Approach To The Patient With Macular Skin Lesions

2/28/2018 Approach to the patient with macular skin lesions - UpToDate
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Approach to the patient with macular skin lesions
Authors: Beth G Goldstein, MD, Adam O Goldstein, MD, MPH

Section Editor: Robert P Dellavalle, MD, PhD, MSPH
Deputy Editor: Rosamaria Corona, MD, DSc
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2018. | This topic last updated: Jun 12, 2017.
INTRODUCTION — Macules are nonpalpable lesions that vary in pigmentation from the surrounding skin.
Macules are not raised or atrophic; clinicians must consider other salient features to assist in developing a
reasonable differential diagnosis. Often, clinicians state that a dermatologic lesion is "macular-papular," when
in fact the lesion's morphology is papules and plaques, not macules. Definitions of dermatologic lesions can
be found separately. (See "Approach to dermatologic diagnosis".)
Relatively few dermatologic disorders account for the majority of conditions presenting with only macules.
Thus, the presence of these lesions can aid in forming an accurate diagnosis (table 1). One to two isolated
macules in young children are often not pathologic; in adults, such lesions may occur frequently as a result of
sun exposure [1,2].
The presence of macules should raise the following questions:
● What is the distribution of the lesion?
● Is there erythema, hypo- or hyperpigmentation?
● Are there secondary characteristics such as scale or erythema?
● Is pruritus present?
● Is the patient taking any medications, such as prescription, over-the-counter, or herbal?
● Is there a photodistribution to the eruption?
ERYTHEMATOUS MACULES — Erythematous macules are frequently caused by either viral exanthems
(picture 1A-D) or drug eruptions (picture 2). Viral exanthems and drug eruptions tend to be diffuse with the
majority of the eruption presenting as isolated, blanching erythematous macules on the trunk and proximal
extremities. (See "Exanthematous (maculopapular) drug eruption" and "Roseola infantum (exanthem
subitum)" and "Rubella" and "Measles: Clinical manifestations, diagnosis, treatment, and prevention".)
Specific features may characterize certain exanthems, such as the reticulated erythematous eruption
associated with erythema infectiosum (picture 3A-C) or the diffuse erythema and perineal accentuation seen
in Kawasaki's disease (picture 4A-B). (See "Clinical manifestations and diagnosis of parvovirus B19 infection"
and "Kawasaki disease: Clinical features and diagnosis".)
PHOTODISTRIBUTED MACULAR ERUPTIONS — Photodistributed macular eruptions may occur in a

variety of skin conditions, including dermatomyositis (picture 5), systemic lupus erythematosus (picture 6A),
porphyria cutanea tarda, drug reactions (picture 7), and polymorphous light eruptions. Photodistributed
lesions often have accentuation on the face, the V of the neck, or the dorsa of the hands and forearms,
sparing the infranasal and submental areas. Patients may present with lesions involving one or more sun-
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exposed areas. (See "Overview of cutaneous photosensitivity: Photobiology, patient evaluation, and
photoprotection" and "Photosensitivity disorders (photodermatoses): Clinical manifestations, diagnosis, and
treatment".)
Dermatomyositis — In dermatomyositis, the upper eyelids tend to develop a macular purplish hue and
edema (picture 8). Confluent violaceous erythema may also be present on the arms, shoulders, upper back,
or "v" area of the neck, and upper chest, and is often pruritic (picture 9). Areas of previous diffuse erythema
may resolve with persistent poikiloderma (characterized by telangiectasia, mottled pigmentation, and some
atrophy).
Mottled erythema and dilated superficial blood vessels, telangiectasia, are seen on the hands, particularly at
the proximal nail fold (picture 10). Erythematous papules (Gottron's sign) may occur over the knuckles,
knees, and elbows (picture 11A-B). Patients may exhibit systemic symptoms such as fatigue, arthralgias, or
other cutaneous findings. Skin findings can precede the onset of systemic disease or the disease may limit
itself to the skin. (See "Clinical manifestations of dermatomyositis and polymyositis in adults".)
Systemic lupus erythematosus — Systemic lupus erythematosus tends to present with erythema in a
malar distribution, the classic "butterfly rash" of the central face (picture 6A-B), in addition to diffuse erythema
in other sun-exposed locations [3]. The additional presence of oral ulcerations may assist in making the
diagnosis. (See "Overview of cutaneous lupus erythematosus".)
Drug-induced photosensitivity reactions — A history of taking a photosensitizing drug suggests the

