Description of Skin Lesions

An extensive language has been developed to standardize the description of

skin lesions, including

Primary morphology (lesion type)

Secondary morphology (configuration)

Texture

Distribution

Color

Rash is a general term for a temporary skin eruption.

Primary Morphology
Macules are flat, nonpalpable lesions usually < 10 mm in diameter. Macules
represent a change in color and are not raised or depressed compared to the
skin surface. A patch is a large macule. Examples include freckles, flat moles,
tattoos, port-wine stains, and the rashes of rickettsial infections, rubella, measles,
and some allergic drug eruptions.
Papules are elevated lesions usually < 10 mm in diameter that can be felt or
palpated. Examples include nevi, warts, lichen planus, insect bites, seborrheic
and actinic keratoses, some lesions of acne, and skin cancers. The term
maculopapular is often loosely and improperly used to describe many red skin
rashes; because this term is nonspecific and easily misused, it should be
avoided.
Plaques are palpable lesions > 10 mm in diameter that are elevated or
depressed compared to the skin surface. Plaques may be flat topped or
rounded. Lesions of psoriasis and granuloma annulare commonly form
plaquesPrimary Morphology
Macules are flat, nonpalpable lesions usually < 10 mm in diameter. Macules
represent a change in color and are not raised or depressed compared to the
skin surface. A patch is a large macule. Examples include freckles, flat moles,
tattoos, port-wine stains, and the rashes of rickettsial infections, rubella, measles,

and some allergic drug eruptions.

Papules are elevated lesions usually < 10 mm in diameter that can be felt or
palpated. Examples include nevi, warts, lichen planus, insect bites, seborrheic
and actinic keratoses, some lesions of acne, and skin cancers. The term
maculopapular is often loosely and improperly used to describe many red skin
rashes; because this term is nonspecific and easily misused, it should be
avoided.
Plaques are palpable lesions > 10 mm in diameter that are elevated or
depressed compared to the skin surface. Plaques may be flat topped or rounded.
Lesions of psoriasis and granuloma annulare commonly form plaques.
Nodules are firm papules or lesions that extend into the dermis or subcutaneous
tissue. Examples include cysts, lipomas, and fibromas.
Vesicles are small, clear, fluid-filled blisters < 10 mm in diameter. Vesicles are
characteristic of herpes infections, acute allergic contact dermatitis, and some
autoimmune blistering disorders (eg, dermatitis herpetiformis).
Bullae are clear fluid-filled blisters > 10 mm in diameter. These may be caused
by burns, bites, irritant or allergic contact dermatitis, and drug reactions. Classic
autoimmune bullous diseases include pemphigus vulgaris and bullous
pemphigoid. Bullae also may occur in inherited disorders of skin fragility.
Pustules are vesicles that contain pus. Pustules are common in bacterial
infections, folliculitis, and may arise in some inflammatory diseases including
pustular psoriasis.
Urticaria (wheals or hives) is characterized by elevated lesions caused by
localized edema. Wheals are a common manifestation of hypersensitivity to
drugs, stings or bites, autoimmunity, and, less commonly, physical stimuli
including temperature, pressure, and sunlight. The typical wheal lasts < 24 h.
Scales are heaped-up accumulations of horny epithelium seen in diseases such
as psoriasis, seborrheic dermatitis, and fungal infections. Pityriasis rosea and
chronic dermatitis of any type may be scaly.
Crusts (scabs) consist of dried serum, blood, or pus. Crusting can occur in

inflammatory or infectious skin diseases (eg, impetigo).

Erosions are open areas of skin that result from loss of part or all of the
epidermis. Erosions can be traumatic or can occur with various inflammatory or
infectious skin diseases. An excoriation is a linear erosion caused by scratching,
rubbing, or picking.
Ulcers result from loss of the epidermis and at least part of the dermis. Causes
include venous stasis dermatitis, physical trauma with or without vascular
compromise (eg, from decubitus ulcers, peripheral arterial disease), infections,
and vasculitis.
Petechiae are nonblanchable punctate foci of hemorrhage. Causes include
platelet abnormalities (eg, thrombocytopenia, platelet dysfunction), vasculitis, and
infections (eg, meningococcemia, Rocky Mountain spotted fever, other
rickettsioses).
Purpura is a larger area of hemorrhage that may be palpable. Palpable purpura
is considered the hallmark of leukocytoclastic vasculitis. Purpura may indicate a
coagulopathy. Large areas of purpura may be called ecchymoses or, colloquially,
bruises.
Atrophy is thinning of the skin, which may appear dry and wrinkled, resembling
cigarette paper. Atrophy may be caused by chronic sun exposure, aging, and
some inflammatory and/or neoplastic skin diseases, including cutaneous T-cell
lymphoma and lupus erythematosus. Atrophy also may result from long-term use
of potent topical corticosteroids.
Scars are areas of fibrosis that replace normal skin after injury. Some scars
become hypertrophic or thickened and raised. Keloids are hypertrophic scars that
extend beyond the original wound margin.
Telangiectasias are a focus of small, permanently dilated blood vessels that are
most often idiopathic but may occur in rosacea, systemic diseases (especially
scleroderma), or inherited diseases (eg, ataxia-telangiectasia, hereditary
hemorrhagic telangiectasia) or after long-term therapy with topical fluorinated
corticosteroids.
Secondary Morphology (Configuration)

