Pityriasis Rosea


Article Author:
Graham Litchman
Pragya Nair


Article Editor:
Jacqueline Le


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/10/2019 1:24:34 AM

Introduction

Pityriasis rosea is an acute self-limiting papulosquamous disorder. It is characterized by a herald patch followed by scaly oval patches on the trunk and proximal extremities in a "Christmas-tree" appearance. Pityriasis rosea means rose-colored scale. Pityriasis rosea is also known as pityriasis circinata, roseola annulata, and herpes tonsurans maculosus. The skin eruption usually lasts 6-8 weeks and begins with a 'herald patch.' [1][2][3]

Etiology

The exact cause of pityriasis rosea is not known, but features like seasonal variation and clustering in communities suggest that it is an infectious disease. Infections like viruses, bacteria, spirochetes, and noninfective causes like atopy and autoimmunity are known causes. Upper respiratory tract infections that precede pityriasis rosea suggest a  role of Streptococcus. Recently, reactivation of latent human herpesvirus-6 and human herpesvirus-7 infection have been found as the possible etiologic agents. Pityriasis rosea-like eruptions have been reported after vaccinations such as Bacillus Calmette-Guerin, influenza, H1N1, diphtheria, smallpox, hepatitis B, and Pneumococcus. Eruptions have also been seen with drugs like gold, captopril, barbiturates, D-penicillamine, and clonidine. In temperate regions, it is more common in the winter season, while in tropical areas some seasonal variation is noted.[4][5][6]

Epidemiology

The approximate incidence of pityriasis rosea is 0.5% to 2%. It affects people of both genders between 15 and 30 years of age, but it also affects older adults and children.[7]

Pathophysiology

A lack of natural killer (NK) cell and B-cell activity in pityriasis rosea lesions has been noted, suggesting a predominantly T-cell mediated immunity. 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) keratinocytes have been found in patients with pityriasis rosea. This may be associated with the exanthem phase of viral infection.

Histopathology

Skin biopsy is not necessary but if performed will reveal non-specific features similar to those seen in chronic dermatitis.

History and Physical

Pityriasis rosea is clinically characterized by a herald patch or mother patch followed by scaly oval plaques on the trunk and proximal extremities along the Langer’s lines of cleavage giving characteristic “Christmas-tree" appearance. Collarette scaling is common. The eruption is usually preceded by a prodrome of a sore throat, gastrointestinal disturbance, fever, and arthralgia.

Pruritus is severe in 25% of cases. Herald patch is seen in 50% to 90% cases and is located on the trunk followed by the neck or proximal extremity.

A generalized eruption then occurs, in which numerous lesions develop in crops over a period of one to two weeks after the onset of the herald patch. The eruptions are symmetric and most commonly involve the thorax, back, abdomen, and adjoining areas of the neck and extremities. These secondary lesions occur as macules and papules that are elliptical or ovular in shape. Fine scaling and central wrinkling, with a cigarette paper aspect, are seen. A characteristic feature is the collarette appearance of the scale, with edges peripherally attached and lifted up near the center of the lesion. The distribution of the lesions is usually bilateral and diffuse, with the long axis running parallel to skin tension lines.

The incidence of atypical pityriasis rosea is 20% which maybe regard morphology, size, distribution, course, or symptoms.

The various atypical morphologies include:

  • Vesicular Pityriasis Rosea presents as a generalized eruption of 2 mm to 6 mm vesicles or as a rosette of vesicles mainly over the head, palms, and soles. It needs to be differentiated from varicella and dyshidrosis. It is commonly seen in children.
  • Purpuric (hemorrhagic) Pityriasis Rosea presents as macular purpura on skin or oral mucosa.
  • Urticarial Pityriasis Rosea
  • Generalized Papular Pityriasis Rosea is rare and is seen in young children, pregnant women, and African Caribbeans. It presents as multiple papules which occur along with classic patches and plaques.
  • Lichenoid Pityriasis Rosea is observed in the course of atypical Pityriasis Rosea, but it is more commonly caused by drugs such as gold, captopril, barbiturates, D-penicillamine, and clonidine.
  • Erythema multiforme-like Pityriasis Rosea: It presents with targetoid lesions along with the classical lesions of pityriasis rosea. Histopathologically, erythema multiform and pityriasis rosea may show similar features except satellite cell necrosis which is a distinguishing feature seen only in erythema multiform where lymphocytes are seen attached to scattered necrotic keratinocytes.
  • Follicular Pityriasis Rosea: The secondary lesions are typically follicular and present  discrete or in groups associated classical lesions.Differential diagnoses includes follicular lichen planus and keratosis pilaris ad atopic dermatitis with a follicular element.
  • Giant Pityriasis Rosea is rarely reported  and was named after Darier. It consists of plaques and circles of very large size ranging from 5 cm to 7 cm with individual lesions reaching the size of the palm of the patient.
  • Pityriasis Rosea presenting as exfoliative dermatitis
  • Pityriasis Rosea with atypical herald patch may be absent in 20% of patients or present with secondary eruptions or occur at unusual sites such as the face, scalp, genitalia, or other sites.
  • Inverse Pityriasis Rosea: Lesions are predominantly present in acral and flexural areas involving axilla, groin, and face.
  • Acral Pityriasis Rosea: Lesions are more concentrated over acral parts of body ie palms and soles, where EM, syphilis, necrolytic acral erythema, and drug eruptions should be kept as differentials.
  • Unilateral Pityriasis Rosea is a rare variant that can be seen in both children and adults, and the lesions are located on one side of the body. The patient has a herald patch with classical secondary lesions.
  • Blaschkoid Pityriasis Rosea: Lesions of Pityriasis Rose follows the lines of Blaschko.
  • Limb-Girdle Pityriasis Rosea: Also known as Pityriasis Rosea of Vidal where eruptions  are  limited to shoulders or pelvic girdle, thus involving axilla and groin. Lesions are usually larger and more annular.
  • Mucosal involvement in pityriasis rosea is seen in 16% of patients affecting oral mucosa, with punctuate, erosive, bullous, hemorrhages, ulcers (with or without raised borders), petechiae, papulovesicular, bullae, and erythematous plaques.
  • Localized pityriasis rosea: Eruptions are localized to one part of the body.

The rashes of pityriasis rosea usually last for five weeks and resolve by 8 weeks in more than 80% of patients. Pityriasis rosea needs to be differentiated from secondary syphilis, dermatophytosis, guttate psoriasis, nummular eczema, pityriasis lichenoid chronic, cutaneous T-cell lymphoma, erythema annular centrifugal and erythema chronic migrans.

Evaluation

Dermatoscopy helps to differentiate pityriasis rosea from other conditions. It shows a yellowish background color, peripheral arrangement of the scales, and patchy distribution of loosely arranged dotted vessels.

Histopathology shows superficial perivascular dermatitis. Focal parakeratosis in mounds, hyperplasia, and focal spongiosis are observed in the epidermis. The epidermis may show exocytosis of lymphocytes, variable spongiosis, mild acanthosis, and a thinned granular layer. Extravasated red blood cells along with a perivascular infiltrate of lymphocytes, histiocytes, and eosinophils are seen in the dermis.[2][8][9]

Treatment / Management

Pityriasis rosea is a self-limiting, exanthematous disease. Most patients need emollients, antihistaminics, and topical steroids. Macrolides and acyclovir lead to faster resolution of lesions and help to relieve pruritus. Narrowband ultraviolet B therapy is also used. It works by altering the immunology in the skin.[10]

Pearls and Other Issues

Atopy is associated with pityriasis rosea. Pityriasis rosea during pregnancy, within the first 15 weeks of gestation, may cause premature delivery and fetal demise.

Enhancing Healthcare Team Outcomes

In the majority of patients, pityriasis is a self-limited condition with an excellent prognosis. However, about 2-3% of patients will experience a recurrence. The skin disorder is benign, non-contagious and does not require any special precautions. Since the majority of patients first present to their primary care provider when the skin lesions appear, it is important for the nurse, pharmacist and primary care provider to educate the patient that the condition is benign and will not last for more than 2 months. For cases that are severe, a dermatology referral should be made. The biggest morbidity is due to pigmentation changes, especially in dark-skinned individuals. However, scarring does not occur. There are reports that pityriasis during pregnancy may be associated with premature birth- but it is not known if this is just a coincidental observation. Patients should be told to avoid applying irritants to the skin and avoid tanning. The itching is mild and usually resolves with a moisturizer. Exposure to the sun may induce pigmentary changes and should be avoided. [11][12] (Level V)


  • Image 342 Not availableImage 342 Not available
    Contributed by DermNetNZ
Attributed To: Contributed by DermNetNZ

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Pityriasis Rosea - Questions

Take a quiz of the questions on this article.

