PITYRIASIS ROSEA

Dr.C.Vijayabhaskar
Assistant Professor, Stanley Medical College,
Chennai, INDIA
For correspondence: buskii@yahoo.com
Key words: Pityriasis rosea
Introduction
Pityriasis rosea (PR) is a common skin condition described for more than 2 centuries
characterized by appearance of a herald patch followed by skin lesions along the
Langers lines or cleavage lines. It peaks between 20 and 29 years of age with no gender
predilection although a study has shown very slight predilection in females. This
condition is reported even in a baby of 3 months old.

Etiology
The exact etiology is unclear although some of the factors relate it to an infectious cause.
Generally the condition occurs in epidemics proving that the infectious agent is present in
the community.
Recurrence of the infection is rare suggesting long lasting immunity to the infectious
agent.
More than 50% of the patients have prodromal symptoms before the onset of the herald
patch.
Some of them have an increase in B lymphocytes and a decrease in T lymphocytes and
increase in Erythrocyte sedimentation rate.
A viral etiology has been proposed 1. In electron microscopy viral changes and particles
have been noticed but the antibody and polymerase chain reaction for viruses proves
negative.
There is a study which shows high amount of Human Herpes Virus 7 (HHV7) in these
patients but further studies have not proved this 2. In addition, HHV 7 is more common in
children and recurrence is very common with this.
Other infective agents considered as causes are Legionella pneumoniae, Chlamydia
pneumoniae and Mycoplasma pneumoniae but there is no support in the form of rise in
antibody titres in subsequent studies.

Clinical features
Patient presents with non specific clinical features. In 50% of these patients there may be
features of upper respiratory tract infection. Malaise, nausea, fever, joint pain, headache
and lymph node enlargement may occur before the appearance of a herald patch. The

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herald patch appears over the trunk commonly but rarely can occur over the neck or
extremities and is usually 1 to 2 cm in diameter. It is ovoid or round in shape with a
salmon coloured area in the centre which is also wrinkled and has a dark red peripheral
zone. Within 10 days secondary eruptions occur. Secondary eruptions are symmetric and
localized predominantly to the trunk and adjacent area of the neck and proximal
extremities, the vest area.
The secondary eruption follows Langers lines. When the back is involved it takes a
Christmas tree or fir tree pattern. On the lower abdomen and back it appears transversely.
It appears in a V shaped pattern on the upper chest and in a circumferential way around
the shoulders.
In children below 5 years of age the lesion may be popular, but the distribution will be as
above.
The secondary rash will be erythematous oval patches with peripheral collarette of scales.
Usually the rash lasts from 3 weeks to 12 weeks.
Pruritis may or may not occur. If itching is present it may vary from mild to severe form.
Post inflammatory pigmentation or hypo-pigmentation can occur.
Recurrence rate is as low as 3%.
Different types of Pityriasis rosea
Inverse PR Here the extremities are affected and the trunk is spared. Facial involvement
is seen in children. Axillae and groin are involved.
Localized PR - Lesion can occur in a localized area and diagnosis becomes difficult.
Pustular PR, vesicular PR, purpuric PR, and erythema multiforme like PR are some of the
other variants.
In Gigantean PR the lesions are larger but less in number.
PR Urticata presents more commonly with urticarial lesions
Oral lesions in the form of erythematous plaques, hemorrhagic puncta and ulcers occur 3.
Pigmentation or hypo-pigmentation may follow the inflammatory phase. Postinflammatory pigmentation is seen more commonly in black skin.
Drugs causing rash similar to pityriasis rosea
Arsenic compounds, Barbiturates, Bismuth, Captopril, Clonidine, Gold, Interferon,
Ketotifen fumarate, Hepatitis B vaccine, Bacillus Calmette-Gurin vaccine.

Investigations
Investigations are rarely needed in case of PR. Though the blood count may be normal,
sometimes leucocytosis, neutrophilia, basophilia and lymphocytosis are seen.

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VDRL test and Fluorescent Trepenomal Antibody test are done to rule out syphilis. Skin
scraping from the lesion rules out superficial fungal infections.

Skin Biopsy
Nonspecific dermatitis features are present and helps ruling out other conditions which
may mimic PR.
Superficial peri vascular infiltration with lymphocytes, histiocytes with rarely eosinophils
is seen. Epidermal cells showing dyskeratosis and extravasated RBCs may be seen.

Differential diagnosis
The following disorders should be considered and ruled out clinically and by
investigation where ever necessary
Secondary syphilis
Drug reaction
Pityriasis versicolor
Tinea corporis
Erythema multiforme
Guttate Psoriasis
Para psoriasis
Seborrhoeic dermatitis
Nummular Eczema
Lichen planus

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Treatment
Reassurance is very important. Patient and the family have to be explained about the
nature and course of the disease. The benign nature of the disease and the tendency to
resolve after a few days or few weeks has to be stressed.
If there are no symptoms there is no need of any treatment.
Oral antihistamines are advised if itching is present.
Topically calamine or alum lotion can be prescribed.
In a small study oral erythromycin for 2 weeks was found to be effective in bringing
down the symptoms and disappearance of rash 4. The exact mechanism is not known.
Anti inflammatory property of the medicine would have resolved the symptoms. A study
was done with azithromycin in children where it was not found to be effective 5.
Topical steroids could be used for a period of 2 weeks. If itching is very severe systemic
steroids can be used for a short time.
UV B therapy has been used in severe cases but the incidence of post inflammatory hyper
pigmentation is high 6.
In one non randomized non blinded study Acyclovir was shown to hasten resolution if
given within 1 week of the appearance of the rash (800mg 5 times a day for 7 days)7.
Children may be allowed to attend school.

Summary
PR, a common benign usually asymptomatic skin disease of varied etiology, needs to be
differentiated from other similar diseases. Reassurance and symptomatic treatment is
sufficient in many cases .However, the role of azithromycin and acyclovir should be
evaluated by further studies.

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References

1. Drago F, Ranieri E, Malaguti F. Human herpes virus 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.
2. Chuh A, Chan H, Zawar V. Pityriasis rosea--evidence for and against an
infectious aetiology. Epidemiol Infect. Jun 2004; 132(3):381-90.
3. Kay MH, Rapini RP, Fritz KA. Oral lesions in pityriasis rosea. Arch
Dermatol. Nov 1985; 121(11):1449-51.
4. Sharma PK, Yadav TP, Gautam RK. Erythromycin in pityriasis rosea: A doubleblind, placebo-controlled clinical trial. J Am Acad Dermatol. Feb 2000; 42(2 Pt
1):241-4.
5. Amer

A,

Fischer

H. Azithromycin

does

not

cure

pityriasis

rosea. Pediatrics. May 2006; 117(5):1702-5.

6.

Stulberg DL, Wolfrey J. Pityriasis rosea. Am Fam Physician. Jan 1 2004;

69(1):87-91.

7. Drago F, Vecchio F, Rebora A. Use of high-dose acyclovir in pityriasis rosea. J

Am Acad Dermatol. Jan 2006; 54(1):82-5.

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