possibility of a photodrug eruption.
● Phototoxic eruptions are the most common drug-induced photoeruption. The eruption is typically an
exaggerated sunburn, often with blisters (picture 7). Nonsteroidal antiinflammatory drugs (NSAIDs),
quinolones, tetracyclines, amiodarone, and the phenothiazines are the most frequent causes of
phototoxicity [4]. The eruption typically occurs with a higher cumulative dose of medication, in contrast to
photoallergic drug eruptions, which can occur at any dose. Topical exposure to plant-derived substances
may also cause a phototoxic reaction termed phytophotodermatitis (picture 12). (See "Photosensitivity
disorders (photodermatoses): Clinical manifestations, diagnosis, and treatment", section on
'Phototoxicity'.)
● Photoallergy is a lymphocyte-mediated reaction caused by exposure to ultraviolet A. The eruption is

characterized by widespread eczema in the photodistribution: face, upper chest, and back of hands
(picture 13). Most photoallergic reactions are caused by topical agents including biocides added to soaps
(halogenated phenolic compounds) and fragrances such as musk ambrette and 6-methyl coumarin [5].
Systemic photoallergens such as the phenothiazines, chlorpromazine, sulfa products, and NSAIDs can
produce photoallergic reactions, although most of their photosensitive reactions are phototoxic [5]. (See
"Photosensitivity disorders (photodermatoses): Clinical manifestations, diagnosis, and treatment",
section on 'Photoallergy'.)
Porphyria cutanea tarda — Porphyria cutanea tarda may present as diffuse erythema in a photodistributed
pattern. Typically, there are also vesicles or bullae, scarring, and hypertrichosis (picture 14A-B). (See
"Porphyria cutanea tarda and hepatoerythropoietic porphyria: Pathogenesis, clinical manifestations, and
diagnosis", section on 'Blistering skin lesions and other cutaneous manifestations'.)
Polymorphous light eruption — Polymorphous light eruption is a diagnosis of exclusion. Once all of the
above conditions have been considered, a light-induced, pruritic eruption, particularly occurring with the first
intense sun exposure of the year, may be consistent with this diagnosis. Polymorphous light eruption can
present simply as diffuse erythema. Look for accentuation of the eruption on the arms and thighs; the face
may be spared entirely or only slightly involved (picture 15). (See "Polymorphous light eruption".)
HYPOPIGMENTED MACULES — Hypopigmented macules are distinguished from depigmented macules by

retention of some pigment.
Vitiligo — Vitiligo presents primarily as an acquired, isolated, or diffuse depigmentation (picture 16) [6].
Hypopigmented areas may also occur during the process of developing or resolving vitiligo. Vitiligo is an
autoimmune process against melanocytes; the etiology is unknown. (See "Vitiligo: Pathogenesis, clinical
features, and diagnosis".)
Tinea versicolor — Hypopigmentation, particularly on the trunk and proximal extremities, in a mottled
distribution, is suggestive of tinea versicolor. Lesions may also be light brown or salmon colored (picture 17A-
B). Tinea versicolor may seem to be photoaccentuated as the areas involved fail to tan and become more
prominent with sun exposure. This disorder is seen in young adults and those living in humid climates. The
diagnosis is confirmed with a positive KOH prep for yeast and hyphae. Erythrasma, a bacterial infection, is a
similar appearing eruption that is pink/brown, slightly scaly, and occurs in the inguinal region (picture 18).
(See "Tinea versicolor (Pityriasis versicolor)" and "Erythrasma".)
Halo nevus — A halo nevus is a depigmented macule that presents in conjunction with a pre-existing
pigmented lesion. A halo nevus is caused by a T-cell mediated immune reaction with melanocytic nevus
cells, ultimately causing the loss of all pigmentation of and around a nevus (picture 19). Halo nevi are
typically a benign process, but occasionally may be associated with the presence of an atypical melanocytic
lesion. (See "Acquired melanocytic nevi (moles)", section on 'Halo nevi'.)
Pityriasis alba — Pityriasis alba occurs predominantly in children aged 3 to 16 years of age [7]. It is
characterized by patches of hypopigmentation, usually distributed on the face, neck, upper trunk, and
proximal extremities (picture 20A-B) [8,9]. The lesions range from 0.5 to 5 cm in diameter, with well-defined
but somewhat irregular borders, and fine scale. They usually are asymptomatic but may be pruritic. Patients
often present after sun exposure when the contrast between affected and nonaffected areas is accentuated
by tanning [9].
Pityriasis alba is thought to represent a nonspecific dermatitis with residual postinflammatory

