Pityriasis Rosea in Emergency Medicine Clinical Presentation

  • Author: Richard Lichenstein, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Aug 24, 2011
 

History

  • Pityriasis rosea (PR) may have prodromal symptoms (eg, malaise, nausea, anorexia, fever, joint pain, lymph node swelling, headache) that may precede the appearance of the herald patch.
  • Pruritus, which may be intense, is present in 75% of cases.
  • Ask the patient whether this is the first episode or a recurrence.
  • Ask if the patient may be pregnant.
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Physical

The herald patch measures 1-2 cm in diameter. The patch is characterized as oval or round with a central, wrinkled, salmon-colored area and a dark red peripheral zone. The areas are separated by a collarette of fine scales. The herald patch is usually located on the trunk but can be seen on the neck or extremities.

The secondary eruption appears at its maximum in about 10 days. The secondary eruption is symmetric and localized, predominantly to the trunk and adjacent areas of the neck and extremities. Involvement is maximal over the abdomen and anterior and dorsal surfaces of the thorax. The secondary lesions appear as the primary patch in miniature, with the two red zones separated by the scaling ring. They are distributed in a Christmas tree pattern with their long axes following the lines of cleavage of the skin. In children under the age of 5 years, papular pityriasis rosea may be seen with a similar distribution.

In atypical pityriasis rosea (20% of patients), the herald patch may be missing or confluent with other lesions. The distribution of the rash may be peripheral, and facial involvement may be seen in children. Involvement of the axilla and groin (inverse variant) can also be seen. The lesions of pityriasis rosea may be large (pityriasis rosea gigantea), urticarial (pityriasis rosea urticata), vesicular, pustular, purpuric, and erythema multiforme –like.

Hypopigmentary and hyperpigmentary skin changes may follow the inflammatory stage. In patients with black skin, hyperpigmentation is more common.

Black children have been shown to have more facial involvement (30%) and scalp involvement (8%) than white children.

Approximately one third of black children have papular lesions, and 48% have residual hyperpigmentation.[2]

Rarely, oral lesions of various types have been reported with pityriasis rosea, including erythematous plaques, hemorrhagic puncta, and ulcers.[3]

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Causes

  • Pityriasis rosea is similar to infectious exanthems in that it occurs in clusters among contacts, has a seasonal predilection to spring and autumn, and has a low rate of recurrence (3%).
  • No bacteria, virus, or fungus has been isolated as a definite causal agent, although human herpesvirus 6 (HHV-6) and human herpesvirus 7 (HHV-7) may play a role.[4, 5]
  • Drugs such as bismuth, barbiturates, captopril, gold, organic mercurials, methoxypromazine, metronidazole, D-penicillamine, isotretinoin, tripelennamine hydrochloride, ketotifen, and salvarsan have been implicated in causing drug-induced pityriasis rosea. Adalimumab, a monoclonal antibody to tumor necrosis factor, has also been reported to induce pityriasis rosea.[6]
  • Atopy, seborrheic dermatitis, acne vulgaris, and dandruff are more common in patients with pityriasis rosea than in control subjects.
  • Pityriasis rosea during pregnancy may foreshadow premature delivery and fetal demise, especially when it develops within the first 15 weeks of gestation[7]
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Contributor Information and Disclosures
Author

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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

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.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

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.

References

  1. Neoh CY, Tan AW, Mohamed K, Sun YJ, Tan SH. Characterization of the inflammatory cell infiltrate in herald patches and fully developed eruptions of pityriasis rosea. Clin Exp Dermatol. Jul 29 2009;[Medline].

  2. 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].

  3. Vidimos AT, Camisa C. Tongue and cheek: oral lesions in pityriasis rosea. Cutis. Oct 1992;50(4):276-80. [Medline].

  4. Drago F, Ranieri E, Malaguti F. Human herpesvirus 7 in patients with pityriasis rosea. Electron microscopy investigations and polymerase chain reaction in mononuclear cells, plasma and skin. Dermatology. 1997;195(4):374-8. [Medline].

  5. Drago F, Broccolo F, Rebora A. Pityriasis rosea: an update with a critical appraisal of its possible herpesviral etiology. J Am Acad Dermatol. Aug 2009;61(2):303-18. [Medline].

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

  7. Drago F, Broccolo F, Zaccaria E, et al. Pregnancy outcome in patients with pityriasis rosea. J Am Acad Dermatol. May 2008;58(5 Suppl 1):S78-83. [Medline].

  8. Drago F, Rebora A. Treatments for pityriasis rosea. Skin Therapy Lett. Mar 2009;14(3):6-7. [Medline].

  9. Sharma PK, Yadav TP, Gautam RK. Erythromycin in pityriasis rosea: A double-blind, placebo-controlled clinical trial. J Am Acad Dermatol. Feb 2000;42(2 Pt 1):241-4. [Medline].

  10. 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].

  11. [Best Evidence] Amer A, Fischer H. Azithromycin does not cure pityriasis rosea. Pediatrics. May 2006;117(5):1702-5. [Medline].

  12. Drago F, Vecchio F, Rebora A. Use of high-dose acyclovir in pityriasis rosea. J Am Acad Dermatol. Jan 2006;54(1):82-5. [Medline].

  13. Stulberg DL, Wolfrey J. Pityriasis rosea. Am Fam Physician. Jan 1 2004;69(1):87-91. [Medline].

  14. Drago F, Vecchio F, Rebora A. Use of high-dose acyclovir in pityriasis rosea. J Am Acad Dermatol. Jan 2006;54(1):82-5. [Medline].

  15. [Guideline] Finnish Medical Society Duodecim. Syphilis. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2008 Jun 6. [Full Text].

  16. Chuh A, Chan H, Zawar V. Pityriasis rosea--evidence for and against an infectious aetiology. Epidemiol Infect. Jun 2004;132(3):381-90. [Medline].

  17. Chuh A, Lee A, Zawar V. Pityriasis rosea--an update. Indian J Dermatol Venereol Leprol. Sep-Oct 2005;71(5):311-5. [Medline].

  18. Coustou D, Leaute-Labreze C, Bioulac-Sage P, et al. Asymmetric periflexural exanthem of childhood: a clinical, pathologic, and epidemiologic prospective study. Arch Dermatol. Jul 1999;135(7):799-803. [Medline].

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

  20. Horio T. Skin disorders that improve by exposure to sunlight. Clin Dermatol. Jan-Feb 1998;16(1):59-65. [Medline].

  21. Kay MH, Rapini RP, Fritz KA. Oral lesions in pityriasis rosea. Arch Dermatol. Nov 1985;121(11):1449-51. [Medline].

  22. Kempf W, Burg G. Pityriasis rosea--a virus-induced skin disease? An update. Arch Virol. 2000;145(8):1509-20. [Medline].

  23. Nanda A, Al-Hasawi F, Alsaleh QA. A prospective survey of pediatric dermatology clinic patients in Kuwait: an analysis of 10,000 cases. Pediatr Dermatol. Jan-Feb 1999;16(1):6-11. [Medline].

  24. Pomeranz AJ, Fairley JA. The systematic evaluation of the skin in children. Pediatr Clin North Am. Feb 1998;45(1):49-63. [Medline].

  25. Scott LA, Stone MS. Viral exanthems. Dermatol Online J. Aug 9 2003;9(3):4. [Full Text].

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

 
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Herald patch. Courtesy of the Drexel Department of Dermatology slide collection.
Christmas tree distribution of lesions on the trunk. Courtesy of the Drexel Department of Dermatology slide collection.
 
 
 
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