eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Pityriasis

Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Rajendra Kapila, MD, MBBS, Professor of Medicine, Department of Medicine, UMDNJ, New Jersey Medical School; Robert L Rogers, MD, Staff Physician, Departments of Internal Medicine and Surgery, Division of Emergency Medicine, University of Maryland; Amal Mattu, MD, FACEP, FAAEM, Program Director, Emergency Medicine Residency, Co-Director, Emergency Medicine/Internal Medicine Combined Residency Program, Department of Surgery, Division of Emergency Medicine, University of Maryland School of Medicine

Updated: Mar 2, 2009

Introduction

Background

Pityriasis rosea, a rash first described by Gilbert in the 19th century, is a common type of papulosquamous skin eruption that is typically acute in onset and self-limiting. Pityriasis rosea has a distinctive morphology and clinical course and a predilection for young adults. Other types of similar skin eruptions include lichen planus, psoriasis, eczema, and pityriasis rubra pilaris. The rash of pityriasis rosea is scaly in appearance and consists of papules and, sometimes, plaques. The rash is usually short-lived and requires only symptomatic treatment. Pityriasis rosea evolves rapidly and usually begins with the well-known herald patch.

Frequency

United States

Pityriasis rosea is very common in the general population, and most cases occur in the spring and winter in temperate climates. The estimated frequency of pityriasis rosea in the United States is approximately 0.13% in females and 0.14% in males.

International

Pityriasis rosea is more common in certain countries (eg, Uganda).

Mortality/Morbidity

Pityriasis is a self-limiting illness that causes very little morbidity. It follows a benign course in most patients, and complete resolution of symptoms is the rule. However, some cases of severe eczematous or drug-induced rashes may be protracted. These cases are known as pityriasis rosea perstans.

Race

Pityriasis has no predilection for any race.

Sex

The incidence of rash development is slightly higher in females than in males.

Age

Approximately 87-90% of pityriasis cases occur in people aged 10-40 years. Pityriasis is rare among very young and very old persons.

Clinical

History

• Patients with pityriasis may report a history of nonspecific symptoms (eg, malaise, nausea, fever) that precede the development of the rash.
• Obtain a detailed dermatologic history in all patients.
  • Ask patients about prior dermatologic diseases and their manifestations.
  • Elicit symptoms of the presenting rash (eg, pruritus, pain).
• When pertinent, obtain a history of sexually transmitted diseases.
• Record travel history, occupational exposure, and drug exposure in the medical record.
• Ask patients about ill contacts.
• The natural history of pityriasis rosea in black children may differ from that described in American, European, and African literature. A study by Amer et al (2007) found that black children with pityriasis rosea had more frequent facial (30%) and scalp lesions (8%) involvement than anticipated in white populations. One third had the papular form of pityriasis rosea.¹

Physical

• The initial skin lesion of pityriasis is a pink (rosea) oval patch approximately 3-6 cm in diameter that can develop anywhere on the body, including on plantar skin, although it is most commonly located on the back.² This is referred to as the herald patch.
  • The herald patch has a scale (pityriasis) that resembles a collarette toward the periphery.
  • The patch is something of a dermatologic enigma because it does not occur in any other known skin disease. The earliest stages of the patch may manifest as pink papules that can be mistaken for other lesions (eg, insect bites).
• A few days later, the initial patch is followed by a rash of similar but smaller lesions.
  • Secondary eruptions appear in crops at intervals of a few days and reach a maximum in about 10 days.
  • The rash typically follows the cleavage lines of the skin, resulting in a Christmas tree–type pattern.
  • The secondary rash is generally distributed on the back, chest, abdomen, arms, and thighs.
  • The rash can last up to 6-8 weeks before fading.
• Lesions are typically symmetric and are not preceded by systemic symptoms.
• Pruritus appears to be the predominant symptom but can be absent in as many as 25% of cases.
• Individuals with dark skin can have a postinflammatory hyperpigmentation that may take a few months to heal. Both hypopigmentation and hyperpigmentation can follow the rash.
• The following atypical features occasionally occur:
  • Herald patch is absent in 10-50% of cases.
  • Skin eruptions may be florid.
  • Lesions may be few, large, and in a particular body region (eg, axilla). In adults, this is known as pityriasis circinata et marginata of Vidal.
  • Rash may be located in areas not usually affected by pityriasis; this is known as inverse pityriasis rosea.
  • Pityriasis may occur in sun-spared areas such as the breast and the axilla.
  • Lesions are sometimes papular, vesicular, or purpuric.