hypopigmentation [9-11]. It is associated with atopy, sun exposure, and frequency of bathing [10].
The affected sites and surrounding areas should be protected from sun exposure. Mild topical glucocorticoids
or calcineurin inhibitors and emollients decrease dryness and scale and may accelerate repigmentation,
which typically takes months to years [8,9,12]. Moisturization during the winter months may prevent
recurrence in subsequent summers. (See "Acquired hypopigmentation disorders other than vitiligo", section
on 'Pityriasis alba'.)
Others — Depigmented areas at birth can also represent ash leaf spots seen in tuberous sclerosis (picture
21A-B), nevus depigmentosus (achromic nevus) (picture 22), or nevus anemicus (picture 23), among others
[13,14]. Some systemic conditions, such as cutaneous T cell lymphoma and leprosy can present with
hypopigmented lesions on the trunk and extremities [15,16]. Sarcoidosis can also present as areas of
splotchy hypopigmentation, typically on the anterior lower extremities. Systemic and pulmonary findings of
sarcoidosis may appear simultaneously. Rarely, cutaneous T cell lymphoma (mycosis fungoides) can present
as hypopigmented macules. (See "Acquired hypopigmentation disorders other than vitiligo".)
HYPERPIGMENTED MACULES — Hyperpigmented macules may signify several different disease

processes.
Postinflammatory hyperpigmentation — Diffuse hyperpigmentation often accompanies postinflammatory

hyperpigmentation, which can occur anywhere after an inciting eruption has resolved [17]. Postinflammatory
hyperpigmentation is particularly common in darker skin types when inflammatory conditions such as acne,
psoriasis, or eczema are resolving (picture 24). (See "Postinflammatory hyperpigmentation".)
Melasma — Melasma occurs as splotchy hyperpigmented macules, typically in a photodistributed pattern,

often with accentuation on the upper lip (picture 25A-B). Melasma tends to occur most commonly in
pregnancy and in conjunction with exogenous hormones, but may also occur in males. (See "Melasma".)
Solar purpura (senile purpura) — Solar purpura (also called actinic purpura, or Bateman purpura) is a
common form of non-inflammatory purpura. It presents as ecchymotic lesions predominantly on the sun-
damaged skin of the forearms and dorsa of the hands of older adult individuals (picture 26). These lesions
result from rupture of superficial blood vessels with subsequent extravasation of blood in the dermis following
a minor trauma. The incidence and severity of solar purpura are increased in individuals taking
anticoagulants or corticosteroids. The ecchymoses may persist for several weeks and resolve spontaneously
without undergoing the usual sequential color changes of a normal bruise. Residual hyperpigmentation can
be observed.
Erythema ab igne — Erythema ab igne is a reticular erythematous pigmented dermatosis resulting from
repeated exposures to moderate heat or infrared radiation. Once common among people who sat near open
fires or stoves, it is infrequently seen after the introduction of central heating. However, it is still seen in
relation to occupational exposure to heat sources (foundry workers, bakers), use of hot water bottles, heating
pads or blankets (picture 27), heated car seats, and among laptop users who hold the computer on their
thighs [18-20]. It can occur at any site, more often in an asymmetrical distribution, and is usually
asymptomatic. The early skin changes of erythema ab igne usually clear spontaneously in several weeks to