Configuration is the shape of single lesions and the arrangement of clusters of

lesions.
Linear lesions take on the shape of a straight line and are suggestive of some
forms of contact dermatitis, linear epidermal nevi, and lichen striatus.
Annular lesions are rings with central clearing. Examples include granuloma
annulare, some drug eruptions, some dermatophyte infections (eg, ringworm),
and secondary syphilis.
Nummular lesions are circular or coin-shaped; an example is nummular
eczema.
Target (bull's-eye or iris) lesions appear as rings with central duskiness and
are classic for erythema multiforme.
Serpiginous lesions have linear, branched, and curving elements. Examples
include some fungal and parasitic infections (eg, cutaneous larva migrans).
Reticulated lesions have a lacy or networked pattern. Examples include cutis
marmorata and livedo reticularis.
Herpetiform describes grouped papules or vesicles arranged like those of a
herpes simplex infection.
Zosteriform describes lesions clustered in a dermatomal distribution similar to
herpes zoster.
Texture
Some skin lesions have visible or palpable texture that suggests a diagnosis.
Verrucous lesions have an irregular, pebbly, or rough surface. Examples
include warts and seborrheic keratoses.
Lichenification is thickening of the skin with accentuation of normal skin
markings; it results from repeated rubbing.
Induration, or deep thickening of the skin, can result from edema, inflammation,
or infiltration, including by cancer. Indurated skin has a hard, resistant feeling.
Induration is characteristic of such skin diseases as panniculitis, some skin

infections, and cutaneous metastatic cancers.

Umbilicated lesions have a central indentation and are usually viral. Examples
include molluscum contagiosum and herpes simplex.
Xanthomas, which are yellowish, waxy lesions, may occur with a lipid disorder.
Location and Distribution
It is important to note whether
Lesions are single or multiple

Particular body parts are affected (eg, palms or soles, scalp, mucosal
membranes)

Distribution is random or patterned, symmetric or asymmetric

Lesions are on sun-exposed or protected skin

Although few patterns are pathognomonic, some are consistent with certain
diseases.
Psoriasis frequently affects the scalp, extensor surfaces of the elbows and
knees, umbilicus, and the gluteal cleft.
Lichen planus frequently arises on the wrists, forearms, genitals, and lower
legs.
Vitiligo may be patchy and isolated or may group around the distal extremities
and face.
Chronic cutaneous lupus erythematosus has characteristic lesions on sunexposed skin of the face, especially the forehead, nose, and the conchal bowl of
the ear.
Hidradenitis suppurativa involves skin containing a high density of apocrine
glands, including the axillae, groin, and under the breasts
Color
Red skin (erythema) can result from many different inflammatory or infectious
diseases. Cutaneous tumors are often pink or red. Superficial vascular lesions
such as port-wine stains may appear red.

Orange skin is most often seen in hypercarotenemia, a usually benign condition

of carotene deposition after excess dietary ingestion of -carotene.
Yellow skin is typical of jaundice, xanthelasmas and xanthomas, and
pseudoxanthoma elasticum.
Green fingernails suggest Pseudomonas aeruginosa infection.
Violet skin may result from cutaneous hemorrhage or vasculitis. Vascular lesions
or tumors, such as Kaposi's sarcoma and hemangiomas, can appear purple. A
lilac color of the eyelids or heliotrope eruption is characteristic of
dermatomyositis.
Shades of blue, silver, and gray can result from deposition of drugs or metals
in the skin, including minocycline SOME TRADE NAMES
MINOCIN
Click for Drug Monograph
, amiodarone SOME TRADE NAMES
CORDARONE
Click for Drug Monograph
, and silver (argyria). Ischemic skin appears purple to gray in color. Deep dermal
nevi appear blue.
Black skin lesions may be melanocytic, including nevi and melanoma. Black
eschars are collections of dead skin that can arise from vascular infarction, which
may be caused by infection (eg, anthrax, angioinvasive fungi including Rhizopus,
meningococcemia), calciphylaxis, arterial insufficiency, or vasculitis.
Other Clinical Signs
Dermatographism is the appearance of an urticarial wheal after focal pressure
(eg, stroking or scratching the skin) in the distribution of the pressure. Up to 5%
of normal patients may exhibit this sign, which is a form of physical urticaria.
Darier's sign refers to rapid swelling of a lesion when stroked. It occurs in
patients with urticaria pigmentosa or mastocytosis.
Nikolsky's sign is epidermal shearing that occurs with gentle lateral pressure on
seemingly uninvolved skin in patients with toxic epidermal necrolysis and some

autoimmune bullous diseases.

