Pityriasis Rosea

Pityriasis rosea is an acute, self-limited skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin disease. The etiology is not known, and it commonly occurs in young adults. Patients initially present with a single, ovoid “herald patch.” This is followed by diffuse, pruritic, scaly, oval lesions over the trunk (often in a “Christmas tree” distribution on the back) and extremities. The diagnosis is clinical. Pityriasis rosea is a self-limiting condition; therefore, usually no treatment is required. However, topical steroids and antihistamines Antihistamines Antihistamines are drugs that target histamine receptors, particularly H1 and H2 receptors. H1 antagonists are competitive and reversible inhibitors of H1 receptors. First-generation antihistamines cross the blood-brain barrier and can cause sedation. Antihistamines may be used for pruritus, if needed.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Epidemiology and Etiology

Epidemiology

  • Incidence: 0.5%–2%
  • Sex: women > men
  • Common age group: 15–30 years
  • Seasonal variation: more common in winter and spring (in temperate climates)

Etiology

  • Idiopathic
  • Possibly infectious; has been associated with:
    • HHV-6 HHV-6 Human herpesvirus (HHV)-6 and HHV-7 are similar double-stranded DNA viruses belonging to the Herpesviridae family. Human herpesviruses are ubiquitous and infections are commonly contracted during childhood. Human Herpesvirus 6 & 7
    • HHV-7 HHV-7 Human herpesvirus (HHV)-6 and HHV-7 are similar double-stranded DNA viruses belonging to the Herpesviridae family. Human herpesviruses are ubiquitous and infections are commonly contracted during childhood. Human Herpesvirus 6 & 7
    • HHV-8
    • Influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza (H1N1)

Clinical Presentation

Prodrome

  • Occurs in a minority of patients a week prior to appearance of cutaneous lesions
  • Symptoms:
    • Malaise 
    • Headache
    • Fever  
    • Arthralgia
    • Sore throat

Cutaneous eruption

Primary:

  • Called the “herald” or  “mother” patch
  • Single lesion
  • Round or oval 
  • 2–5 cm in diameter
  • Well-defined borders
  • Pink or salmon-colored 
  • Collarette scaling:
    • Fine scaling that remains attached near the border
    • Scale lifts up near the center of the lesion.
    • Center may appear wrinkled.
  • Located on: 
    • Back
    • Chest 
    • Neck

Secondary:

  • Occurs within 1–2 weeks after the herald patch 
  • Same features as the herald patch, except:
    • Smaller (< 1.5 cm)
    • Appears in crops
    • Symmetrical
    • Bilateral 
  • Located on: 
    • Back
    • Chest
    • Extremities
  • “Christmas tree” distribution 
    • Term used to describe the rash’s appearance on the back
    • Due to the lesions’ orientation along skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin tension lines (Langer’s lines)
  • Pruritus usually present (severe in 25% of cases)
  • Usually resolves spontaneously in 6–8 weeks: 
    • Generally leaves few residual cutaneous changes
    • Postinflammatory hyperpigmentation is common in dark-skinned patients.

Diagnosis and Management

Diagnosis

Pityriasis rosea is a clinical diagnosis. The following tests may be used if the diagnosis is not clear.

  • Skin biopsy:
    • Rarely needed
    • Findings:
      • Superficial perivascular infiltrate ( lymphocytes Lymphocytes Lymphocytes are heterogeneous WBCs involved in immune response. Lymphocytes develop from the bone marrow, starting from hematopoietic stem cells (HSCs) and progressing to common lymphoid progenitors (CLPs). B and T lymphocytes and natural killer (NK) cells arise from the lineage. Lymphocytes and histiocytes)
      • Focal parakeratosis
  • KOH examination of scales → rule out tinea corporis 
  • Rapid plasma reagin and VDRL tests → rule out secondary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis

Management

Pityriasis rosea is a self-limiting condition; therefore, usually no treatment is required. 

  • General:
    • Reassurance
    • Emollients
  • Medical management:
    • Pruritus: 
      • Topical corticosteroids 
      • Oral antihistamines Antihistamines Antihistamines are drugs that target histamine receptors, particularly H1 and H2 receptors. H1 antagonists are competitive and reversible inhibitors of H1 receptors. First-generation antihistamines cross the blood-brain barrier and can cause sedation. Antihistamines
      • Menthol
    • Severe symptoms: 
      • Acyclovir 
      • Ultraviolet light therapy

Complications

  • In pregnant patients (especially if occurring within the first 15 weeks):
    • Miscarriage and spontaneous abortion Spontaneous abortion Spontaneous abortion, also known as miscarriage, is the loss of a pregnancy before 20 weeks' gestation. However, the layperson use of the term "abortion" is often intended to refer to induced termination of a pregnancy, whereas "miscarriage" is preferred for spontaneous loss. Spontaneous Abortion
    • Premature delivery
    • Neonatal hypotonia 
  • Bacterial superinfections are rare.

