Pityriasis Rosea

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jun 02, 2016
 

Background

Pityriasis rosea (PR) is a benign rash first described by Gilbert in 1860; the name means “fine pink scale.” It is a common skin disorder observed in otherwise healthy people, most frequently children and young adults. Other types of similar skin eruptions include lichen planus, psoriasis, and pityriasis rubra pilaris.

PR manifests as an acute, self-limiting, papulosquamous eruption with a duration of 6-8 weeks. It evolves rapidly, usually beginning with patch that heralds the eruption, the so-called “herald patch” (see the image below). It may sometimes occur in atypical variants or may mimic other skin disorders, such as tinea corporis and secondary syphilis.[1, 2, 3] Guidelines for diagnosing syphilis (and distinguishing the roseola from pityriasis rosea) have been established.[4] As a rule, PR requires only symptomatic treatment.

Herald patch. Image courtesy of Drexel Department Herald patch. Image courtesy of Drexel Department of Dermatology slide collection.

See 15 Rashes You Need to Know: Common Dermatologic Diagnoses, a Critical Images slideshow, to help identify and treat various rashes.

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Pathophysiology

PR has often been considered to be a viral exanthem, a view supported by the condition’s seasonal occurrence, its clinical course, the possibility of epidemic occurrence, the presence of occasional prodromal symptoms, and the low rate of recurrence. Oxidative stress may play a role too.[5]

PR has been linked to upper tract respiratory infections. An increased incidence is reported among groups with close physical contact (eg, families, students, and military personnel), though the condition does not appear to be highly contagious. The incidence of PR among dermatologists is 3-4 times that among other physicians.

A higher incidence of PR is also noted among patients with decreased immunity (eg, pregnant women and bone marrow transplant recipients). Additionally, ampicillin increases the distribution of the eruption, an effect bearing a striking resemblance to the drug’s effect on the rash of infectious mononucleosis.

Some immunologic data also suggest a viral etiology.[6] A lack of natural killer (NK) cell and B-cell activity in PR lesions has been noted, suggesting a predominantly T-cell mediated immunity in the development of the condition. Increased amounts of CD4 T cells and Langerhans cells are present in the dermis, possibly reflecting viral antigen processing and presentation. Anti−immunoglobulin M (IgM) to keratinocytes has been found in patients with PR; this finding may be associated with the exanthem phase of the presumed viral infection.

The primary plaque is seen on the skin in 50-90% of cases a week or more before the onset of the eruption of smaller lesions. This secondary eruption occurs 2-21 days later in crops following the lines of cleavage of the skin. On the back, this eruption produces a “Christmas tree” pattern (see Presentation).

Atopy, seborrheic dermatitis, and acne vulgaris are more common in patients with PR than in control subjects. PR during pregnancy may foreshadow premature delivery and fetal demise, especially when it develops within the first 15 weeks of gestation.[7]

Recurrences of PR are generally regarded as rare and are thought by some to indicate a lasting immunity when they do occur.

A classification based on pathogenetic mechanisms associated wth the different presentations of PR has been proposed.[8]

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Etiology

Infectious agents

An infectious etiology for PR has been sought for many years. It has been suggested that the condition is precipitated by a viral agent. Accordingly, a number of viruses have been studied with a view to determining whether they are linked to PR.

Picornaviruslike particles have been seen in the tissue of African green monkeys inoculated from human pityriasis rosea lesions. A follow-up study failed to find picornavirus RNA in patients with pityriasis rosea. Serology and polymerase chain reaction (PCR) assay for viral DNA have been negative for Epstein-Barr virus (EBV), parvovirus B19, cytomegalovirus (CMV), human herpesvirus (HHV)-8,[9] HHV-1, and HHV-2 in patients diagnosed with PR.

Some initial reports using PCR analysis suggested a role for human herpesvirus (HHV)-7 and HHV-6, but subsequent studies have not been confirmatory.[10, 11, 12, 9, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22] That HHV-7 is frequently found in healthy individuals casts further doubt on its proposed etiologic role.[21] The influenza virus H1N1 has also been proposed as a possible causative pathogen.[23]

Some investigators have suggested that a fungal infection is a more likely cause of PR than a viral infection is. However, no fungus has been isolated as a definite causal agent. No bacterial pathogen, such as Mycoplasma, has been found to be causative either. Thus far, the search for an infectious cause of PR has been unsuccessful.

Drugs

PR-like eruptions can also occur in association with many drugs (eg, acetylsalicylic acid, barbiturates, bismuth, captopril, clonidine, gold, imatinib, isotretinoin, ketotifen, levamisole, metronidazole, omeprazole, D-penicillamine, and terbinafine), as well as certain vaccines (eg, bacille Calmette-Guérin [BCG], human papilloma virus, and diphtheria).[2, 24, 25]

Anti−tumor necrosis factor (TNF)-α agents such as adalimumab and etanercept have also been implicated.[26, 27] PR-like drug eruptions have been reported to be related to use of rituximab,[28] nortriptyline,[29] and clozapine.[30]

PR-like drug eruptions may be difficult to distinguish from non–drug-induced cases. Drug-induced PR often lasts longer than non–drug-induced pityriasis rosea. Lesions are also thought to be increased in individuals with high stress levels.