Auspitz sign is the appearance of pinpoint bleeding after scale is removed from
plaques in psoriasis.
Koebner phenomenon describes the development of lesions within areas of
trauma (eg, caused by scratching, rubbing, injury). Psoriasis frequently exhibits
this phenomenon, as may lichen planus.
Last full review/revision May 2009 by Robert J. MacNeal, MD
Content last modified May 2009

Diagnostic Tests

Diagnostic tests are indicated when the cause of a skin lesion or disease
is not obvious from history and physical examination alone (for patch
testing, see Dermatitis: Diagnosis).
Biopsy: A skin biopsy can be done by a primary care physician. One
procedure is a punch biopsy, in which a tubular punch (diameter usually 4
mm) is inserted into deep dermal or subcutaneous tissue to obtain a
specimen, which is snipped off at its base. More superficial lesions may
be biopsied by shaving with a scalpel or razor blade. Bleeding is
controlled by aluminum chloride SOME TRADE NAMES
HEMODENT
Click for Drug Monograph
solution or electrodesiccation; large incisions are closed by sutures.
Larger or deeper biopsies can be done by excising a wedge of skin with a
scalpel. All pigmented lesions should be excised deeply for histologic
evaluation of depth; superficial biopsies are often inadequate. Diagnosis

and cure are achieved simultaneously for most small tumors by complete
excision that includes a small border of normal skin.
Scrapings: Skin scrapings help diagnose fungal infections and scabies.
For fungal infection, scales are taken from the border of the lesion and
placed onto a microscope slide. Then a drop of 10 to 20% potassium
hydroxide (KOH) is added. Hyphae, budding yeast, or both confirm the
diagnosis of tinea or candidiasis. For scabies, scrapings are taken from
suspected burrows and placed directly under a coverslip with mineral oil;
findings of mites, feces, or eggs confirm the diagnosis.
Wood's light: Wood's light (black light) can help distinguish
hypopigmentation from depigmentation (depigmentation of vitiligo
fluoresces ivory-white and hypopigmented lesions do not). Erythrasma
fluoresces bright orange-red. Tinea capitis caused by Microsporum canis
and Microsporum audouinii fluoresces a light, bright green. (NOTE: Most
tinea capitis in the US is caused by Trichophyton species, which do not
fluoresce.) The earliest clue to cutaneous Pseudomonas infection (eg, in
burns) may be green fluorescence.
Tzanck testing: Tzanck testing can be used to diagnose viral disease,
such as herpes simplex and herpes zoster, and is done when active
intact vesicles are present. Tzanck testing cannot distinguish between
herpes simplex and herpes zoster infections. An intact blister is the
preferred lesion for examination. The blister roof is removed with a sharp
blade, and the base of the unroofed vesicle is scraped with a #15 scalpel
blade. The scrapings are transferred to a slide and stained with Wright's
stain or Giemsa stain. Multinucleated giant cells are a sign of herpes
infection
Diascopy: Diascopy is used to determine whether a lesion is vascular
(inflammatory) or nonvascular (nevus) or hemorrhagic (petechia or
purpura). A microscope slide is pressed against a lesion to see whether it
blanches. Hemorrhagic lesions and nonvascular lesions do not blanch;
inflammatory lesions do. Diascopy is sometimes used to identify sarcoid
skin lesions, which, when tested, turn an apple jelly color.
Itching

: A Merck Manual of Patient Symptoms podcast

Itching is a symptom that can cause significant discomfort and is one of

the most common reasons for consultation with a dermatologist. Itching
leads to scratching, which can cause inflammation, skin degradation, and
possible secondary infection. The skin can become lichenified, scaly, and
excoriated.
Pathophysiology
Itch can be prompted by diverse stimuli, including light touch, vibration,
and wool fibers. There are a number of chemical mediators as well as
different mechanisms by which the sensation of itch occurs.
Mediators: Histamine is one of the most significant mediators. It is
synthesized and stored in mast cells in the skin and is released in
response to various stimuli. Other mediators (eg, neuropeptides) can
either cause the release of histamine or act as pruritogens themselves,
thus explaining why antihistamines ameliorate some cases of itching and
not others. Opioids have a central pruritic action as well as stimulating the
peripherally mediated histamine itch.
Mechanisms: There are four mechanisms of itch:

Dermatologictypically caused by inflammatory or pathologic

processes (eg, urticaria, eczema)

Systemicrelated to diseases of organs other than skin (eg,

cholestasis)

Neuropathicrelated to disorders of the CNS or peripheral

nervous system (eg, multiple sclerosis)

Psychogenicrelated to psychiatric conditions

Intense itching stimulates vigorous scratching, which in turn can cause

secondary skin conditions (eg, inflammation, excoriation, infection), which
can lead to more itching. However, scratch can temporarily reduce the
sensation of itch by activating inhibitory neuronal circuits.
Etiology
Itching can be a symptom of a primary skin disease or, less commonly, a
systemic disease (see Table 1: Approach to the Dermatologic Patient:
Some Causes of Itching ).
Skin diseases: Many skin disorders cause itching. The most common

include

Dry skin

Atopic dermatitis (eczema)

Contact dermatitis

Fungal skin infections

Systemic diseases: In systemic disease, itching may occur with or

without skin lesions. However, when itching is prominent without any
identifiable skin lesions, systemic disease and drugs should be
considered more strongly. Systemic disease is less often a cause of
itching than skin disorders, but some of the more common causes include

