eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Pityriasis Rosea

Author: Maria R Nasca, MD, PhD, Assistant Professor, Department of Dermatology, University of Catania School of Medicine, Italy
Coauthor(s): Giuseppe Micali, MD, Head, Professor, Department of Dermatology, University of Catania School of Medicine, Italy
Contributor Information and Disclosures

Updated: Sep 24, 2009

Introduction

Background

Pityriasis rosea (PR) was first described by Camille Melchior Gilbert in 1860. The term pityriasis rosea means fine pink scale. It is a common skin disorder observed in otherwise healthy people, most frequently children and young adults. Pityriasis rosea manifests as an acute, self-limiting, papulosquamous eruption with a 6-week to 8-week duration. It may sometimes occur in atypical variants or may mimic other skin disorders, such as secondary syphilis.1,2 Guidelines for diagnosing syphilis (and distinguishing the roseola from pityriasis rosea) have been established.3

Herald patch. Courtesy of the Drexel Department o...

Herald patch. Courtesy of the Drexel Department of Dermatology slide collection.

Herald patch. Courtesy of the Drexel Department o...

Herald patch. Courtesy of the Drexel Department of Dermatology slide collection.


Pathophysiology

The specific cause of the disorder remains unclear; however, its seasonal occurrence, clinical course, possibility of epidemic occurrence, presence of occasional prodromal symptoms, and infrequent likelihood of recurrences have all suggested an infectious viral etiology.

The disease has been associated with recent upper respiratory infections. Increased incidence among groups with close physical contact (eg, families, students, military personnel) has been reported. A higher incidence among patients with decreased immunity (eg, pregnant women, bone marrow transplant patients) has also been noted. Additionally, ampicillin has been found to increase the distribution of the eruption; this phenomenon bears a striking resemblance to the effect of ampicillin on the rash of infectious mononucleosis. Finally, some immunological findings, including the presence of immunoglobulin (Ig)M directed against keratinocytes or the increase of Langerhans cells and CT4 T lymphocytes in the dermal infiltrate of patients with pityriasis rosea also support the pathogenetic role of a transmissible agent.

Many common infectious microorganisms have been considered (eg, influenza A and B; parainfluenza I, II, and III; Epstein-Barr virus; parvovirus B19; cytomegalovirus; herpesviruses 1, 2, and 8; Mycoplasma) and have been shown not to be causative. Recent reports using polymerase chain reaction (PCR) analysis have suggested a role for human herpesvirus (HHV)-7 and HHV-6 but this has not been confirmed in later studies.4,5,6,7,8,9,10,11

Despite the prevailing opinion that pityriasis rosea is caused by an infectious agent, it does not appear to be very contagious; household contacts and schoolmates usually do not develop the disease.

Pityriasis rosea–like eruptions can also occur in association with many drugs. These include acetylsalicylic acid, barbiturates, bismuth, captopril, clonidine, gold, imatinib, isotretinoin, ketotifen, levamisole, metronidazole, omeprazole, D-penicillamine, terbinafine, and Bacillus Calmette-Guérin or diphtheria vaccine. Adalimumab has also been implicated.12 Drug-induced pityriasis rosea often lasts longer than non–drug-induced pityriasis rosea.

Frequency

United States

An estimated frequency of 0.13-0.14% has been reported, with a 0.3-3% prevalence at dermatologic centers.

International

Pityriasis rosea accounts for approximately 2% of outpatient visits in dermatology. It is present worldwide and occurs year round, although it may be more common in the fall and spring. In some geographic areas, such as India, Malaysia, and Australia, it may be more frequent in the dry hot season.

Mortality/Morbidity

Pityriasis rosea is a self-limiting, benign disorder with a recurrence rate of less than 3%. It usually lasts for 6-8 weeks but can last as long as 3-6 months. Postinflammatory pigment changes are common, especially in black people. Bacterial superinfections are rarely observed. In pregnant women, it has sometimes been associated with miscarriage (if occurring within the first 15 wk of pregnancy), or premature delivery, neonatal hypotonia and hyporeactivity.13

Race

Pityriasis rosea shows no racial specificity, although black people may have more extensive or atypical disease. The lesions may show a dark hue and lack the erythematous component.