Causes

• An infectious etiology for pityriasis rosea has been sought for many years.
• A viral agent was once postulated as a precipitant for pityriasis rosea. Over the past few years, there has been considerable interest in human herpesvirus 7 as a possible etiologic agent. Investigative studies have failed to link this virus, as well as others, to the well-known rash of pityriasis rosea.³
• Some investigators believe that a fungal infection is more likely.
• Thus far, the search for an infectious agent has been unsuccessful.
• The incidence of pityriasis rosea among dermatologists is 3-4 times that of other physicians.
• Recurrences of pityriasis rosea are generally regarded as rare and are thought by some to indicate a lasting immunity when they do occur.
• Certain medications have been implicated as possible causes of pityriasis rosea.⁴ Adalimumab was recently linked with pityriasis rosea.⁵

Differential Diagnoses

Kaposi Sarcoma
Syphilis

Other Problems to Be Considered

Pityriasis versicolor (tinea versicolor)
Guttate psoriasis
Seborrheic eczema
Parapsoriasis
Drug eruptions/toxins (eg, arsenic, bismuth, barbiturates, gold, captopril, organic mercurials)
Pityriasis lichenoides (extremity lesions)
Pityriasis rubra pilaris
Tinea
Lichen planus
Seborrheic dermatitis
Nummular eczema
Pityriasis alba (on the face, arms, and thorax in children and young adults)

Workup

Laboratory Studies

• In most cases of pityriasis rosea, laboratory studies are unnecessary.
• Syphilis should be strongly considered in the differential diagnosis.
• Generally, order a rapid plasma reagin (RPR) test, and ensure that the patient receives follow-up care.

Treatment

Medical Care

• In most cases, pityriasis rosea is a self-limited disorder, and treatment is not necessary in uncomplicated cases.
• The rash usually disappears in a few weeks.
• Patients should avoid irritants such as wool, certain irritant soaps, perfumes, and household products.
• Pruritus is commonly associated with pityriasis rosea and can be treated conservatively with calamine lotion or oral antihistamine therapy.
• If the rash is severe, topical steroids can be applied.
  • Remember that steroids alleviate the pruritus, but they do not modify the eruption.
  • Cases of severe exacerbations have been reported in association with oral steroid use.

Consultations

In some instances, obtaining a consultation with an infectious disease specialist or dermatologist is warranted, especially in patients with atypical pityriasis rosea, comorbid conditions, solid organ transplants, or hematopoietic stem cell transplants.

Medication

Drug therapy for pityriasis rosea primarily consists of symptomatic treatment of pruritus. Oral antihistamines and topical corticosteroids can be used as needed. For patients in whom superficial tinea infection is a concern or possibility, topical antifungal therapy can be used.

Chuh et al (2007) recently assessed the efficacy of interventions for pityriasis rosea.⁶ They found that evidence for efficacy for most treatments for pityriasis rosea is inadequate. Erythromycin has been reported as effective in the treatment of pityriasis rosea. However, in a placebo-controlled study conducted by Rasi et al (2008), oral erythromycin was not found to confer a significant benefit in 184 patients with pityriasis rosea.⁷

Antihistamines

Consider oral antihistamine therapy in patients with pruritus. These agents may control itching by blocking effects of endogenously released histamine.

Hydroxyzine (Atarax, Vistaril)

Effective antipruritic in the treatment of pityriasis rosea. Antagonizes H1 receptors in periphery.

Dosing

Adult

25-100 mg PO/IM qd/qid or prn

Pediatric

<6 years: 50 mg/d PO divided qid
>6 years: 50-100 mg/d PO divided qid

Interactions

CNS depression may increase with alcohol or other CNS depressants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic disease; not safe in lactating women; may cause sedation and adverse GI effects

Diphenhydramine (Benadryl, Benylin)

Very safe oral antihistamine. Can be used safely in pregnancy. For symptomatic relief of symptoms caused by release of histamine in allergic reactions. Very effective in controlling pruritus.

