Download Recognition and management of Pityriasis Rosea

Case HISTORY
Recognition and management
of Pityriasis Rosea
Andrew Herd
Some skin conditions resolve spontaneously. The challenge is then to convince the patient of this, reduce their
fears and so ensure compliance. Pityriasis rosea is such a condition and is defined by MacKie as “a self-limiting
disorder characterised by the developing of asymptomatic erythematous scaling macules on the trunk”.
Key words
Herald Patch
Christmas tree pattern
Human herpes virus 6/7
Spontaneous resolving
Summary
Pityriasis rosea can start with viral
symptoms, usually in autumn or winter,
and occurs mostly to children and young
adults, the majority female. An oval
patch appears on the trunk, followed by
smaller oval patches. These may itch but
are self-limiting, lasting only a few weeks.
Building confidence between the patient
is most important; supplying a leaflet full
of information on the subject helps.
Presentation of pityriasis rosea
Pityriasis (scaly) rosea (pink)
(Gawkrodger, 2000) was first described
in 1860 by Camille Melchior Gilbert
(Allen, 2007). It belongs to a group
called papulosquamous skin eruptions
(Fitzpatrick, 2001). 75% start with one
thin, oval plaque. Called a Herald Patch
(Fitzpatrick, 2001) or Mother Plaque
(Hunter, 2002), it is found on the trunk
with a collarette of scale peripherally
on the patch. Days or weeks later, small
Dr Andrew Herd has been a GP in Coventry
for 23 years and is a GPwSI in dermatology.
He runs a skin clinic for surgery patients
in Coventry and lectures Warwick medical
students
48
similar lesions come to the trunk and
proximal extremities avoiding the face,
soles and palms. Ashton (2005) says if
the Herald Patch is on the limbs, the
rash will be on the limbs. If the Herald
Patch is on the neck, the rash will be
on the face and trunk. The rash follows
Langer’s Lines as a Christmas tree
pattern (MacKie, 2002). It can last 4 to
6 weeks, or longer if severe, and affects
children and young adults and women
more often. It occurs mostly in the
autumn or winter seasons and is thought
to be viral in origin, as once affected
it never usually recurs, suggesting a
build-up of immunity. Outbreaks can
occur in nursing homes and institutions.
Dermatology doctors are affected four
times more than ENT doctors (DuVivier,
2002). The virus may be Human Herpes
Virus 6 and 7 (MacKie, 2002, Allen, 2007,
DuVivier, 2002, Stulberg, 2004).
Problems in identification
Nothing is ever exact, even with
identifying pityriasis rosea (DuVivier,
2002). The following can cause problems:
1.No Herald Patch, only a small, oval
rash
2.Suntan when lesions show at covered
areas (breast, axillae, pubic area,
buttocks)
3.Lesions are large and fewer at axillae/
groin in adults and last months
4.Dark skin is more widespread to
lower limbs and lasts months. Hyper
or hypo-pigmentation may happen
5.The face and limbs are affected, not
the body (inverse pityriasis rosea)
6.Could be papular, vesicular or
purpuric
7.So florid patches coalesce
Case history
IR is 42. He presented to the
clinic complaining of a rash present
for 4 weeks. He developed cold
symptoms, then a solitary red
patch 4cm in diameter appeared
under his left breast. A week later
the rash had spread to the back
and front of his trunk. He noted
a slight itch when using soap on
showering and had to turn the
temperature of the water down
to reduce the irritation. Warm
clothes and jogging worsened the
symptoms. There was no medical
or operation history and no skin
problems in the past. He was
sexually active with one female
partner. His main concern was of
potentially having to change his
occupation as a mechanic, as he
thought the rash was a result of
his profession. He wasn’t on any
drugs and had no allergies. He had
used anti-fungal cream when his
partner thought he had ringworm.
Quality of Life Index (Finlay, 1997)
was 7, indicating moderate effects
on his life. An explanation (and
leaflet) over his condition was
given and Hydrocortisone 1%
ointment prescribed to use twice
a day for the itch. He failed to
attend after 4 weeks for review,
but on phone contact it was found
that the rash had gone, leaving no
side effects.
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Differential diagnosis
Erythema Multiform
Small plaque parapsoriasis
Diffuse nummular eczema
Tinea corporis
Pityriasis vesicolor
Pityriasis lichenoides
Guttate psoriasis
Viral exanthema
Lichen planus
Syphilis
Seborrhoeic dermatitis
(Mackie, 2002, Gawkrodger, 2000,
Allen, 2007, Stulberg, 2004, Wilkin,
1982, Fitzpatrick, 2001, Hunter, 2002,
Wolffe, 2009).