Allergic reaction (eg, to foods, drugs, bites and stings)

Cholestasis

Chronic renal failure

Less common systemic causes of itching include hyperthyroidism,

hypothyroidism, diabetes, iron deficiency, dermatitis herpetiformis, and
polycythemia vera.
Drugs: Drugs can cause itching as an allergic reaction or by directly
triggering histamine release (most commonly morphine SOME TRADE
NAMES
DURAMORPH
MS CONTIN
MSIR
ROXANOL
Click for Drug Monograph
, some IV contrast agents).
Table 1
Some Causes of Itching
Cause

Suggestive Findings

Diagnostic
Approach

Primary skin disorders

Atopic dermatitis

Presence of erythema, Clinical

possible lichenification,

keratosis pilaris,
evaluation
xerosis, Dennie-Morgan
lines, hyperlinear palms
Usually a family history
of atopy or chronic
recurring dermatitis
Contact dermatitis

Dermatitis secondary to Clinical

contact with allergen; evaluation
erythema, vesicles

Dermatophytosis
(eg, tinea capitis,
tinea corporis, tinea
cruris, tinea pedis)

Localized itching,
circular lesions with
raised scaly borders,
areas of alopecia

KOH examination
of lesion
scrapings

Common sites are

genital area and feet in
adults; scalp and body
in children
Sometimes,
predisposing factors
(eg, moisture, obesity)
Lichen simplex
chronicus

Areas of skin thickening Clinical

secondary to repetitive evaluation
scratching
Lesions are discrete
erythematous, scaly
plaques, wellcircumscribed, rough,
lichenified skin

Pediculosis

Common sites are

Visualization of
scalp, axillae, waist, or eggs (nits), and
pubic area
sometimes lice
Areas of excoriation,
possible punctate
lesions from fresh bites,
possible bilateral
blepharitis

Psoriasis

Plaques with silvery

Clinical

scales typically on
extensor surfaces of
elbow, knees, scalp,
and trunk

evaluation

Itching not necessarily

limited to plaques
Possibly small-joint
arthritis manifesting as
stiffness and pain
Scabies

Small erythematous or Clinical

dark papules at one endevaluation
of a fine, wavy, slightly Microscopic
scaly line up to 1 cm
examination of
long (burrow). Possibly skin scrapings
on web spaces, belt
from burrows
line, flexor surfaces,
and areolas of women
and genitals of men;
intense nocturnal
itching
Family or close
community members
with similar symptoms

Urticaria

Evanescent,
circumscribed, raised,
erythematous lesions
with central pallor

Clinical
evaluation

Can be acute or chronic

( 6 wk)
Xerosis (dry skin)

Most common in the

Clinical
winter; itchy, dry, scaly evaluation
skin, mostly on lower
extremities;
exacerbated by dry
heat

Systemic disorders
Allergic reaction,
internal (numerous

Generalized itching,
maculopapular or

Trial of avoidance

ingested
substances)

urticarial rash

Cancer (eg,
Hodgkin lymphoma,
polycythemia vera,
mycosis fungoides)

Itching may precede

any other symptoms

CBC

Burning quality to
itching, primarily in
lower extremities
(Hodgkin lymphoma)

Chest x-ray

May or may not have

known allergy

Itching after bathing

(polycythemia vera)
Heterogeneous
cutaneous lesions
plaques, patches,
tumors, erythroderma
(mycosis fungoides)

Sometimes skinprick testing

Peripheral smear
Biopsy (bone
marrow for
polycythemia
vera, lymph node
for Hodgkin
lymphoma, skin
lesion for
mycosis
fungoides)

Cholestasis

Findings suggestive of Evaluation for

liver/gallbladder
cause of jaundice
damage or dysfunction
(eg, jaundice,
steatorrhea, fatigue,
right upper quadrant
pain)

Diabetes*

Urinary frequency,
thirst, weight loss,
vision changes

Urine and blood

glucose

History of ingestion

Clinical
evaluation

Drugs (eg, aspirin

SOME TRADE
NAMES
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug
Monograph
, barbiturates,
morphine SOME
TRADE NAMES
DURAMORPH

HbA1C

MS CONTIN
MSIR
ROXANOL
Click for Drug
Monograph
, cocaine, penicillin,
some antifungal
drugs,
chemotherapeutic
agents)
Iron deficiency
anemia

Fatigue, headache,
irritability, exercise
intolerance, pica, hair
thinning

Multiple sclerosis

Intermittent intense
MRI
itching, numbness,
CSF analysis
tingling in limbs, optic
Evoked potentials
neuritis, vision loss,
spasticity or weakness,
vertigo

Psychiatric illness

Linear excoriations,
Clinical
presence of psychiatric evaluation
condition (eg, clinical
Diagnosis of
depression, delusions of exclusion
parasitosis)

Renal disease

End-stage renal
Diagnosis of
disease; generalized
exclusion
itching, may be worse
during dialysis, may be
prominent on the back

Thyroid disorders*

Weight loss, heart

TSH, T4
palpitations, sweating,
irritability
(hyperthyroidism)
Weight gain,
depression, dry skin
and hair

