Pityriasis rosea L42

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Erythema anulatum; Floret lichen; herpes tonsurans maculosus; ibertian disease; lichen anulatus; pityriasis maculata circinata; Pityriasis marginé et circiné de Vidal; Pseudoexanthème desquamatif (Besnier); Roseola anulata; Scaly Florets

History
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Gibert, 1860

Definition
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Frequent, exanthematic, self-limiting, inflammatory skin disease of unknown (probably viral etiology) etiology with typical two-phase course.

Etiopathogenesis
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Unknown. Increasingly, the role of HHV-6 (HHV-7), possibly also HHV-8, is being discussed, especially since the disease responds to antiviral substances such as acyclovir. In individual cases, an association with the H1N1 virus has been reported. This association could not be confirmed in a larger study series (Demirkan S et al. 2019). Similarly, associations with other viruses (EBV, CMV) could not be detected.

The following are also discussed: stress, medication, impregnated clothing.

Manifestation
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Occurs in healthy people aged 10-35 years; an occurrence of pityriasis rosea in children <10 years is rather unusual. Women seem to be preferentially affected (m:w = 1:2). Occurs worldwide in equal measure. Occurs mainly in spring and autumn.

Localization
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Trunk (up to the base of the neck) and proximal (approximately upper third) extremities. Head, neck, peripheral extremities remain free. An inverse form(pityriasis rosea inversa) affects the axillae and the groin region.

Clinical features
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Occasionally, slight prodromas such as respiratory symptoms (about 50% of patients), nausea, fatigue, fever and headaches precede the first skin changes. Initially, a 0.4-7.0 cm large, oval, light-red to pink, mostly scaly (Collerette scaling), marginal plaque ("primary medallion") appears. The primary medallion (tache mère, herald patch) is a regularly occurring symptom in > 50% of cases and often occurs on the trunk.

In the further course of the disease, exanthematic spreading (stem accentuated) of 0.2-1.0 cm large, oval or elongated, slightly raised, scaly spots and plaques, which are aligned according to the splitting lines (fir tree pattern), and which last for 1-2 weeks.

The face, neck and distal halves of the extremities usually remain free. Enanthema of the oral mucosa is (extremely) rare.

Special forms are follicular exanthema, haemorrhages, urticarial forms, circulatory, vesicular, squamous or psoriasiform variants

An inverse form is preferred in children and African-Americans(Pityriasis rosea inversa).

Notice! The exanthema appears more infiltrated in colored people than in whites with a clear tendency to hyperpigmentation! Depending on the degree of pigmentation, the typical red tone of the skin symptoms is missing in white skin.

Histology
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Nonspecific superficial dermatitis with moderate acanthosis, slightly prolonged reticulum, papilloedema, perivascular and interstitial lymphocytic infiltrate; occasionally admixtures of eosinophilic granulocytes. Distinct epidermotropia with focal spongiotic loosening of the epithelium and focal parakeratosis. Rare erythrocyte extravasations.

Differential diagnosis
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  • Clinical Differential Diagnosis:
    • Tinea corporis: never exanthematic, but chronically continuous course (rare exception is microsphere, here there is self-fluorescence under wood light); pathogen detection by native examination and culture is proof.
    • Psoriasis vulgaris: first manifestation of an acute, exanthematic psoriasis as an important DD. The exanthema phenomenon is always negative in pityriasis rosea!
    • Parapsoriasis en plaques (benign small-field form): chronic process, never acute exanthematic. Single florescences significantly larger than in Pityriasis rosea. Typical is a "pseudoatrophy of the surface".
    • Drug exanthema: Acute monomorphic exanthema; rarely eczematous or psoriasiform. Drug anamnesis with prompt re-prescription of a drug.
    • Pityriasis lichenoides: Similar distribution pattern. However, PLEVA and PLC show a groundbreaking polymorphism (colourful picture) of the efflorescences.
    • Early syphilis: Syphillis are usually accompanied by swelling of the LK. Distribution pattern: Frequent infestation of palms and face. Serology is conclusive! Histology is conclusive (plasmacellular dermatitis).
  • Histological differential diagnoses:
    • Acute and subacute eczema: spongiosis, extensive parakeratosis, in atopic eczema possible prominent eosinophilia. Often indistinguishable.
    • Psoriasis guttata: acanthosis, extensive hyper- and parakeratosis with neutrophil inclusions, diffuse, also perivascularly compressed lymphocytic infiltrate with neutrophil granulocytes, no erythrocyte extravasations, strong epidermotropism.
    • Parapsoriasis en plaques: Fibrosis of the papillary stratum; surface epithelium rather atrophic, epidermotropy present, hardly any spongiosis, no parakeratosis!
    • Allergic contact dermatitis: Clinically clearly distinguishable! Prominent, flat spongiosis, surface epithelium acanthotic, long hills of parakeratosis. Histological differentiation can only be reliably made in connection with clinical data.
    • Tinea corporis: Varied histological pattern, which is characterized by the acuteity of the infection. In early stages low superficial perivascular lymphocyte infiltrate, focal spongiosis; later stage with neutrophil component. Compact ortho- and parakeratosis. In the PAS preparation, detection of hyphae (then safe DD); otherwise safe DD is only possible in connection with clinical data.
    • Erythema anulare centrifugum: Clinically clearly distinguishable; histologically safe differentiation only in connection with clinical data! Mostly dense perivascular infiltrate sheaths.
    • Drug exanthema: Cancellous drug exanthema are rare! Mostly combined with interface dermatitis.
    • Early syphilis: Interface dermatitis with psoriasiform epidermal reaction dense, band-shaped infiltrate in the upper and middle dermis (lymphocytes, histiocytes and plasma cells. Extension of the infiltrate to the deep vascular plexus).