months, after the removal of the heat source from the skin. However, longstanding lesions may be associated
with permanent hyperpigmentation (picture 28). (See "Acquired hyperpigmentation disorders", section on
'Erythema ab igne'.)
Solar lentigo — Solar lentigo, most commonly known as liver spots or "old age'' spots, is a proliferation of
normal melanocytes secondary to chronic solar damage. These lesions occur most commonly in whites with
fair complexion who have a history of chronic sun exposure. Hyperpigmentation may vary from light to dark
brown, but is uniform within an individual lesion. The diagnosis is based upon the clinical appearance of flat,
oval, evenly pigmented macules in (picture 29A-B) areas of chronic sun exposure, particularly the face, dorsa
of the hands, shoulders, and back. (See "Acquired hyperpigmentation disorders", section on 'Solar
lentigines'.)
Schamberg's disease — Schamberg's disease, also called Schamberg's purpura is a type of pigmented
purpuric dermatosis characterized by brownish discoloration of the skin, particularly of the lower extremities
and ankle area (picture 30) [21]. It is caused by capillary leakage of blood and subsequent breakdown,
resulting in hemosiderin staining. (See "Pigmented purpuric dermatoses (capillaritis)", section on
'Schamberg's disease (progressive pigmentary purpura)'.)
Ochronosis — "Ochronosis" is a term used to describe pigment deposition that occurs in the connective
tissues of patients with alkaptonuria, an autosomal recessive disorder that results from a deficiency of
homogentisic acid oxidase (picture 31). Brown or blue-gray discoloration of the skin may be seen on the
axillary and inguinal areas, face, palms, or soles. In addition, blue-black discoloration can be apparent on
skin overlying cartilage in which the pigment is deposited, such as the ears. The sclerae are also typically
involved. (See "Disorders of tyrosine metabolism", section on 'Alkaptonuria'.)
The term "exogenous ochronosis" is used to refer to the occurrence of localized blue-gray discoloration of the
skin associated with the use of topical hydroquinone. (See "Topical skin-lightening agents: Complications
associated with misuse", section on 'Exogenous ochronosis'.)
Fixed drug eruption — A fixed drug eruption is characterized acutely by erythematous and edematous
plaques with a grayish center or frank bullae, and chronically by a dark postinflammatory pigmentation
(picture 32). Favored sites include the mouth (lips and tongue), genitalia, face, and acral areas [4]. The
defining features of this eruption include the postinflammatory hyperpigmentation and the recurrence of
lesions at exactly the same site with drug reexposure [4]. The drugs commonly involved include
phenolphthalein (laxatives), tetracyclines, barbiturates, sulfonamides, nonsteroidal antiinflammatory drugs
(NSAIDs), and salicylates [2]. (See "Fixed drug eruption".)
Melanoma — A changing, pigmented macule should raise suspicion for melanoma [22]. Changes suggestive
of a melanoma include asymmetry, change in size (particularly, but not necessarily, larger than 6 mm),
irregular or notched borders, change in color, or change in sensation (picture 33). (See "Melanoma: Clinical
features and diagnosis".)
Others — The differential diagnosis of isolated, stable hyperpigmented macules also includes sun-induced
lentigines, ephelides (freckles), café-au-lait macules, bluish-black lesions (Mongolian spots), or nevi. (See
"Acquired hyperpigmentation disorders".)
Minocycline-induced hyperpigmentation tends to be isolated, hyperpigmented blue-black macules