Related videos

Differential Diagnosis

  • Tinea corporis: a superficial fungal infection of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin that can affect the face, trunk, and extremities: The lesions of tinea corporis are characterized by peripheral scaling, central clearing, and erythema. The appearance may be similar to that of the herald patch of pityriasis rosea. The diagnosis is usually clinical, though a KOH examination would show fungal hyphae. Management includes topical or oral antifungal medications. 
  • Tinea versicolor: a fungal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin infection due to Malassezia Malassezia Malassezia is a lipophilic yeast commonly found on the skin surfaces of many animals, including humans. In the presence of certain environments or triggers, this fungus can cause pathologic diseases ranging from superficial skin conditions (tinea versicolor and dermatitis) to invasive disease (e.g., Malassezia folliculitis, catheter-associated fungemia, meningitis, and urinary tract infections). Malassezia Fungi furfur: Multiple scaly patches of various colors (e.g., brown, salmon, pink, or white) can occur on the trunk, abdomen, neck, and face. The diagnosis is clinical and is confirmed with KOH examination, which shows fungal hyphae and budding. Management includes topical or oral antifungal medications.
  • Secondary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis: STI STI Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections caused by Treponema Treponema Treponema is a gram-negative, microaerophilic spirochete. Owing to its very thin structure, it is not easily seen on Gram stain, but can be visualized using dark-field microscopy. This spirochete contains endoflagella, which allow for a characteristic corkscrew movement. Treponema pallidum: Secondary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis presents after the primary stage (chancre) with a maculopapular rash (including the palms and soles), fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, and lymphadenopathy Lymphadenopathy Lymphadenopathy is lymph node enlargement (> 1 cm) and is benign and self-limited in most patients. Etiologies include malignancy, infection, and autoimmune disorders, as well as iatrogenic causes such as the use of certain medications. Generalized lymphadenopathy often indicates underlying systemic disease. Lymphadenopathy. Systemic manifestations are common and are not seen in pityriasis rosea. The diagnosis is established through nontreponemal and treponemal testing. Penicillin G is the antibiotic of choice in management.
  • Guttate psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis: variant of psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis: Guttate psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis is an immune-mediated inflammatory skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin condition. This form of psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis presents with small, salmon-colored papules that look like dewdrops on the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin. The trunk and extremities are commonly involved. No herald patch precedes this eruption. The diagnosis is clinical, and management includes topical corticosteroids, calcitriol, and phototherapy. 
  • Atopic dermatitis Atopic Dermatitis Atopic dermatitis, also known as eczema, is a chronic, relapsing, pruritic, inflammatory skin disease that occurs more frequently in children, although adults can also be affected. The condition is often associated with elevated serum levels of IgE and a personal or family history of atopy. Skin dryness, erythema, oozing, crusting, and lichenification are present. Atopic Dermatitis (Eczema): a chronic, relapsing, inflammatory skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin condition: Patients present with pruritic, erythematous, thickened, scaly patches that frequently affect flexural regions. This distribution and the chronicity of the condition differentiates atopic dermatitis from pityriasis rosea. The diagnosis is clinical. Management focuses on avoiding potential triggers, topical steroids, and immunosuppressive therapy.

References

  1. Goldstein AO, Goldstein BG (2020). Pityriasis rosea. In Ofori AO (Ed.), UpToDate. Retrieved February 22, 2021, from https://www.uptodate.com/contents/pityriasis-rosea
  2. Das S (2020). Pityriasis rosea. MSD Manual Professional Version. Retrieved February 25, 2021, from https://www.msdmanuals.com/professional/dermatologic-disorders/psoriasis-and-scaling-diseases/pityriasis-rosea
  3. Litchman G, Nair PA, Le JK (2020). Pityriasis rosea. StatPearls. Retrieved February 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK448091/
  4. Schwartz RA, Janniger CK, Lichenstein R (2021). Pityriasis rosea. In Elston DM (Ed.), Medscape. Retrieved February 25, 2021, from https://emedicine.medscape.com/article/1107532-overview

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