Dosing

Adult

25-50 mg PO/IV/IM q4-6h; not to exceed 300-400 mg/d

Pediatric

<6 years: Not established
6-12 years: 12.5-25 mg PO q4-6h or 5 mg/kg/d PO/IV/IM divided qid; not to exceed 150 mg/d
>12 years: Administer as in adults

Interactions

Potentiates effect of CNS depressants; because of alcohol content, do not administer syrup dosage form to patient taking medications that can cause disulfiramlike reactions

Contraindications

Documented hypersensitivity; MAOIs

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause somnolence; avoid use with drugs that may have anticholinergic properties; may exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction

Follow-up

Further Outpatient Care

Patients with pityriasis rosea should receive follow-up care to ensure that the rash is improving. Further evaluation of other etiologies may be warranted if the rash worsens or fails to improve or if the patient develops other signs or symptoms.

Complications

Complications of pityriasis rosea are extremely rare but can include superinfection of the rash in vesicular pityriasis and changes in pigmentation.

Prognosis

The prognosis of vesicular pityriasis is generally very good.

Patient Education

• Patients with vesicular pityriasis should be educated regarding the noninfectious nature of the rash and the time course expected before resolution occurs.
• For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Also, see eMedicine's patient education article Eczema.

Miscellaneous

Medicolegal Pitfalls

• Until proven otherwise, consider syphilis to be present in a patient who has a pityriasis-type rash and risk factors for sexually transmitted diseases (eg, intravenous drug use, HIV infection, promiscuity).
• Rarely, herpes zoster infection is confused with the vesicular variant of pityriasis rosea.

References

1. Amer A, Fischer H, Li X. The natural history of pityriasis rosea in black American children: how correct is the "classic" description?. Arch Pediatr Adolesc Med. May 2007;161(5):503-6. [Medline].

2. Robati RM, Toossi P. Plantar herald patch in pityriasis rosea. Clin Exp Dermatol. Mar 2009;34(2):269-70. [Medline].

3. Kempf W, Adams V, Kleinhans M, et al. Pityriasis rosea is not associated with human herpesvirus 7. Arch Dermatol. Sep 1999;135(9):1070-2. [Medline].

4. González LM, Allen R, Janniger CK, et al. Pityriasis rosea: an important papulosquamous disorder. Int J Dermatol. Sep 2005;44(9):757-64. [Medline].

5. Rajpara SN, Ormerod AD, Gallaway L. Adalimumab-induced pityriasis rosea. J Eur Acad Dermatol Venereol. Oct 2007;21(9):1294-6. [Medline].

6. Chuh AA, Dofitas BL, Comisel GG, et al. Interventions for pityriasis rosea. Cochrane Database Syst Rev. Apr 18 2007;CD005068. [Medline].

7. Rasi A, Tajziehchi L, Savabi-Nasab S. Oral erythromycin is ineffective in the treatment of pityriasis rosea. J Drugs Dermatol. Jan 2008;7(1):35-8. [Medline].

8. Chuang TY, Ilstrup DM, Perry HO, et al. Pityriasis rosea in Rochester, Minnesota, 1969 to 1978. J Am Acad Dermatol. Jul 1982;7(1):80-9. [Medline].

9. Cohen EL. Pityriasis rosea. Br J Dermatol. Oct 1967;79(10):533-7. [Medline].

10. Harman M, Aytekin S, Akdeniz S, et al. An epidemiological study of pityriasis rosea in the Eastern Anatolia. Eur J Epidemiol. Jul 1998;14(5):495-7. [Medline].

11. Hartley AH. Pityriasis rosea. Pediatr Rev. Aug 1999;20(8):266-9, quiz 270. [Medline].

12. Parsons JM. Management of toxic epidermal necrolysis. Cutis. Oct 1985;36(4):305-7, 310-1. [Medline].

13. Tay YK, Goh CL. One-year review of pityriasis rosea at the National Skin Centre, Singapore. Ann Acad Med Singapore. Nov 1999;28(6):829-31. [Medline].

14. Wyndham M. Pityriasis. Practitioner. Jun 1997;241(1575):358. [Medline].

Keywords

pityriasis, pityriasis rosea, pityriasis circinata et marginata of Vidal, papulosquamous skin eruption, pityriasis lichenoides, pityriasis rubra pilaris, pityriasis rosea perstans, papular pityriasis rosea, vesicular pityriasis rosea, purpuric pityriasis rosea, inverse pityriasis rosea, herald patch

Contributor Information and Disclosures

Author

Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Rajendra Kapila, MD, MBBS, Professor of Medicine, Department of Medicine, UMDNJ, 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.

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.

Amal Mattu, MD, FACEP, FAAEM, Program Director, Emergency Medicine Residency, Co-Director, Emergency Medicine/Internal Medicine Combined Residency Program, Department of Surgery, Division 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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

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.

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