predominantly located in scars [23]. Isolated or diffuse pinkish brown lesions that urticate upon pressure,
rubbing, or heat are suggestive of mastocytomas or mastocytosis/urticaria pigmentosa [24,25]. (See
"Mastocytosis (cutaneous and systemic): Epidemiology, pathogenesis, and clinical manifestations".)
Irregular whorls of hyperpigmentation may occur during treatment with bleomycin and after ingestion of
shiitake mushrooms [26,27]. (See "Cutaneous side effects of conventional chemotherapy agents", section on
'Serpentine, flagellate, and reticular hyperpigmentation' and "Acquired hyperpigmentation disorders", section
on 'Drug-induced linear hyperpigmentation'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics"
and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want
in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Melasma (The Basics)")
SUMMARY
● Macules are flat skin lesions that may occur in a variety of skin disorders. Characteristics such as lesion
distribution, color, and associated signs or symptoms are useful for identifying the correct diagnosis.
(See 'Introduction' above.)
● Erythematous macules are frequently caused by either viral exanthems (picture 1A-D) or drug eruptions
(picture 2). (See 'Erythematous macules' above.)
● Photosensitive disorders may present with macular lesions in areas exposed to sunlight. Examples of
autoimmune disorders that can exhibit these findings include dermatomyositis (picture 5) and systemic
lupus erythematosus (picture 6A). Medications can also induce photodistributed macular skin reactions
(picture 13). Phototoxic drug eruptions resemble an exaggerated sunburn and may be accompanied by
blisters (picture 7). (See 'Photodistributed macular eruptions' above.)
● Pigmentation is a feature that can assist in the diagnosis of macular skin disorders. Hypopigmented
macules may range from lesions that are slightly lighter in color than unaffected skin to completely
depigmented areas of skin, as are seen in vitiligo or halo nevi. Hyperpigmented macules may occur as a
feature of a primary skin disorder or as a consequence of a preceding inflammatory process
(postinflammatory hyperpigmentation). (See 'Hypopigmented macules' above and 'Hyperpigmented
macules' above.)
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REFERENCES
1. Vanderhooft SL, Francis JS, Pagon RA, et al. Prevalence of hypopigmented macules in a healthy
population. J Pediatr 1996; 129:355.
2. Pagnoni A, Kligman AM, Sadiq I, Stoudemayer T. Hypopigmented macules of photodamaged skin and
their treatment with topical tretinoin. Acta Derm Venereol 1999; 79:305.
3. Drenkard C, Villa AR, Reyes E, et al. Vasculitis in systemic lupus erythematosus. Lupus 1997; 6:235.
4. Stern RS, Shear NH. Cutaneous reactions to drugs and biological modifiers. In: Cutaneous Medicine an
d Surgery, Arndt KA, LeBoit PE, Robinson JK, Wintroub BU (Eds), W.B. Saunders, Philadelphia 1996. V
ol 1, p.412.
5. González E, González S. Drug photosensitivity, idiopathic photodermatoses, and sunscreens. J Am
Acad Dermatol 1996; 35:871.
6. Jimbow K. Vitiligo. Therapeutic advances. Dermatol Clin 1998; 16:399.
7. Leung AK, Feingold M. Pityriasis alba. Am J Dis Child 1986; 140:379.
8. Galan EB, Janniger CK. Pityriasis alba. Cutis 1998; 61:11.
9. Lin RL, Janniger CK. Pityriasis alba. Cutis 2005; 76:21.
10. Blessmann Weber M, Sponchiado de Avila LG, Albaneze R, et al. Pityriasis alba: a study of pathogenic
factors. J Eur Acad Dermatol Venereol 2002; 16:463.
11. Urano-Suehisa S, Tagami H. Functional and morphological analysis of the horny layer of pityriasis alba.
Acta Derm Venereol 1985; 65:164.
12. Eczematous eruptions in childhood. In: Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disor
ders of Childhood and Adolescence, 3rd ed, Paller AS, Mancini AJ (Eds), WB Saunders, Philadelphia 2
006. p.49.
13. Jóźwiak S, Schwartz RA, Janniger CK, et al. Skin lesions in children with tuberous sclerosis complex:
their prevalence, natural course, and diagnostic significance. Int J Dermatol 1998; 37:911.
14. Miura Y, Tajima S, Ishibashi A, Hata Y. Multiple anemic macules on the arms: a variant form of nevus
anemicus? Dermatology 2000; 201:180.
15. Choe YB, Park KC, Cho KH. A case of hypopigmented mycosis fungoides. J Dermatol 2000; 27:543.
16. Sarkar R, Kaur I, Das A, Sharma VK. Macular lesions in leprosy: a clinical, bacteriological and
histopathological study. J Dermatol 1999; 26:569.
17. Pandya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin 2000; 18:91.
18. Beleznay K, Humphrey S, Au S. Erythema ab igne. CMAJ 2010; 182:E228.
19. Arnold AW, Itin PH. Laptop computer-induced erythema ab igne in a child and review of the literature.
Pediatrics 2010; 126:e1227.
20. Adams BB. Heated car seat-induced erythema ab igne. Arch Dermatol 2012; 148:265.
21. Ratnam KV, Su WP, Peters MS. Purpura simplex (inflammatory purpura without vasculitis): a
clinicopathologic study of 174 cases. J Am Acad Dermatol 1991; 25:642.
22. Rocamora V, Puig L, Romaní J, de Moragas JM. Amelanotic lentigo maligna melanoma: report of a
case and review of the literature. Cutis 1999; 64:53.
23. Geria AN, Tajirian AL, Kihiczak G, Schwartz RA. Minocycline-induced skin pigmentation: an update.
Acta Dermatovenerol Croat 2009; 17:123.
24. Alto WA, Clarcq L. Cutaneous and systemic manifestations of mastocytosis. Am Fam Physician 1999;
59:3047.
25. Pollack CV Jr, Pender ES. Recognizing an index case of type 1 neurofibromatosis. Am Fam Physician
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27. Todkill D, Taibjee S, Borg A, Gee BC. Flagellate erythema due to bleomycin. Br J Haematol 2008;
142:857.
Topic 1732 Version 19.0
GRAPHICS
Differential diagnosis of macules
Erythematous macules Hyperpigmented macules