Hb, Hct, red cell

indices, serum
ferritin, iron, and
iron-binding
capacity

(hypothyroidism)
*Itching as the patient's presenting complaint is unusual.
HbA1C = glycosylated Hb; KOH = potassium hydroxide; T4 = thyroxine;
TSH = thyroid-stimulating hormone.
Evaluation
History: History of present illness should determine onset of itching,
initial location, course, duration, patterns of itching (eg, nocturnal or
diurnal, intermittent or persistent, seasonal variation), and whether any
rash is present. A careful drug history should be obtained, both oral (eg,
opioids, cocaine, aspirin SOME TRADE NAMES
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
, prescription and OTC) and topical (eg, hydrocortisone SOME TRADE
NAMES
CORTEF
SOLU-CORTEF
Click for Drug Monograph
, benadryl, moisturizers). History also should include any factors that
make the itching better or worse.
Review of systems should seek symptoms of causative disorders,
including steatorrhea and right upper quadrant pain (cholestasis);
constitutional symptoms of fever, weight loss, and night sweats (cancer);
intermittent weakness, numbness, tingling, and visual disturbances or
loss (multiple sclerosis); irritability, sweating, weight loss, and palpitations
(hyperthyroidism) or depression, dry skin, and weight gain
(hypothyroidism); urinary frequency, excessive thirst, and weight loss
(diabetes); and headache, pica, hair thinning, and exercise intolerance
(iron deficiency anemia).
Past medical history should identify known causative disorders (eg,
renal disease, cholestatic disorder, cancer being treated with
chemotherapy) and patient's emotional state. Social history should focus
on family members with similar itching and skin symptoms (eg, scabies,
pediculosis); relationship of itching to occupation or exposures to plants,

animals, or chemicals; and history of recent travel.

Physical examination: Physical examination begins with a review of
clinical appearance for signs of jaundice, weight loss or gain, and fatigue.
Close examination of the skin should be done, taking note of presence,
morphology, extent, and distribution of lesions. Cutaneous examination
also should make note of signs of secondary infection (eg, erythema,
swelling, warmth, yellow/honey crusting).
The examination should make note of significant adenopathy suggestive
of cancer. Abdominal examination should focus on organomegaly,
masses, and tenderness (cholestatic disorder or cancer). Neurologic
examination focuses on weakness, spasticity, or numbness (multiple
sclerosis).
Red flags: The following findings are of particular concern:

Constitutional symptoms of weight loss, fatigue, and night sweats

Extremity weakness, numbness, or tingling

Abdominal pain and jaundice

Urinary frequency, excessive thirst, and weight loss

Interpretation of findings: Generalized itching that begins shortly after

use of a drug is likely caused by that drug. Localized itching (often with
rash) that occurs in the area of contact with a substance is likely caused
by that substance. However, many systemic allergies can be difficult to
identify because patients typically have consumed multiple different foods
and have been in contact with many substances before developing
itching. Similarly, identifying a drug cause in a patient taking multiple
drugs may be difficult. Sometimes the patient has been on the offending
drug for months or even years before developing a reaction.
If an etiology is not immediately obvious, the appearance and location of
skin lesions can suggest a diagnosis (see Table 1: Approach to the
Dermatologic Patient: Some Causes of Itching ).
In the minority in whom no skin lesions are evident, a systemic disorder
should be considered. Some disorders that cause itching are readily
apparent on evaluation (eg, chronic renal failure, cholestatic jaundice).

Other systemic disorders that cause itching are suggested by findings

(see Table 1: Approach to the Dermatologic Patient: Some Causes of
Itching ). Rarely, itching is the first manifestation of significant systemic
disorders (eg, polycythemia vera, certain cancers, hyperthyroidism).
Testing: Many dermatologic disorders are diagnosed clinically. However,
when itching is accompanied by discrete skin lesions of uncertain
etiology, biopsy can be appropriate. When an allergic reaction is
suspected but the substance is unknown, skin testing (either prick or
patch testing depending on suspected etiology) is often done. When
systemic disease is suspected, testing is directed by the suspected cause
and usually involves CBC; liver, renal, and thyroid function
measurements; and appropriate evaluation for underlying cancer.
Treatment
Any underlying disorder is treated. Supportive treatment involves the
following (see also Table 2: Approach to the Dermatologic Patient: Some
Therapeutic Approaches to Itching ):

Local skin care

Topical treatment

Systemic treatment

Skin care: Itching due to any cause benefits from use of cool or
lukewarm (but not hot) water when bathing, mild or moisturizing soap,
limited bathing duration and frequency, frequent lubrication, humidification
of dry air, and avoidance of irritating or tight clothing. Avoidance of
contact irritants (eg, wool clothing) also may be helpful.
Topical drugs: Topical drugs may help localized itching. Options include
camphor/menthol lotions or creams, pramoxine SOME TRADE NAMES
ANUSOL OINTMENT
PROCTOFOAM NS
TRONOLANE CREAM
TUCKS HEMORRHOIDAL
Click for Drug Monograph
, and corticosteroids. Corticosteroids are effective in relieving itch caused
by inflammation but should be avoided for conditions that have no
evidence of inflammation. Topical diphenhydramine SOME TRADE