Therapy
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Causal therapy not known. The skin changes heal spontaneously within 3-8 weeks.

General therapy
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Avoidance of heat accumulation, occlusive clothing, sports, sauna and moisturising external agents. No excessively hot and long baths, no sunbathing!

External therapy
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Cave! Irritation from aggressive external agents. No fat creams or ointments. Treatment e.g. with Tannolact Lotio, Tannosynt Lotio (shaking mixture), Optiderm Lotio. Blande skin care with O/W emulsion (e.g. Eucerin O/W). Recommended especially for itching are creams containing 5% polidocanol or shaking mixture R200 or weakly effective glucocorticoids like 0.5% hydrocortisone emulsion R123.

Internal therapy
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If necessary, oral antihistamines such as levocetirizine (e.g. Xusal Tbl.) once/day 5 mg p.o. or desloratadine (e.g. Aerius Tbl.) once/day 5 mg p.o.

Alternative: In a randomized study in a medium sized collective a positive clinical effect (shortening of the duration of the disease) could be proven by an oral, 7 days long administration of Aciclovir (OFF Label Use) (400 mg/5xday p.o.). This therapeutic option should be carefully considered in view of the self-limiting course of the disease.

Alternative: Oral erythromycin (250mg 4x/day for 2 weeks) is significantly successful after a meta-analysis (Chuh A et al. 2005)

Progression/forecast
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Healing in 3-8 weeks, generally without permanent skin changes. Hyperpigmentation, leukoderm formation, scarring possible. Recurrences are rare (<3%) (pityriasis rosea recidivans).

Note(s)
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Remember! A primary medallion is a regularly occurring, diagnostically usable symptom; in > 50% of cases

Notice! Pityriasis rosea (almost) never affects the face and mucous membranes; only rarely the extremities! Patients have no disturbed general condition!

Notice! The course of pityriasis rosea is critical for the fetus up to the 15th week of pregnancy with an increased risk (57%) of miscarriage or premature birth (Monastirli A et al. 2016).

Literature
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  1. Chuang TY et al (1983) Recent upper respiratory tract infection and pityriasis rosea: a case-control study of 249 matched pairs. Br J Dermatol 108: 587-591
  2. Chuh A et al(2006) Atypical presentations of pityriasis rosea: case presentations. J Eur Acad Dermatol Venereol 19:120-126.
  3. The A et al (2015) Acyclovir in pityriasis rosea: An observer-blind, randomized controlled trial of effectiveness, safety and tolerability. Indian Dermatol Online J 6:181-184
  4. Demirkan S et al (2019). Does influenza subtype H1N1 have a place in the etiology of pityriasis rosea? Postepy dermatologii i alergologii 36: 164-166 .
  5. Drago Fet al.(2014) Relapsing pityriasis rosea. Dermatology 229:316-318
  6. DragoF et al (2008) Pregnancy outcome in patients with pityriasis rosea. J Am Acad DErmatol 58: 78-83
  7. Gibert CM (1860) Traite' Pratique des Maladies de la peau et de la Syphilis, 3 rd edn. Plon (Paris) pp:402
  8. Kempf W (2002) Human herpesvirus 7 in dermatology: what role does it play? Am J Clin Dermatol 3: 309-315
  9. Kempf W, Burg G (2000) Pityriasis rosea--a virus-induced skin disease? To update. Arch Virol 145: 1509-1520
  10. Monastirli A et al (2016) Gestational Pityriasis Rosea: Suggestions for Approaching Affected Pregnant Women. Acta Dermatovenerol Croat 24:312-313.
  11. Rassai S et al (2011) Low dose of acyclovir may be an effective treatment against pityriasis rosea: a random investigator-blind clinical trial on 64 patients. JEAV 25: 24-26
  12. Renner R et al (2010) Chronic inflammatory and autoimmune mediated dermatoses in pregnancy. Dermatologist 61: 1021-1026
  13. Watanabe T et al (2002) Pityriasis rosea is associated with systemic active infection with both human herpesvirus-7 and human herpesvirus-6 J Invest Dermatol 119: 793-797

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.