Drug eruption Nevi
Viral exanthem Fixed drug eruption
Secondary syphilis Postinflammatory
Rheumatic fever Ephelis (freckle)
Photodistributed macules Lentigo
Drugs Schamberg's purpura
Dermatomyositis Nevus
Lupus erythematosus Mongolian spot
Porphyria cutanea tarda Purpura
Polymorphous light eruption Stasis dermatitis
Melasma
Hypopigmented macules
Melanoma
Postinflammatory
Ochronosis
Tinea versicolor
Mastocytosis
Vitiligo
Café-au-lait spot
Halo nevus
Sarcoidosis
Tuberous sclerosis
Cutaneous T cell lymphoma
Leprosy
Graphic 61066 Version 2.0
Measles
Numerous erythematous macules are present on the face.
Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.
Measles exanthem
Blanching erythematous macules with some confluent areas on the trunk in a

patient with measles.
Copyright Dr. Michael Bennish; reproduced with his permission.
https://www.uptodate.com/contents/approach-to-the-patient-with-macular-skin-lesions/print?search=vitiligo&source=search_result&selectedTitle… 10/56
Rubella rash on a child's back
The distribution is similar to that of measles (rubeola), though the lesions are
less intensely red.
Image from Centers for Disease Control and Prevention.
Characteristic roseola rash
The rash of roseola appears as the fever abates. It starts on the neck and trunk and
spreads to the extremities. As depicted above, it is erythematous, blanching, and macular
or maculopapular.
Courtesy of Michael Brady, MD.
Exanthematous (morbilliform) drug eruption
Drug-induced exanthems, such as this morbilliform eruption, often begin in

dependent areas and generalize.
Courtesy of Andrew Samel, MD.
Erythema infectiosum
Reticulated blanching erythema on the extremities due to parvovirus B19. Rash

is more common in children. The presence of intense erythema (a slapped
cheek appearance) on the face is highly characteristic.
Courtesy of Lee T Nesbitt, Jr. The Skin and Infection: A Color Atlas and Text, Sanders
CV, Nesbitt LT Jr (Eds), Williams & Wilkins, Baltimore, 1995.
http://www.lww.com
Slapped cheek rash of parvovirus B19
A child with the characteristic malar ("slapped cheek") rash associated with parvovirus B19 (erythema
infectiosum, fifth disease).
Slapped cheek rash of parvovirus B19
A child with the characteristic malar ("slapped cheek") rash associated with
parvovirus B19 (erythema infectiosum, fifth disease).
Courtesy of Moise L Levy, MD.
Diffuse rash of Kawasaki disease
Morbilliform confluent rash on the face and trunk of a child with Kawasaki disease. Some targetoid
lesions are also present.
Perineal erythema of Kawasaki disease
Perineal erythema and desquamation are characteristic of Kawasaki disease.
Heliotrope eruption in dermatomyositis
Violaceous erythema on the upper lids in a patient with dermatomyositis. Mid-facial erythema that
does not spare the nasolabial folds is also present.
Courtesy of Jeffrey Callen, MD, FACP, FAAD.
Acute cutaneous lupus erythematosus
Malar erythema and subtle edema are present in this patient with systemic lupus
erythematosus.
Phototoxic eruption
A bright red, confluent rash on the "V" of the neck of a patient with drug-induced
photosensitivity reaction.
Heliotrope euption in dermatomyositis
A reddish-purple eruption on the upper eyelid (the heliotrope eruption),

accompanied by swelling of the eyelid in a patient with dermatomyositis (DM).
This is the most specific cutaneous eruption in DM, although it is only present in
a minority of patients.
Courtesy of John H Stone, MD, MPH.
The shawl sign in dermatomyositis
Courtesy of John H. Stone, MD, MPH.
Dilated capillary loops at the proximal nail fold in

dermatomyositis
Gottron's sign in dermatomyositis
An erythematous, scaly eruption over the extensor surfaces of the

metacarpophalangeal joints and digits in a patient with dermatomyositis. These
lesions, called Gottron's sign, can mimic psoriasis.
Courtesy of John H Stone, MD, MPH
Gottron's sign in dermatomyositis
Erythematous to violaceous patches with overlying scale are present on the extensor
surfaces of both knees in this child with dermatomyositis.
Copyright © 2017 American College of Rheumatology. Used with permission.
Acute cutaneous lupus erythematosus
An erythematous, edematous eruption is present on the malar area. Note the sparing of
the nasolabial folds.
Phytophotodermatitis
Meadow grass-induced phytophotodermatitis. The bizarre, linear

hyperpigmented lesions on the lower leg correspond to the areas of contact with
the grass.
Photoallergic eruption
This 45-year-old woman developed an acute, well-demarcated, erythematous

plaque with vesicles after topical application of ketoprofen gel followed by sun
exposure. The patient wore socks, which protected the foot from the sun,
creating the line of demarcation that is visible in the image.
Copyright © Eric Ehrsam, MD, Dermatlas; http://www.dermatlas.org.
Porphyria cutanea tarda
Vesicles and erosions are visible on the dorsum of the hand in a patient with
porphyria cutanea tarda related to underlying hepatitis C virus infection.
Courtesy of Jean-François Dufour, MD.
Porphyria cutanea tarda
Macular erythema, erosions, crusts, and scars are present on the hands of this
patient with porphyria cutanea tarda.
Reproduced with permission from: Stedman's Medical Dictionary. Copyright © 2008

