PITYRIASIS ROSEA

By Gary M. White, MD

Pityriasis Rosea of the Back with Herald Patch
Classic herald patch, the "mother," on the left shoulder, with secondary lesions, the "babies," scattered around on the back.


Pityriasis rosea (PR) is a common, benign, self-limited papulosquamous skin condition affecting primarily children and young adults. Many studies have looked for an infectious cause, with human herpes virus 7, and to a lesser extent virus 6, being most strongly implicated [J Invest Dermatol 124:1234 –1240, 2005]. Seventy-five percent of patients are from 10 to 35 years of age.

There is no internal involvement. It is somewhat more common in the winter. Most cases occur in isolation, but occasionally there will be two family members affected. Various drugs have been reported to have caused a PR-like eruption, but it is highly unlikely that a drug can cause the classic presentation of a herald patch followed by secondary lesions. See also PR gallery, herald patch, PR of groin and PR vesicular.

Clinical

In many patients, a herald patch appears first. The herald patch is round to oval, red and scaly, and may be from 2-6 cm in diameter. It typically occurs on the trunk, neck or proximal extremities. When a patient presents with a solitary papulosquamous lesion of short duration, think PR.

One to several weeks later, the patient experiences a diffuse eruption of red, oval plaques on the trunk, axilla, sides of neck and the groin. PR definitely prefers the sun-protected areas and this is a helpful diagnostic sign. The palms and soles are usually spared (as compared to secondary syphilis where they are usually involved). Many of the plaques may be noted to have a collarette of scale which is also a helpful diagnostic sign. Usually, the long axis of the plaques runs parallel to the ribs giving a Christmas tree pattern. A variant with enormous plaques is known as pityriasis rosea gigantea of Darier.

Oral lesions (exanthema) may occur [JAAD 2017;77;833]. Typical are erythematous macules and papules, vesicles and petechiae especially of the palate.

Prodromal symptoms of headache and/or malaise may be elicited in some patients, but whether this occurs any more commonly than in controls is not proven.

Differential Diagnosis

Common considerations are guttate psoriasis, secondary syphilis, drug-induced PR-like eruptions and PLEVA. If there is any question that the patient may have secondary syphilis (e.g., no herald patch and the palms and soles are involved), an RPR should be obtained.

PR in Pregnancy

PR developing during pregnancy may be followed by premature delivery and even fetal death. When PR developed on or before the 15th gestational week, there has been reported an abortion rate on the order of 60% [J Am Acad Dermatology 71;198–199, July 2014].

PR and Vaccines

PR and PR-like eruptions have occurred after vaccination. Some eruptions are similar to classic PR with a herald patch and prodromal symptoms. Others are PR-like and do not have prodromal symptoms nor a herald patch. These PR-like eruptions may also occur after drugs including captropril, barbiturates, and isotretinoin.

Recurrent PR

Recurrent pityriasis rosea and its association with oral ulcers and herald patches for each episode in different locations has been reported. [Singapore Med J. 2014 Jan;55]. However, another study [Dermatology. 2014;229(4):316-8], found that the herald patch was always absent, the size and number of the lesions were reduced, and duration was shorter than that of the primary episodes. Constitutional symptoms were present, though less severe than in the primary eruption. Most recurrences occurred within 1 year (16/21, 76.2%). Reactivation of human herpesvirus 6/7, as with other human herpesviruses (varicella zoster virus and Epstein-Barr virus), is proposed.

Persistant PR (PPR)

In one study of PR that lasted longer than 12 weeks, a persistent reactivation of HHV-6 and/or HHV-7 with higher viral loads than in typical PR was found [Dermatology. 2015;230:23-6]. Cases of PPR tended to have more frequent and more severe systemic symptoms as well as oral lesions (for a picture, see Dermatology 2015;230:23–26).

Treatment

Untreated, PR usually resolves spontaneously within 2-3 months although some cases may last 6 months. In asymptomatic patients, no active treatment is necessary. If itching is a problem, a topical steroid may be helpful.

Acyclovir

Drago et al in 2006 [JAAD 2006;54:82] conducted a study of oral acyclovir (800 mg 5/day x 7 days) vs placebo in 87 patients, aged. He found on 2 week follow up, 79% of patients had fully regressed compared with 4% of the placebo group. Unfortunately, his study was neither randomized nor double blinded. Rassai et al in 2001[J Eur Acad Dermatol Venereol. 2011;25:24] conducted a study of low dose acyclovir (400 mg 5day x 7 days) vs no treatment in a randomized, investigator-blinded study of 64 patients. They found resolution of lesions in 78% of acyclovir-treated vs 27% of placebo-treated patients at 2 weeks. Ganguly et al[J Clin Diagn Res. 2014;8:YC01–4] in 2014 conducted a randomized, double-blinded, placebo controlled study of 73 patients with acyclovir 800 mg 5/day for 7 days vs placebo and found resolution of lesions on the 14th day in 87% of treated patients vs 33% of placebo-treated patients. Recently in 2016, Singh et al [Indian J Dermatol Venereol Leprol 2016;82:505] published a smaller study of 27 patients in an randomized, blinded, placebo-controlled trial using acyclovir 800 mg 5/day x 7 days and complete clearing as the endpoint. They found no benefit to the use of acylovir. The number of days to cure was 27 in the placebo group and 33 days in the acyclovir group.

Of all the published studies, that by Ganguly et al is the most robust, being randomized and double blinded. It does support the use of acyclovir in PR. Although the study by Singh et al gives contrary results, it is much smaller in size. It seems reasonable for more severe cases of PR to give acyclovir 800 mg 5/day x 7 days.

Ultraviolet Light

Sunlight chases PR lesions away. The patient may expose his/her skin to the sun several times a week (don't burn) or if necessary, receive light therapy (UVB) in the dermatologist's office.

Topical Steroids

Topical steroids only show modest benefit. For mild to moderate itching, a medium-potency topical steroid may be given (e.g., triamcinolone 0.1% cream).

Other

Azithromycin was NOT effective in a DBPCT [Indian J Dermatol Venereol Leprol. 2014 Jan-Feb;80(1):36-40].

The patient should be told that if the condition persists beyond 4-6 months, return for further evaluation. Such cases of chronic PR should be biopsied to exclude psoriasis, pityriasis lichenoides or other conditions.

Additional Pictures

The typical mother (herald) patch and the babies.
Pityriasis Rosea Herald Patch of Pityriasis Rosea

An oval red plaque with a collarette of scale is characteristic.
Pityriasis Rosea with collarette of Scale

Areas hidden from the sun--like the axilla, neck and groin--are favored sites.
Pityriasis Rosea of the Axilla

For more photos of PR, see PR gallery.

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