Drugs causing rashes similar to pityriasis
rosea:
Arsenic; Barbiturates; Bismuth;
Calmette-Guérin bacillus therapy;
Captopril; Clonidine; Gold; Hepatitis
B vaccine; Imatinib; Zaditon
Investigations
Exact history and examination should
make investigation unnecessary. But
as secondary syphilis can mimic
pityriasis rosea, testing is best done
(Hunter, 2002). Some dermatologists
do VDRL (Venereal Disease Research
Laboratory) or RPR (Rapid Plasma
Reagin) routinely on every affected
patient (Fitzpatrick, 2001) and HIV on
positive VDRL (Allen, 2007). Negative
skin scrapings would eliminate
pityriasis versicolor and tinea corporis
and no drug taking eliminates drugs
causation. If the rash persists for over
3 months, biopsy may be required
(Stulberg, 2004). The histology is
similar to syphilis. Lymphocytic dermal
infiltrate and papillary oedema are
seen. At the edge of the new lesion
spongiosis in the epidermis is present
(MacKie, 2002, Wolffe, 2009).
Treatment
Asymptomatic patients need
reassurance of the harmless nature
of pityriasis rosea and to be told that
it will disappear in 6/8 weeks from
the onset. In 2% of cases it can recur.
Itching can be soothed by calamine,
zinc oxide, oral anti-histamines and
oral steroids. Scales can be reduced
using 1% salicylic acid in soft white
paraffin. Advice should be given to
take luke-warm water baths and
showers, avoid soap and use plain
water/bath oil/aqueous cream/soap
substitutes and moisturise dry skin. No
strenuous activity should be taken until
the rash is gone. Acyclovir can speed
recovery. In vesicular pityriasis rosea,
Dapsone 20mg twice a day is used.
Erythromycin may stop the attack as
is it an anti-inflammatory. Sunlight or
UVB soothes itching and can speed up
resolution in severe cases. Leaflets on
the condition can further emphasise
instructions. Dermatology nurses play
an important role here, providing
a link between dermatologist and
patient, giving psychological, practical
and social support, and understanding
the patient’s ideas, concerns and
expectations. (Allen, 2007, Ashton,
2005, Stulberg, 2007, DuVivier, 2002,
Fitzpatrick, 2001, Hunter, 2002.)
Conclusion
The Quality of Life Index shows
little concern over the itching in the
condition. Despite being self-limiting,
it can still influence a patient’s lifestyle.
Chuh (2004) showed patients’ quality
of life with pityriasis rosea was less
affected than for atopic patients, but
was insignificantly different from acne
patients. Compliance is required if we
are to see improvement of the condition.
Donovan (1992) shows compliance
improves if a more open doctor/patient
relationship exists and Cameron (1996)
emphasises this. This is aided by giving
patient leaflets out. Papadopoulos
(2006) states lack of health education
stigmatises skin conditions and doctors
trivialising skin problems make patients
feel unimportant. Use of the Quality
of Life Index can establish patients’
concerns and relieve them. Pityriasis
rosea must be shown to the patient
to be just as important to the doctor
as any condition requiring complex
treatment. DN
DermQuest.com/Galderma
Case HISTORY
Figure 1. Oval patches on the trunk are an
indication of pityriasis rosea.
Cameron C (1996) Patient compliance;
recognition of factors involved and
suggestions for promoting compliance
with therapeutic regimens. J Adv Nurs
24(2): 244-250
Chuh AAT, Chan HHL (2005) Effect on
quality of life in patients with pityriasis
rosea: is it associated with rash severity?
Int J Dermatol 44: 372-7
Donovan JL, Blake DR (1992) Patient
non-compliance: defiance or reasoned
decision-making? Soc Sci Med 34(5):
507-13
DuVivier A (2002) Atlas of Clinical
Dermatology, 3rd ed. London: Churchill
Livingston; 87, 89-90
Finlay AY (1997) Quality of life
measurement in dermatology: a practical
guide. Br J Dermatol 136: 305-314
Fitzpatrick JE, Aeling JL (2001)
Dermatology Secrets in Color, 2nd ed.
Philadelphia: Hasley & Belfies, 42, 47-48
Gawkrodger DJ (2000) Dermatology, an
illustrated colour text, 3rd ed. London:
Churchill Livingston; 38
Hunter J, Savin J, Dahl M (2002) Clinical
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Publishing, 63-64
MacKie RM (2002) Clinical Dermatology,
5th ed. Oxford; Oxford Core Text, 48,
81-82
Papadopoulos L (2006) The psychological
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Derm Pract 14(2): 15-17
Stulberg DL, Wolfrey J (2004) Pityriasis
Rosea. Am Fam Physician 69(1): 87-92
References
Allen RA (2007) Pityriasis Rosea. eMedicine
[serial online] www.emedicine.com/derm/
topic335.htm
Ashton R, Leppard B (2005) Differential
Diagnosis in Dermatology, 3rd ed. Oxford:
Radcliffe Publishing, 191-192
Wilkin JK, Kirkendall WM (1982)
Pityriasis rosea-like rash from captopril.
Arch Dermatol 118(3): 186-7
Wolff K, Johnson RA (2009) Fitzpatrick’s
Color Atlas & Synopsis of Clinical
Dermatology, 6th ed. London: McGraw Hill
Medical, 122-124
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