NAMES
BENADRYL
NYTOL
Click for Drug Monograph
and doxepin SOME TRADE NAMES
SINEQUAN
ZONALON
Click for Drug Monograph
should be avoided because they may sensitize the skin.
Systemic drugs: Systemic drugs are indicated for generalized itching or
local itching resistant to topical agents. Antihistamines, most notably
hydroxyzine SOME TRADE NAMES
ATARAX
VISTARIL
Click for Drug Monograph
, are effective, especially for nocturnal itch, and are most commonly used.
Sedating antihistamines must be used cautiously in elderly patients
during the day because they can lead to falls; newer nonsedating
antihistamines such as loratadine SOME TRADE NAMES
ALAVERT
CLARITIN
Click for Drug Monograph
, fexofenadine SOME TRADE NAMES
ALLEGRA
Click for Drug Monograph
, and cetirizine SOME TRADE NAMES
ZYRTEC
Click for Drug Monograph
can be useful for daytime itching. Other drugs include doxepin SOME
TRADE NAMES
SINEQUAN
ZONALON
Click for Drug Monograph
(typically taken at night due to high level of sedation), cholestyramine
SOME TRADE NAMES
QUESTRAN
Click for Drug Monograph

(for renal failure, cholestasis, polycythemia vera), opioid antagonists such

as naltrexone SOME TRADE NAMES
REVIA
Click for Drug Monograph
(for biliary pruritus), and possibly gabapentin SOME TRADE NAMES
NEURONTIN
Click for Drug Monograph
(for uremic pruritus).
Physical agents that may be effective for itching include ultraviolet
phototherapy.
Table 2
Some Therapeutic Approaches to Itching
Drug/Agent

Usual Regimen

Comments

Apply regularly
for required
period o

May require 2 wk for

effect

Topical therapy
Capsaicin cream

time

Vegetable oil can help

with removal
Initial burning
sensation dissipates
with time

Cortisone creams or Apply to affected Avoid face, moist

ointments
area twice daily skinfolds
for 57 days
Should not be used for
prolonged periods of
time (> 2 wk)
Menthol/camphorcontaining creams

Apply to affected These preparations

areas as needed have strong odors
for relief

Pramoxine SOME
TRADE NAMES
ANUSOL OINTMENT
PROCTOFOAM NS

Apply prn, 46
times/day

Can cause dryness or

irritation at application
site

TRONOLANE CREAM
TUCKS
HEMORRHOIDAL
Click for Drug
Monograph
cream
Tacrolimus SOME
TRADE NAMES
PROGRAF
Click for Drug
Monograph
ointment or
pimecrolimus SOME
TRADE NAMES
ELIDEL
Click for Drug
Monograph
cream

Apply to affected Should not be used for

area twice daily long periods of time or
for 10 days
on children < 2 yr

Ultraviolet B therapy 13 times/wk

until itching
lessens;
treatment often
continued for
months

Sunburn-like adverse
effects can occur
Long-term risk of skin
cancer, including
melanoma

Systemic therapy
Cetirizine SOME
TRADE NAMES
ZYRTEC
Click for Drug
Monograph
*

510 mg po
once/day

Rarely can have a

sedating effect in
elderly patients

Cholestyramine
SOME TRADE
NAMES
QUESTRAN
Click for Drug
Monograph
(cholestatic

416 g po
once/day

Adherence can be poor

Constipating,
unpalatable
Can interfere with
absorption of other
drugs

pruritus)
Cyproheptadine
SOME TRADE
NAMES
PERIACTIN
Click for Drug
Monograph

4 mg po tid

Sedating, also helpful

when given before
bedtime

2550 mg po q
46 h (no more
than 6 doses in
24 h)

Sedating, also helpful

when given before
bedtime

Doxepin SOME
TRADE NAMES
SINEQUAN
ZONALON
Click for Drug
Monograph

25 mg po
once/day

Helpful in severe and

chronic pruritic states

Fexofenadine SOME
TRADE NAMES
ALLEGRA
Click for Drug
Monograph
*

60 mg po bid

Gabapentin SOME
TRADE NAMES
NEURONTIN
Click for Drug
Monograph
(uremic pruritus)

100 mg po after Sedation can be a

hemodialysis
problem

Hydroxyzine SOME
TRADE NAMES
ATARAX

2550 mg po q
46 h (no more
than 6 doses in

Diphenhydramine
SOME TRADE
NAMES
BENADRYL
NYTOL
Click for Drug
Monograph

Very sedating so taken

at bedtime

Headache can be an
adverse effect

Low doses to start and

titrated up to clinical
effect
Sedating, also helpful
when given before
bedtime

VISTARIL
Click for Drug
Monograph

24 h)

Loratadine SOME
TRADE NAMES
ALAVERT
CLARITIN
Click for Drug
Monograph
*

10 mg po
once/day

Rarely can have a

sedating effect in
elderly patients

Naltrexone SOME
TRADE NAMES
REVIA
Click for Drug
Monograph
(cholestatic
pruritus)

12.550 mg po
once/day

Can lead to pain in

patients who have
underlying pain

*Nonsedating antihistamine.

