Papules Nodules

1. Skin color a. Warts: caused by the human papilloma virus are transmitted by contact. They may dissipate without therapy. When they are noted in the genitalia sexual abuse should be considered.

b. Molluscum contagiosum: a viral disease caused by a member of the pox virus group. Discrete single or multiple dome-shaped umbilicated papules may be found all over the body. It is contagious with a tendency for auto inoculation and may dissipate without therapy.

c. Keratosis pilaris: an autosomal dominant disorder characterized by minute keratotic, follicular papules on the outer aspects of arms, thighs, and cheeks; seen in association with atopy and dry skin; may dissipate at puberty especially on face d. Granuloma annular (Fig 33-19): skin-colored or dull red papules spread peripherally with a normal appearing center; usually found on the dorsum of hands and feet. The cause is unknown, and spontaneous resolution in months to years is common. Intralesional corticosteroid injections and cryosurgery are helpful but painful.

e. Angiofibroma: firm papules. When multiple and seen in a symmetrical distribution on the face they are associated with tuberous sclerosis.

2. Brown a. Pigmented nevi (Fig 33-2.0): Depending on the basis of the location of the nevus cells, these may be called junctional (at the border of the epidermis and dermis, usually flat and black or dark brown), intradermal (within the dermis, usually flesh-colored and elevated) or compound nevi (both at the junction of the epidermis and dermis and intradermal, usually elevated and brown). They occur anywhere on the body and may be flat, elevated, verrucous, or papillomatous. If they are black, multicolored, large (3 6 mm), or irregular in border, an excisional biopsy should be considered.

b. Urticaria pigmentosa (Fig 33-21): part of the mastocytosis syndrome, seen as tan brown macules and papules that urticate when stroked (Darier's sign);

usually has an excellent prognosis if there is not systemic involvement and few lesions.

3. Yellow Papules a. Xanthogranuloma (nevoxanthoendothelioma): usually develop in the first year of life and disappear around 5 years of age. They present as small yellow single or multiple papules on the scalp or body. Rarely there is eye involvement.

b. Nevus sebaceous (see Chap,.32): noted at birth as an orange oval or linear area on the scalp. At puberty they become raised and warty. Basal cell carcinomas develop in approximately 10 to 15% of children with nevus sebaceous. Nevus sebaceous may occur in conjunction with a benign, appendageal, warty tumor callled syringocystadenoma papilliferum.

4. Red Papules a. Papular acrodermatitis (Gianotti-Crosti syndrome): nonpruritic flat-topped papules occur in the acral areas especially elbows and knees; originally associated with the hepatitis B virus, but recently many other viruses implicated; benign and self-limited b. Papular urticaria: lesions caused by a delayed hypersensitivity to a variety of arthropod bites; present as pruritic erythematous papules with surrounding urticaria. Recurrent crops are seen in the summer and can be quite extensive.

c. Erythema multiforme (see Chap 12): an acute hypersensitivity syndrome presenting with macular, urticarial, or vesiculobullous lesions, especially on the palms, soles, hands, and feet. Target or "bull's eye" lesions with concentric alternating rings of red and white are a hallmark of this condition. It is commonly divided into erythema multiforme minor, which is a more benign, recurrent, and self-limited condition with one mucous-membrane surface involved and commonly associated with herpes-simples virus; and erythema multiforme major, which presents with at least two mucous-membrane surfaces involved, widespread bullous lesions, and more systemic symptoms and is associated with mycoplasma pneumoniae or drugs.

d. Pyogenic granuloma: An easily bleeding bright red papule may arise at sites of trauma or spontaneously.

e. Viral exanthems (see Fig, 33-16): Roseola, rubeolla, echo-viruses, coxsackieviruses, and rubella may present as erythematous macules and papules.

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