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Epidemiology

United States statistics

PR is very common in the general population, and most cases occur in the spring and winter in temperate climates. The estimated frequency of PR in the United States is approximately 0.13% in females and 0.14% in males, with a 0.3-3% prevalence at dermatologic centers.

International statistics

Worldwide, pityriasis rosea has been estimated to account for 2% of dermatologic outpatient visits. The disease is more common in the spring and the fall in temperate climate zones. However, it may be more frequent in the summer in some other regions. It favors the hot, dry season in Australia, India, and Malaysia.

An increase in the prevalence of pityriasis rosea has been reported in Uganda. No change in the prevalence of pityriasis rosea has been reported in Sweden. It has also been seen in the United Kingdom, Nigeria, Sudan, Brazil, Lagos, Singapore, Turkey, Kuwait, and Hong Kong.

Age-, sex-, and race-related demographics

PR is observed in people of all age groups, though it is most common in persons aged 10-35 years and rare in infants and elderly persons. The youngest patient reported in the literature was aged 3 months, and the oldest was aged 85 years.

PR occurs slightly more often in females than in males.[31] The female-to-male ratio is reported as 2:1 or 3:2 in the United States.

No racial predominance is reported. More intensely pigmented Africans tend to have more widespread disease. The lesions in African Americans may lack a rose color, and they may appear darker than the surrounding skin.

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Prognosis

PR is a self-limiting, generally benign disorder for which the prognosis is excellent and the recurrence rate is low (approximately 2%). Because it is not considered a transmissible disease, patients do not require isolation and may return to work or school. PR usually lasts for 6-8 weeks, but can last as long as 3-6 months. Protracted cases of severe eczematous or drug-induced PR are referred to as pityriasis rosea perstans.

The main morbidity is from pigmentary changes, which may develop as lesions heal, especially in black people. Both postinflammatory hyperpigmentation and hypopigmentation may occur. However, lesions do not result in scars. Bacterial superinfections may occur, but are rare. In pregnant women, PR is sometimes associated with miscarriage if occurring within the first 15 weeks of pregnancy, premature delivery, or neonatal hypotonia and hyporeactivity.[7, 32]

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Patient Education

Patients should be instructed to avoid contact with irritants. In addition, patients and families should be educated regarding the benign and noninfectious nature of the rash and the relatively lengthy course of the disease. Typically, the secondary rash develops over 2 weeks, persists for another 2 weeks, and then fades over another 2 weeks, without the need for treatment, though some lesions have persisted for as long as 3-4 months.

For patient education resources, see the Skin Conditions & Beauty Center, as well as Eczema (Atopic Dermatitis).

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Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Richard Lichenstein, MD Professor, Pediatric Emergency Department, University of Maryland School of Medicine

Richard Lichenstein, MD is a member of the following medical societies: American Medical Association, American Academy of Pediatrics

Disclosure: Nothing to disclose.

Camila K Janniger, MD Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, Rutgers New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Robert A Allen, MD Staff Physician, Department of Dermatology, Drexel University College of Medicine-Hahnemann Hospital

Robert A Allen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Medical Association

Disclosure: Nothing to disclose.

Jerry Balentine, DO Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mark W Fourre, MD Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

Rajendra Kapila, MD, MBBS Professor of Medicine, Department of Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Infectious Diseases Society of New Jersey

Disclosure: Nothing to disclose.

Thomas M Kerkering, MD Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine

Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Mark G Lebwohl, MD Chairman, Department of Dermatology, Mount Sinai School of Medicine

Mark G Lebwohl, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Amgen/Pfizer Honoraria Consulting; GlaxoSmithKline None Investigator; Novartis Honoraria Consulting; Ranbaxy None Consulting; Pfizer None Consulting; BioLineRX, Ltd. Honoraria Consulting; Celgene Corporation Consulting; Clinuvel None Investigator; Eli Lilly & Co. Honoraria Consulting; Genentech None Consulting

Daniel R Lucey, MD, MPH Chief, Fellowship Program Director, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center; Professor, Department of Internal Medicine, Uniformed Services University of the Health Sciences

Daniel R Lucey, MD, MPH is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians

Disclosure: Nothing to disclose.

Amal Mattu, MD, FACEP, FAAEM Professor and Vice Chair, Department of Emergency Medicine, University of Maryland School of Medicine

Amal Mattu, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Giuseppe Micali, MD Head, Professor, Department of Dermatology, University of Catania School of Medicine, Italy

Giuseppe Micali, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Maria R Nasca, MD, PhD Assistant Professor, Department of Dermatology, University of Catania School of Medicine, Italy

Disclosure: Nothing to disclose.

Robert L Rogers, MD Staff Physician, Departments of Internal Medicine and Surgery, Division of Emergency Medicine, University of Maryland

Robert L Rogers, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Herald patch. Image courtesy of Drexel Department of Dermatology slide collection.
Christmas tree distribution of lesions on trunk. Image courtesy of Drexel Department of Dermatology slide collection.
Histopathologic features of pityriasis rosea. Image courtesy of Gary R Kantor, MD, Department of Dermatology, Drexel University, Philadelphia, PA.
 
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