Sedating antihistamine.
Geriatric Essentials
Xerotic eczema is very common among elderly patients. It is especially
likely if itching is primarily on the lower extremities.
Severe, diffuse itching in the elderly should raise concern for cancer,
especially if another etiology is not immediately apparent.
When treating the elderly, sedation can be a significant problem with
antihistamines. Use of nonsedating antihistamines during the day and
sedating antihistamines at night, liberal use of topical ointments and
corticosteroids (when appropriate), and consideration of ultraviolet
therapy can help avoid the complications of sedation.
Key Points

Itching is usually a symptom of a skin disorder or systemic allergic

reaction but can result from a systemic disease.

If skin lesions are not evident, systemic causes should be

investigated.

Skin care (eg, limiting bathing, avoiding irritants, moisturizing

regularly, humidifying environment) should be observed.

Symptoms can be relieved by topical or systemic drugs.

Last full review/revision May 2009 by Robert J. MacNeal, MD
Content last modified May 2009

Skin Lesion (Macule)

Skin Lesion (Papule)

Skin Lesion (Plaque)

Skin Lesion (Vesicle)

Skin Lesion (Bullae)

Skin Lesion (Pustule)

Skin Lesion (Urticaria)

Skin Lesion (Scales)

Telangiectasia
Lesion (Annular)

Skin Lesion (Nummular)

Skin Lesion (Target)

Skin Lesion
(Herpetiform)

Annular lesions are rings with

central clearing.

Nodules are firm papules or lesions that extend into the dermis or subcutaneous tissue. Examples include cysts, lipomas, and
fibromas.

Vesicles are small, clear, fluid-filled blisters < 10 mm in diameter. Vesicles are characteristic of herpes infections, acute
allergic contact dermatitis, and some autoimmune blistering disorders (eg, dermatitis herpetiformis).

Bullae are clear fluid-filled blisters > 10 mm in diameter. These may be caused by burns, bites, irritant or allergic contact
dermatitis, and drug reactions. Classic autoimmune bullous diseases include pemphigus vulgaris and bullous pemphigoid.
Bullae also may occur in inherited disorders of skin fragility.

Pustules are vesicles that contain pus. Pustules are common in bacterial infections, folliculitis, and may arise in some
inflammatory diseases including pustular psoriasis.

Urticaria (wheals or hives) is characterized by elevated lesions caused by localized edema. Wheals are a common
manifestation of hypersensitivity to drugs, stings or bites, autoimmunity, and, less commonly, physical stimuli including
temperature, pressure, and sunlight. The typical wheal lasts < 24 h.

Scales are heaped-up accumulations of horny epithelium seen in diseases such as psoriasis, seborrheic dermatitis, and
fungal infections. Pityriasis rosea and chronic dermatitis of any type may be scaly.

Crusts (scabs) consist of dried serum, blood, or pus. Crusting can occur in inflammatory or infectious skin diseases (eg,
impetigo).

Erosions are open areas of skin that result from loss of part or all of the epidermis. Erosions can be traumatic or can occur
with various inflammatory or infectious skin diseases. An excoriation is a linear erosion caused by scratching, rubbing, or
picking.

Ulcers result from loss of the epidermis and at least part of the dermis. Causes include venous stasis dermatitis, physical
trauma with or without vascular compromise (eg, from decubitus ulcers, peripheral arterial disease), infections, and vasculitis.

Petechiae are nonblanchable punctate foci of hemorrhage. Causes include platelet abnormalities (eg, thrombocytopenia,
platelet dysfunction), vasculitis, and infections (eg, meningococcemia, Rocky Mountain spotted fever, other rickettsioses).

Purpura is a larger area of hemorrhage that may be palpable. Palpable purpura is considered the hallmark of leukocytoclastic
vasculitis. Purpura may indicate a coagulopathy. Large areas of purpura may be called ecchymoses or, colloquially, bruises.

Atrophy is thinning of the skin, which may appear dry and wrinkled, resembling cigarette paper. Atrophy may be caused by
chronic sun exposure, aging, and some inflammatory and/or neoplastic skin diseases, including cutaneous T-cell lymphoma
and lupus erythematosus. Atrophy also may result from long-term use of potent topical corticosteroids.

Scars are areas of fibrosis that replace normal skin after injury. Some scars become hypertrophic or thickened and raised.
Keloids are hypertrophic scars that extend beyond the original wound margin.

Telangiectasias are a focus of small, permanently dilated blood vessels that are most often idiopathic but may occur in
rosacea, systemic diseases (especially scleroderma), or inherited diseases (eg, ataxia-telangiectasia, hereditary hemorrhagic
telangiectasia) or after long-term therapy with topical fluorinated corticosteroids.

Secondary Morphology (Configuration)

Configuration is the shape of single lesions and the arrangement of clusters of lesions.

Linear lesions take on the shape of a straight line and are suggestive of some forms of contact dermatitis, linear epidermal
nevi, and lichen striatus.