Lippincott Williams & Wilkins.
Polymorphous light eruption
This 12-year-old girl developed a pruritic eruption that consisted of discrete and
coalescing erythematous papules on the face. The lesions were photodistributed
and appeared within hours after intense sun exposure in the spring.
Copyright © Bernard Cohen, MD, Dermatlas; http://www.dermatlas.org.
Segmental vitiligo
Segmental vitiligo: patches of depigmentation on the anterior trunk.
Reproduced with permission from: Stedman's Medical Dictionary. Copyright ©2008

Tinea versicolor
Multiple small salmon-colored macules are evident on the arm that coalesce in
some areas.
Courtesy of Beth G Goldstein, MD, and Adam O Goldstein, MD.
Tinea versicolor
Multiple light brown, coalescing macules are present on the chest.
Courtesy of Beth G Goldstein, MD, and Adam O Goldstein, MD.
Erythrasma
Red-brown plaques of erythrasma in the groin.
Reproduced with permission from John L Aeling, MD.
Halo nevus
An inflamed compound nevus is encircled by a white halo of depigmentation.
Reproduced with permission from: Goodheart HP. Goodheart's Photoguide of

Common Skin Disorders, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003.
Copyright © 2003 Lippincott Williams & Wilkins.
Pityriasis alba
Hypopigmented macules are present on the face of this young girl with pityriasis
alba.
Copyright © Nicole Sorensen, RN, Dermatlas; http://www.dermatlas.org.
Pityriasis alba
Pityriasis alba. Hypopigmented, slightly scaly macules are present on this child's
cheeks.

Child with tuberous sclerosis complex and hypomelanotic

macules
Three-year-old child with tuberous sclerosis complex and hypomelanotic macules involving
the leg (A) and abdomen (B).
Tuberous sclerosis complex
Hypomelanotic macule on the torso of a patient with tuberous sclerosis complex.
Nevus depigmentosus
Nevus depigmentosus presenting as a large hypopigmented patch involving the back and posterior aspect of
the arm.
Nevus anemicus
Nevus anemicus presenting as a pale, irregularly shaped patch on the face.
Courtesy of Sang Ho Oh, MD.
Postinflammatory hyperpigmentation
In this patient, healing acne was the cause of the postinflammatory

hyperpigmented patch.
Reproduced with permission from: Goodheart HP. Goodheart's Photoguide of

Common Skin Disorders, 2nd ed. Lippincott Williams & Wilkins, Philadelphia 2003.
Melasma
A mottled hyperpigmented patch is present on the cheek.
Melasma lip
A hyperpigmented patch is present on the upper lip in this patient with

melasma.
Actinic (solar) purpura
Ecchymoses are present on the dorsal forearms in an older adult.
Reproduced with permission from: Goodheart, HP. Goodheart's Photoguide of

Common Skin Disorders, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003.
Erythema ab igne
A reticular, erythematous and hyperpigmented area on the back of a patient

who used to sit in close proximity of a heating radiator.
Reproduced with permission from: Wolters Kluwer Health. Copyright © 2011.
Erythema ab igne with residual hyperpigmentation
Reproduced with permission from: Berg D, Worzala K. Atlas of Adult Physical

Diagnosis. Philadelphia: Lippincott Williams & Wilkins, 2006. Copyright © 2006
Solar lentigines
Solar lentigines typically present as small, well-circumscribed, brown macules on sun-exposed

areas.
Solar lentigines presenting as brown macules on the

dorsum of the hand
Multiple brown macules are present on the dorsal hand.
Schamberg's disease
Brown macules and patches with red-brown (cayenne-pepper-like) pinpoint

macules are present in this patient with Schamberg's disease, a variant of
pigmented purpuric dermatosis.

