Papules are solid, circumscribed skin elevations up to 5 mm in diameter. If they are larger, they are called nodules – these are dealt with elsewhere (see ‘Nodules’). (Clearly, many nodules start life as a papule; to avoid confusion, if they are generally ‘nodular’ by the time they present to the GP, then they are dealt with in that section, and not repeated here.) They are usually round but the shape, and the colour, may vary. They may be transitional lesions, e.g. becoming vesicular, or about to ulcerate. NOTE: There are more causes of papules than can be listed here. This is a sensible selection.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Acne
  • Scabies
  • Viral Wart and Molluscum Contagiosum
  • Campbell De Morgan Spot
  • Skin Tag

Occasional Diagnoses

  • Viral Illness
  • Milia
  • Insect Bites
  • Early Seborrhoeic Wart
  • Xanthomata
  • Guttate Psoriasis
  • Pityriasis Lichenoides Chronica, Lichen Planus
  • Prickly Heat
  • Keratosis Pilaris

Rare Diagnoses

  • Malignant Melanoma, Early Basal Cell Carcinoma, Kaposi’s Sarcoma
  • Darier’s Disease
  • Acanthosis Nigricans
  • Pseudoxanthoma Elasticum
  • Tuberous Sclerosis

Ready reckoner

Key distinguishing features of the most common diagnoses

AcneScabiesViral WartC. de M. SpotSkin Tag
Characteristic DistributionYesYesNoYesNo
Associated LesionsYesYesNoNoNo
History of ContactNoYesPossibleNoNo

Possible investigations

  • In practice, very few investigations are needed with this presentation: A lipid screen is required in the presence of xanthomata; genital warts require referral for screening for other STDs; thorough investigation may be needed in the very rare case where underlying malignancy is possible (e.g. acanthosis nigricans); and obscure rashes or solitary papules may occasionally require excision biopsy for a definitive diagnosis.

Top Tips

  • Bear in mind that skin cancer is usually uppermost in the patient’s mind, especially in subacute or chronic cases – so provide appropriate reassurance.
  • In obscure solitary lesions, record clinical findings carefully and arrange to review in due course.
  • Itchy, asymmetrical grouped papules are likely to be insect bites, although the patient may take some convincing!

Red Flags

  • An enlarging dark blue or blue-black papule may be a malignant melanoma, blue naevus or Kaposi’s sarcoma. Refer for urgent opinion.
  • Brown, skin-coloured papules crowded around the nose of a child may be tuberous sclerosis. This can be associated with serious systemic pathology so refer for expert opinion.
  • An intensely itchy papular rash which is worse at night and has no other obvious cause is likely to be scabies, even if scabetic burrows are not evident – treat on suspicion.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.