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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. Dermatological Nursing, 2009, Vol 8, No 4 48-49_Pityriasis rosea.mjjp C.indd 50 03/12/2009 18:03 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 Dermatology, 3rd ed. Oxford: Blackwell Publishing, 63-64 MacKie RM (2002) Clinical Dermatology, 5th ed. Oxford; Oxford Core Text, 48, 81-82 Papadopoulos L (2006) The psychological implications of dermatology conditions. 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 Dermatological Nursing, 2009, Vol 8, No 4 48-49_Pityriasis rosea.mjjp C.indd 51 49 03/12/2009 18:03