Sex

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

Age

Pityriasis rosea is observed in people of all age groups, although it is most common in persons aged 10-35 years. The youngest patient reported in the literature was aged 3 months, and the oldest was aged 85 years.

Clinical

History

  • A small number of patients (5%) with pityriasis rosea (PR) have mild prodromal symptoms, such as malaise, fatigue, headache, nausea, anorexia, chills, fever, and arthralgias. Lymphadenopathy may occur prior to onset of the rash.
  • Some patients (8-20%) may have a history of recent upper respiratory infection. Patients should also be asked about recent medication intake or close contacts with similar eruptions.
  • Rash may be pruritic (25-75% of cases), especially in the first few weeks of the illness.
  • Approximately 50-80% of patients present with a herald patch.

Physical

  • Primary herald patch
    • A herald patch is a pink macule or papule that gradually expands over a few days to become a 2-cm to 10-cm, salmon-pink–to–brown, oval plaque. The lesion usually shows a collarette of fine scales just inside its well-demarcated edges and may exhibit central clearing, which mimics tinea corporis.
    • Primary herald patch is most commonly observed on the trunk, neck, and proximal extremities.
  • Subsequent lesions
    • Numerous subsequent lesions occur in crops 1-2 weeks (range 1-30 d) after onset of the herald patch and symmetrically involve the thorax, back, abdomen, and proximal extremities. They are not usually observed on the face, hands, and feet.
    • These lesions occur as macules and papules that are elliptical or ovular in shape and 0.5-1.5 cm across. Fine scaling and central wrinkling, with a cigarette paper aspect, is usually present. A characteristic feature is the collarette appearance of the scale, with edges peripherally attached and lifted up near the center of the lesion. However, unlike classic tinea corporis, the scale does not extend to the border of the lesion.
    • The distribution is usually bilateral and diffuse, with the long axis of the lesions running parallel to skin tension lines. This produces a "Christmas tree" pattern on the back.
  • Pigment changes: With resolution of the eruption, postinflammatory pigment changes can be observed.
  • Oral findings: Oral lesions are infrequently observed (10-16% of cases) but may include plaques, petechiae, papules, blisters, and ulcers (with or without raised borders).
  • Variants and atypical forms
    • Approximately 20% of patients present with atypical forms of pityriasis rosea.
    • The herald patch may be absent in 10-50% of the cases, a finding that is more frequently observed in drug-induced pityriasis rosea. Alternatively, it may occur as multiple lesions or in atypical locations, such as the soles.14 Sometimes, it is the only manifestation of the disease and is not followed by the typical rash.
    • The generalized rash may occasionally spread to the face, hands, and feet. The face may be more commonly affected in young children, pregnant women, and black people. In such cases, the physician should consider secondary syphilis in the differential diagnosis, especially when involvement of the palms and soles is present.
    • An inverse pattern may also occur, with most of the lesions limited to the face and extremities. This happens more frequently in children than in adults.
    • Sometimes, lesions may be limited to single body areas, such as the abdomen, or show a unilateral distribution.
    • A morphologic variant characterized by atypical large patches, that tend to be fewer in number and coalescent, has been described as pityriasis circinata et marginata of Vidal.
    • A predominantly papular form is believed to occur more commonly in young children, pregnant women, and black people.
    • Lesions can also be vesicular, pustular, urticarial, purpuric, or even erythema multiform–like, making the diagnosis difficult.15,16
    • Secondary eczematous changes can occur if pruritus is severe.
    • Black people tend to show more often widespread forms and concurrent lymphadenopathy, with hyperpigmentation upon resolution. Black children have also been found to more frequently develop papular lesions (33%), scalp (8%) and facial (30%) involvement, and a shorter course, with resolution within 2 weeks.17

Causes

More on Pityriasis Rosea

Overview: Pityriasis Rosea
Differential Diagnoses & Workup: Pityriasis Rosea
Treatment & Medication: Pityriasis Rosea
Follow-up: Pityriasis Rosea
Multimedia: Pityriasis Rosea
References

References

  1. Allen RA, Janniger CK, Schwartz RA. Pityriasis rosea. Cutis. Oct 1995;56(4):198-202. [Medline].

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

  3. [Guideline] Finnish Medical Society Duodecim. Syphilis. EBM Guidelines. Jun 6 2008.

