicle .0.5-cm diameter
from several mm to several cm;
may become infected
Freckle, lentigo, purpura
Pityriasis rosea, melasma, lentigo
Nevi, seborrheic keratosis, dermatofibroma
Nevi, basal cell carcinoma, keratoacanthoma
Psoriasis, mycosis fungoides
Urticaria
Basal cell carcinoma, squamous cell
carcinoma, malignant melanoma
Folliculitis, acne (closed comedones)
Herpes simplex, herpes zoster, contact
(irritant) dermatitis
Bullous pemphigoid, contact (irritant) dermatitis,
blisters of second-degree sunburn
Sebaceous cyst
SECONDARY LESIONS (APPEAR AS RESULT OF CHANGES IN PRIMARY LESIONS)
Crust
Scale Thin plates of desquamated stratum
Excoriation Shallow hemorrhagic excavation; linear
Lichenification Thickening of skin with exaggeration
Erosion Partial break in epidermis Herpes simplex or zoster, pemphigus vulgaris
Fissure Linear crack in epidermis Xerosis, angular cheilitis, severe eczema
DISTRIBUTION OF LESIONS
Localized Lesion appears in one small area Impetigo, herpes simplex (e.g., labialis), tinea
Regional Lesions involve specific region of body Acne vulgaris (pilosebaceous gland
Generalized Lesions appear widely distributed or in
Dried exudate that may have been
serous, purulent, or hemorrhagic
corneum that flake off rather easily
or punctate; results from scratching
of skin creases; hallmark of chronic
eczematous dermatitis
numerous areas simultaneously
Impetigo herpes zoster (late phase)
Xerosis, ichthyosis, psoriasis
Contact (irritant) dermatitis
Chronic eczema
corporis (“ringworm”)
distribution), psoriasis (extensor
surfaces and skinfolds)
Urticaria, disseminated drug eruptions
Chapter 28 • Rashes and Skin Lesions
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Table 28-1
Morphological Criteria of Rashes and Skin Lesions—cont’d
NATURE OF LESION DESCRIPTION EXAMPLES
SHAPE/ARRANGEMENT
Round/discoid
Oval Ovoid shape Pityriasis rosea
Annular Round, active margins with central
Zosteriform
(dermatomal)
Polycyclic Interlocking or coalesced circles (formed
Linear In a line Contact dermatitis
Iris/target lesion Pink macules with purple central
Stellate Star shaped Meningococcal septicemia
Serpiginous Snakelike or wavy line track Cutanea larva migrans
Reticulate Netlike or lacy Polyarteritis nodosa, lichen planus lesions of
Morbilliform Confluent and salmon colored Rubeola
BORDER/MARGIN
Discrete
Indistinct Poorly defined; having borders that
Active Margin of lesion shows greater activity
Irregular Nonsmooth or notched margin Malignant melanoma
Border raised above
center
Advancing Expanding at margins Cellulitis
Coin or ring shaped (no central clearing) Nummular eczema
Tinea corporis, sarcoidosis
clearing
Following nerve or segment of body Herpes zoster
Psoriasis, urticaria
by enlargement of annular lesions)
Erythema multiforme
papules
erythema infectiosum
Well demarcated or defined; able to
draw a line around it with confidence
merge into normal skin or outlying
ill-defined papules
than center
Center of lesion depressed compared to
edge
Psoriasis
Nummular eczema
Tinea species eruptions
Basal cell carcinoma
ASSOCIATED CHANGES WITHIN LESIONS
Central clearing Erythematous border surrounds lighter
Desquamation Peeling or sloughing of skin Rash of toxic shock syndrome
Keratotic Hypertrophic stratum corneum Calluses, warts
Punctate Central umbilication, or dimpling Basal cell carcinoma
Telangiectasias Dilated blood vessels within lesion
PIGMENTATION
Flesh
Pink Eczema, pityriasis rosea
Erythematous Tinea eruptions, psoriasis
Salmon Psoriasis
Tan-brown
Black Malignant melanoma
Pearly Basal cell carcinoma
Purple Purpura, Kaposi sarcoma
Violaceous Erysipelas
Yellow Lipoma
White Lichen planus
skin
Tinea eruptions
Basal cell carcinoma, actinic keratosis
blanch completely; may be markers
of systemic disease
Neurofibroma, some nevi
Most nevi, pityriasis versicolor
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Chapter 28 • Rashes and Skin Lesions
Table 28-2
Descriptive Dermatological Terms
LESION* CHARACTERISTICS EXAMPLES
Annular Ring shaped Ringworm
Arcuate
Bizarre
Circinate Circular
Confluent Lesions run together Childhood exanthems
Discoid Disc-shaped without central clearing Lupus erythematosus
Discrete eczematoid Lesions remain separate; Inflammation
Generalized grouped Widespread; lesions clustered together Herpes simplex
Partial rings Syphilis
Irregular or geographic pattern
not related to any underlying
anatomic structure
with tendency to vesiculate and
crust
Factitial dermatitis
Eczema
Iris Circle within circle; bull’s-eye lesion Erythema multiforme
(iris)
Keratotic
Linear
Multiform papulosqua-
mous reticulated
Serpiginous Snakelike, creeping Cutaneous larva migrans
Telangiectatic Relatively permanent dilation
Horny thickening Psoriasis
In lines Poison ivy dermatitis
More than one type of shape
or lesion
Papules or plaques associated with
scaling; lacelike network
of superficial blood vessels
Erythema multiforme
psoriasis
Oral lichen planus
Osler-Weber-Rendu
disease
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