Pityriasis rosea L42

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 24.03.2021

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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

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Gibert, 1860

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

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Unknown. Increasingly, the role of HHV-6(HHV-7), possibly also HHV-8, is discussed, especially since their antigens were detectable in the lesions and the disease responds to antiviral substances such as aciclovir. An association with H1N1 virus has been reported in individual cases. This association could not be confirmed in a larger series of studies (Demirkan S et al. 2019). Likewise, associations with other viruses(EBV, CMV) could not be demonstrated.

Furthermore, stress, medication and impregnated clothing were discussed as triggering factors.

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Occurring in healthy people aged 10-35 years. Occurrence of pityriasis rosea in children <10 years of age is uncommon. Females seem to be preferentially affected (m:w = 1:2). Worldwide equally occurring. Endemic occurrence possible especially in spring and autumn.

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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, mild prodromes such as respiratory symptoms (about 50% of patients), nausea, faintness, fever and headache precede the first skin changes. Initially, a 0.4-7.0 cm large, oval, light-red to pink, usually scaling (collerette scaling), edge accentuated plaque ("primary medallion") is seen. The primary medallion (tache mère, herald patch) is a regularly occurring symptom in > 50% of cases and often appears on the trunk.

In the further course, there is a relapsing, exanthematous (symmetrical) spread (truncal) of 0.2-1.0 cm, oval or elongated, slightly raised, scaly patches and scaly plaques aligned according to the cleavage lines (fir tree pattern), lasting for 1-2 weeks. Evidence of collerette scaling, an inwardly directed delicate scaly ruff, is also possible in individual plaques. This type of scaling is a supporting diagnostic phenomenon (see Fig.). The foci that appear later are usually smaller than the primary medallion, which is not always detectable in the exanthema stage.

The face, neck, and distal halves of the extremities usually remain free. Oropharyngeal mucosal lesions are rare but can be attributed to the clinical picture (Ciccarese G et al. 2017).

Special forms to note are follicular exanthema, hemorrhagic and urticarial exanthema, circine, vesicular, squamous or psoriasiform variants.

An inverse form is observed preferentially in children and African-Americans(pityriasis rosea inversa).

Notice. In coloured persons the exanthema appears more infiltrated than in whites with a clear tendency to hyperpigmentation! Here, depending on the degree of pigmentation, the red tone of the skin manifestations typical in white skin is missing.

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Nonspecific superficial dermatitis with moderate acanthosis, slightly elongated rice ridges, papilledema, perivascular and interstitial lymphocytic infiltrate; occasionally admixtures of eosinophilic granulocytes. Marked epidermotropia with focal spongiotic loosening of the epithelium and focal, stratified parakeratosis (histologic counterpart of Collerette's pucker). Rarely 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).

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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)

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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).

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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).

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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. Ciccarese G et al (2017) Oropharyngeal lesions in pityriasis rosea. J Am Acad Dermatol 77:833-837.

  4. Das 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
  5. 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.
  6. Drago Fet al.(2014) Relapsing pityriasis rosea. Dermatology 229:316-318
  7. DragoF et al. (2008) Pregnancy outcome in patients with pityriasis rosea. J Am Acad DErmatol 58: 78-83
  8. Gibert CM (1860) Traite' Pratique des Maladies de la peau et de la Syphilis, 3 rd edn. Plon (Paris) pp:402
  9. Kempf W (2002) Human herpesvirus 7 in dermatology: what role does it play? Am J Clin Dermatol 3: 309-315
  10. Kempf W, Burg G (2000) Pityriasis rosea--a virus-induced skin disease? An update. Arch Virol 145: 1509-1520
  11. Monastirli A et al. (2016) Gestational pityriasis rosea: Suggestions for Approaching Affected Pregnant Women. Acta Dermatovenerol Croat 24:312-313.
  12. 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
  13. Renner R et al (2010) Chronic inflammatory and autoimmune-mediated dermatoses in pregnancy. Dermatologist 61: 1021-1026
  14. Vaccaro M et al (2020) Pityriasis rosea during omalizumab treatment for chronic spontaneous urticaria. Dermatol Ther 33:e14356.

  15. 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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