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Milker's Nodules Clinical Presentation

  • Author: Justin J Finch, MD, FAAD; Chief Editor: William D James, MD  more...
Updated: Mar 25, 2016


Patients typically have no previous history of milker's nodule. Patients with milker's nodules have had recent contact with infected cows, calves, or viral fomites. (Milker's nodules are contracted from cows; orf nodules are contracted from sheep or goats.) The incubation period for milker's nodules may be as brief as 4 days or as long as several weeks.

Lesions of milker's nodules are often solitary, and they may be pruritic or painful. Some authorities divide the clinical course of milker's nodules into 6 stages, each lasting roughly 1 week, as follows:

  • Erythematous maculopapular
  • Target (a papulovesicular lesion with a red center, white ring, and red periphery)
  • Acute weeping nodule (characterized by loss of epidermis over the center)
  • Dry, crusted nodular
  • Papillomatous
  • Regressive


Lesions of milker's nodules are usually found on the fingers, the hands, and the forearms and are nearly identical to those seen in orf.[5] Usually, only a few or even a single lesion is present. Occasionally, many lesions are distributed in a larger area, such as a burn site.[6, 7]

Classic milker's nodules lesions are 0.5-1.5 cm in diameter, firm, movable, dome-shaped papules or nodules. Milker's nodules may be red or purplish red in color, or they may have a targetlike appearance. Central ulceration or crust may occur. Lesions typically have a grayish coating in the target stage and a verrucous surface in the papillomatous stage.

Milker's nodules often present with a vascular appearance resembling pyogenic granuloma. Milker's nodules are on average smaller than orf lesions, but they may not be distinguishable on a clinical basis. Variant lesions may include vesicles, scaly patches, and erosions. (The patient's history guides the differential diagnosis in these cases.) Local lymphadenopathy may be present.

A focused physical examination should be performed. The following findings have been described in patients with milker's nodules:

  • Lymphangitis
  • Regional lymphadenopathy
  • Fever
  • Diarrhea
  • Abdominal cramping


Milker's nodules are caused by a double-stranded DNA virus of the genus Parapoxvirus. Milker's nodule is a zoonosis endemic to and common in cattle worldwide.

Human milker's nodules are contracted through direct transmission (ie, handling of infected cow teats, calf muzzles, other sites of active bovine infection) or through indirect transmission (ie, handling of virally contaminated objects).

Evidence suggests that milker's nodule virus (traditionally associated with disease contracted from papulonodular lesions on cow teats) and bovine papular stomatitis virus (traditionally isolated from erosive lesions on calf muzzles) may be different though closely related viruses. It seems that they may both cause milker's nodule in humans. In fact, each may cause both types of lesions in cattle.

Contributor Information and Disclosures

Justin J Finch, MD, FAAD Assistant Professor, Director of Clinical Photography, Director of the Center for Cutaneous Laser Surgery, Department of Dermatology, University of Connecticut Health Center

Justin J Finch, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, Society for Pediatric Dermatology, New England Dermatological Society, Connecticut Society of Dermatology and Dermatologic Surgery, Midwest Arts in Healthcare Network, Arts & Health Alliance

Disclosure: Nothing to disclose.


Steven Brett Sloan, MD Associate Professor, Department of Dermatology, University of Connecticut School of Medicine; Residency Site Director, Connecticut Veterans Affairs Healthcare System; Assistant Clinical Professor, Yale University School of Medicine

Steven Brett Sloan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Connecticut State Medical Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Journal of the American Academy of Dermatology;Up to Date;Medical Review Institute of America.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Paul Krusinski, MD Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Franklin Flowers, MD Department of Dermatology, Professor Emeritus Affiliate Associate Professor of Pathology, University of Florida College of Medicine

Franklin Flowers, MD is a member of the following medical societies: American College of Mohs Surgery

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Gary W. Cole, MD, and Lily L. Tinkle, MD, PhD, to the development and writing of this article.

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