Ochronotic pigmentation of ear cartilage and sclera
A) Bluish-gray auricular cartilage in a patient with alkaptonuria. B) Ocular

ochronosis with scleral pigmentation.
Reproduced with permission from: Gold DH, Weingeist TA. Color Atlas of the Eye in
Systemic Disease. Baltimore: Lippincott Williams & Wilkins, 2001. Copyright © 2001
Fixed drug eruption
Fixed drug eruptions (A) typically resolve with postinflammatory

hyperpigmentation (B).
Copyright © Chris Ha, MD, DermAtlas; http://www.dermatlas.org.
Acral lentiginous melanoma
An acral lentiginous melanoma shows the asymmetry and color variegation of

typical melanomas. They are distinguished clinically by their location on the
palms, soles, or nails.
Courtesy of James C Shaw, MD.
Contributor Disclosures
Beth G Goldstein, MD Nothing to disclose Adam O Goldstein, MD, MPH Nothing to disclose Robert P
Dellavalle, MD, PhD, MSPH Grant/Research/Clinical Trial Support: Pfizer Pharmaceuticals [Independent
research grant to the University of Colorado (Development of patient decision aids)]. Other Financial Interest:
Editorial stipends from the Journal of Investigative Dermatology and the Journal of the American Academy of
Dermatology. Rosamaria Corona, MD, DSc Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy

Approach To The Patient With Macular Skin Lesions - UpToDate

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Approach To The Patient With Macular Skin Lesions - UpToDate

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2/28/2018 Approach to the patient with macular skin lesions - UpToDate

Official reprint from UpToDate®

Authors: Beth G Goldstein, MD, Adam O Goldstein, MD, MPH

The presence of macules should raise the following questions:

● What is the distribution of the lesion?

● Is there erythema, hypo- or hyperpigmentation?

● Are there secondary characteristics such as scale or erythema?

● Is the patient taking any medications, such as prescription, over-the-counter, or herbal?

● Is there a photodistribution to the eruption?

PHOTODISTRIBUTED MACULAR ERUPTIONS — Photodistributed macular eruptions may occur in a

Drug-induced photosensitivity reactions — A history of taking a photosensitizing drug suggests the

● Photoallergy is a lymphocyte-mediated reaction caused by exposure to ultraviolet A. The eruption is

HYPOPIGMENTED MACULES — Hypopigmented macules are distinguished from depigmented macules by

Pityriasis alba is thought to represent a nonspecific dermatitis with residual postinflammatory

HYPERPIGMENTED MACULES — Hyperpigmented macules may signify several different disease

Postinflammatory hyperpigmentation — Diffuse hyperpigmentation often accompanies postinflammatory

Melasma — Melasma occurs as splotchy hyperpigmented macules, typically in a photodistributed pattern,

Minocycline-induced hyperpigmentation tends to be isolated, hyperpigmented blue-black macules

● Basics topic (see "Patient education: Melasma (The Basics)")

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 1732 Version 19.0

Differential diagnosis of macules

Erythematous macules Hyperpigmented macules

Viral exanthem Fixed drug eruption

Secondary syphilis Postinflammatory

Rheumatic fever Ephelis (freckle)

Photodistributed macules Lentigo

Drugs Schamberg's purpura

Lupus erythematosus Mongolian spot

Porphyria cutanea tarda Purpura

Polymorphous light eruption Stasis dermatitis

Cutaneous T cell lymphoma

Graphic 61066 Version 2.0

Numerous erythematous macules are present on the face.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 73806 Version 3.0

Blanching erythematous macules with some confluent areas on the trunk in a

Copyright Dr. Michael Bennish; reproduced with his permission.

Graphic 57093 Version 4.0

Rubella rash on a child's back

Image from Centers for Disease Control and Prevention.

Graphic 61263 Version 1.0

Characteristic roseola rash

Courtesy of Michael Brady, MD.

Graphic 81967 Version 2.0

Exanthematous (morbilliform) drug eruption

Drug-induced exanthems, such as this morbilliform eruption, often begin in

Courtesy of Andrew Samel, MD.

Graphic 70062 Version 5.0

Reticulated blanching erythema on the extremities due to parvovirus B19. Rash

Slapped cheek rash of parvovirus B19

Graphic 89522 Version 2.0

Slapped cheek rash of parvovirus B19

Courtesy of Moise L Levy, MD.

Graphic 71737 Version 2.0

Diffuse rash of Kawasaki disease

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 91531 Version 1.0

Perineal erythema of Kawasaki disease

Perineal erythema and desquamation are characteristic of Kawasaki disease.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 91532 Version 1.0