Take Quiz
After a vacation to Hawaii, a patient reports a rash on the chest. The rash started 3 days ago and is not pruritic. It is salmon colored, oval, and has a collarette, or surrounding ring, of scale. What should be the next step in her management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has a mild, pruritic rash on her trunk that first appeared a few days earlier. Examination reveals that the rash has a "fir tree" appearance. This patient most likely has which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Herald patch is pathognomonic of which of the following disorders?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with pityriasis rosea would most likely be what age?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 16 year old boy is brought in with a 10 day history of a mildly pruritic rash on the trunk that started with a 3 cm solitary lesion. The patient has no medical history, unusual exposures, or medications. There are hyperpigmented plaques on the trunk but none on the face. Select the most likely diagnosis.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following impending conditions may be announced by a "herald patch"?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A herald patch is associated with:



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What age patient is most likely to develop pityriasis rosea?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A herald patch followed by a Christmas tree pattern rash on the trunk is most likely to be which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Pityriasis rosea primarily affects the trunk and which other body part?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 32-year-old female develops a pruritic, fine scaling rash that is most marked on the trunk. The rash was preceded by a 4 centimeter, red, scaling plaque. The lesions are maculopapular and follow the lines of skin cleavage. What is the most likely diagnosis?

(Move Mouse on Image to Enlarge)
  • Image 342 Not availableImage 342 Not available
    Contributed by DermNetNZ
Attributed To: Contributed by DermNetNZ



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Pityriasis Rosea - References

References

Drago F,Ciccarese G,Parodi A, Pityriasis rosea and pityriasis rosea-like eruptions: How to distinguish them? JAAD case reports. 2018 Sep     [PubMed]
Trayes KP,Savage K,Studdiford JS, Annular Lesions: Diagnosis and Treatment. American family physician. 2018 Sep 1     [PubMed]
Chang HC,Sung CW,Lin MH, The efficacy of oral acyclovir during early course of pityriasis rosea: a systematic review and meta-analysis. The Journal of dermatological treatment. 2018 Sep 4     [PubMed]
Gay JT,Gross GP, Herald Patch null. 2018 Jan     [PubMed]
Engelmann I,Ogiez J,Ogiez L,Alidjinou EK,Lazrek M,Dewilde A,Hober D, Relapsing Pityriasis Rosea With HHV-7 Reactivation in an 11-Year-Old Girl. Pediatrics. 2018 May     [PubMed]
Alame MM,Chamsy DJ,Zaraket H, Pityriasis rosea-like eruption associated with ondansetron use in pregnancy. British journal of clinical pharmacology. 2018 May     [PubMed]
VanRavenstein K,Edlund BJ, Diagnosis and management of pityriasis rosea. The Nurse practitioner. 2017 Jan 20     [PubMed]
Rodriguez-Zuniga M,Torres N,Garcia-Perdomo H, Effectiveness of acyclovir in the treatment of pityriasis rosea. A systematic review and meta-analysis. Anais brasileiros de dermatologia. 2018 Sep-Oct     [PubMed]
Sonthalia S,Kumar A,Zawar V,Priya A,Yadav P,Srivastava S,Gupta A, Double-blind randomized placebo-controlled trial to evaluate the efficacy and safety of short-course low-dose oral prednisolone in pityriasis rosea. The Journal of dermatological treatment. 2018 Sep     [PubMed]
Krishnamurthy K,Walker A,Gropper CA,Hoffman C, To treat or not to treat? Management of guttate psoriasis and pityriasis rosea in patients with evidence of group A Streptococcal infection. Journal of drugs in dermatology : JDD. 2010 Mar     [PubMed]
Cook B,Crutchfield CE 3rd, Pityriasis rosea. Dermatology nursing. 2006 Aug     [PubMed]
Black JB,Pellett PE, Human herpesvirus 7. Reviews in medical virology. 1999 Oct-Dec     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatrics-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatrics-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatrics-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatrics-Medical Student. When it is time for the Pediatrics-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatrics-Medical Student.