Skin Lesion (Annular)

Skin Lesion (Nummular)

Skin Lesion (Target)

Skin Lesion
(Herpetiform)

Annular lesions are rings with central clearing. Examples include granuloma annulare, some drug eruptions, some
dermatophyte infections (eg, ringworm), and secondary syphilis.

Nummular lesions are circular or coin-shaped; an example is nummular eczema.

Target (bull's-eye or iris) lesions appear as rings with central duskiness and are classic for erythema multiforme.

Serpiginous lesions have linear, branched, and curving elements. Examples include some fungal and parasitic infections
(eg, cutaneous larva migrans).

Reticulated lesions have a lacy or networked pattern. Examples include cutis marmorata and livedo reticularis.

Herpetiform describes grouped papules or vesicles arranged like those of a herpes simplex infection.

Zosteriform describes lesions clustered in a dermatomal distribution similar to herpes zoster.

Texture
Some skin lesions have visible or palpable texture that suggests a diagnosis.

Verrucous lesions have an irregular, pebbly, or rough surface. Examples include warts and seborrheic keratoses.

Lichenification is thickening of the skin with accentuation of normal skin markings; it results from repeated rubbing.

Induration, or deep thickening of the skin, can result from edema, inflammation, or infiltration, including by cancer. Indurated
skin has a hard, resistant feeling. Induration is characteristic of such skin diseases as panniculitis, some skin infections, and
cutaneous metastatic cancers.

Skin Lesion (Verrucous)

Skin Lesion
(Lichenification)

Umbilicated lesions have a central indentation and are usually viral. Examples include molluscum contagiosum and herpes
simplex.

Xanthomas, which are yellowish, waxy lesions, may occur with a lipid disorder.

Location and Distribution

It is important to note whether

Lesions are single or multiple

Particular body parts are affected (eg, palms or soles, scalp, mucosal membranes)

Distribution is random or patterned, symmetric or asymmetric

Lesions are on sun-exposed or protected skin

Although few patterns are pathognomonic, some are consistent with certain diseases.

Psoriasis frequently affects the scalp, extensor surfaces of the elbows and knees, umbilicus, and the gluteal cleft.

Lichen planus frequently arises on the wrists, forearms, genitals, and lower legs.

Vitiligo may be patchy and isolated or may group around the distal extremities and face.

Chronic cutaneous lupus erythematosus has characteristic lesions on sun-exposed skin of the face, especially the
forehead, nose, and the conchal bowl of the ear.

Hidradenitis suppurativa involves skin containing a high density of apocrine glands, including the axillae, groin, and under
the breasts

Color
Red skin (erythema) can result from many different inflammatory or infectious diseases. Cutaneous tumors are often pink or
red. Superficial vascular lesions such as port-wine stains may appear red.

Orange skin is most often seen in hypercarotenemia, a usually benign condition of carotene deposition after excess dietary

ingestion of -carotene.

Yellow skin is typical of jaundice, xanthelasmas and xanthomas, and pseudoxanthoma elasticum.

Green fingernails suggest Pseudomonas aeruginosa infection.

Violet skin may result from cutaneous hemorrhage or vasculitis. Vascular lesions or tumors, such as Kaposi's sarcoma and
hemangiomas, can appear purple. A lilac color of the eyelids or heliotrope eruption is characteristic of dermatomyositis.

Shades of blue, silver, and gray can result from deposition of drugs or metals in the skin, including minocycline SOME

TRADE NAMES
MINOCIN
Click for Drug Monograph
, amiodarone SOME TRADE NAMES

CORDARONE
Click for Drug Monograph
, and silver (argyria). Ischemic skin appears purple to gray in color. Deep dermal nevi appear blue.

Black skin lesions may be melanocytic, including nevi and melanoma. Black eschars are collections of dead skin that can
arise from vascular infarction, which may be caused by infection (eg, anthrax, angioinvasive fungi including Rhizopus,
meningococcemia), calciphylaxis, arterial insufficiency, or vasculitis.

Other Clinical Signs

Dermatographism is the appearance of an urticarial wheal after focal pressure (eg, stroking or scratching the skin) in the
distribution of the pressure. Up to 5% of normal patients may exhibit this sign, which is a form of physical urticaria.

Darier's sign refers to rapid swelling of a lesion when stroked. It occurs in patients with urticaria pigmentosa or mastocytosis.

Nikolsky's sign is epidermal shearing that occurs with gentle lateral pressure on seemingly uninvolved skin in patients with
toxic epidermal necrolysis and some autoimmune bullous diseases.

Auspitz sign is the appearance of pinpoint bleeding after scale is removed from plaques in psoriasis.

Koebner phenomenon describes the development of lesions within areas of trauma (eg, caused by scratching, rubbing,
injury). Psoriasis frequently exhibits this phenomenon, as may lichen planus.

Last full review/revision May 2009 by Robert J. MacNeal, MD

Content last modified May 2009
Lesion (Annular)

Skin Lesion (Nummular)

Skin Lesion (Target)

Skin Lesion
(Herpetiform)

Annular lesions are rings with central clearing.

Skin Lesion (Verrucous)

Skin Lesion
(Lichenification)