  4. Blauvelt A. Skin diseases associated with human herpesvirus 6, 7, and 8 infection. J Investig Dermatol Symp Proc. Dec 2001;6(3):197-202. [Medline].

  5. Broccolo F, Drago F, Careddu AM, Foglieni C, Turbino L, Cocuzza CE, et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpesvirus-6 and -7. J Invest Dermatol. Jun 2005;124(6):1234-40. [Medline].

  6. Canpolat Kirac B, Adisen E, Bozdayi G, et al. The role of human herpesvirus 6, human herpesvirus 7, Epstein-Barr virus and cytomegalovirus in the aetiology of pityriasis rosea. J Eur Acad Dermatol Venereol. Jan 2009;23(1):16-21. [Medline].

  7. Chuh AA, Chan PK, Lee A. The detection of human herpesvirus-8 DNA in plasma and peripheral blood mononuclear cells in adult patients with pityriasis rosea by polymerase chain reaction. J Eur Acad Dermatol Venereol. Jul 2006;20(6):667-71. [Medline].

  8. Drago F, Malaguti F, Ranieri E, Losi E, Rebora A. Human herpes virus-like particles in pityriasis rosea lesions: an electron microscopy study. J Cutan Pathol. Jul 2002;29(6):359-61. [Medline].

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

  10. Watanabe T, Kawamura T, Jacob SE, Aquilino EA, Orenstein JM, Black JB, et al. Pityriasis rosea is associated with systemic active infection with both human herpesvirus-7 and human herpesvirus-6. J Invest Dermatol. Oct 2002;119(4):793-7. [Medline].

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

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

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

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

  15. Anderson CR. Dapsone treatment in a case of vesicular pityriasis rosea. Lancet. Aug 28 1971;2(7722):493. [Medline].

  16. Sezer E, Saracoglu ZN, Urer SM, Bildirici K, Sabuncu I. Purpuric pityriasis rosea. Int J Dermatol. Feb 2003;42(2):138-40. [Medline].

  17. 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].

  18. Chuh AA, Dofitas BL, Comisel GG, Reveiz L, Sharma V, Garner SE. Interventions for pityriasis rosea. Cochrane Database Syst Rev. 2007;(2):CD005068. [Medline].

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

  20. 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].

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

  22. 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].

  23. Arndt KA, Paul BS, Stern RS, Parrish JA. Treatment of pityriasis rosea with UV radiation. Arch Dermatol. May 1983;119(5):381-2. [Medline].

  24. Leenutaphong V, Jiamton S. UVB phototherapy for pityriasis rosea: a bilateral comparison study. J Am Acad Dermatol. Dec 1995;33(6):996-9. [Medline].

Further Reading

Keywords

pityriasis rosea, PR, fine pink scale, inverse pityriasis rosea, inverse PR, vesicular pityriasis rosea, vesicular PR, bullous pityriasis rosea, bullous PR, papular pityriasis rosea, papular PR, syphilis, roseola, bone marrow transplantation, mononucleosis, influenza, parainfluenza, Epstein-Barr virus, parvovirus B19, cytomegalovirus, herpesvirus, infection, acetylsalicylic acid, barbiturates, bismuth, captopril, clonidine, gold, imatinib, isotretinoin, ketotifen, levamisole, metronidazole, omeprazole, D-penicillamine, terbinafine, Bacillus Calmette-Guérin vaccine, diphtheria vaccine, miscarriage, prematurity, neonatal hypotonia, hyporeactivity, lymphadenopathy, herald patch, tinea corporis, treatment, diagnosis

Contributor Information and Disclosures

Author

Maria R Nasca, MD, PhD, Assistant Professor, Department of Dermatology, University of Catania School of Medicine, Italy
Disclosure: Nothing to disclose.

Coauthor(s)

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.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; 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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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