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childhood exanthems
John C. Browning
Pediatrics and Dermatology, University of Texas Health
Science Center at San Antonio, San Antonio, Texas,
USA
Correspondence to John C. Browning, MD, FAAP,
Assistant Professor, Pediatrics and Dermatology,
University of Texas Health Science Center at San
Antonio, 7703 Floyd Curl Drive, MSC 7808, San
Antonio, TX 78229, USA
Tel: +1 210 562 5344;
e-mail: BrowningJ3@UTHSCSA.edu
Current Opinion in Pediatrics 2009, 21:481485
Purpose of review
Pityriasis rosea is a common skin condition seen in children and adults. Whereas
pityriasis rosea is a benign condition, it is important to distinguish it from other childhood
exanthems.
Recent findings
Pityriasis rosea can present in a variety of manners. Most often a herald patch precedes
the generalized eruption, although this is not always the case. Pityriasis rosea may lead
to undesirable outcomes when affecting pregnant women. Guttate psoriasis, secondary
syphilis, cutaneous lupus erythematosus, capillaritis, pityriasis versicolor, nummular
eczema, and cutaneous T-cell lymphoma are important to consider in the differential
diagnosis of pityriasis rosea.
Summary
Pityriasis rosea is self-limiting, usually lasting 13 months. Treatment may be
considered in certain cases, although there is a paucity of medical studies supporting
any definitive treatment. However, treatment may be warranted for other conditions that
mimic pityriasis rosea.
Keywords
childhood exanthems, erythromycin, pityriasis rosea, syphilis
Curr Opin Pediatr 21:481485
2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
1040-8703
Introduction
Pityriasis rosea is a common rash seen in children and
adults. It was first described in 1798 by British physician
Robert Willan (17571812) under the name roseola
annulata [1]. In 1860, the French doctor Camille Melchior Gilbert named the exanthema pityriasis rosea [2].
Since then we have done much to describe the rash of
pityriasis rosea but much still remains to be discovered
regarding its cause and treatment.
Pityriasis rosea derives its name from pityriasis, meaning
bran-like, and rosea, meaning pink. In other words,
pityriasis rosea is an intelligent-sounding way of saying
pink, scaly rash. There are other pityriasis rashes such
as pityriasis lichenoides, pityriasis alba, pityriasis rubra
pilaris, and pityriasis versicolor. Interestingly, other than
pityriasis lichenoides, these exanthems are not part of the
same family as pityriasis rosea but simply share scaliness
as a unifying feature. It was common in the early days of
dermatology to name rashes according to their appearance rather than their underlying cause.
Epidemiology
One study found patients most commonly affected with
pityriasis rosea to be between the ages of 10 and 35 years
[3], although it has also been reported in infants [4],
1040-8703 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical appearance
Classically, pityriasis rosea begins as an erythematous,
scaly patch on the trunk known as a herald patch. It is
called a herald patch because it is heralding the coming
of numerous smaller macules and patches. The herald
patch is usually several centimeters in size, compared
with the typical 1-cm lesions in generalized pityriasis
rosea (Fig. 1). The herald patch is often mistaken for
tinea corporis, although a simple KOH examination can
be done to exclude this diagnosis. Occasionally certain
patients will not develop a herald patch prior to the
generalized rash, or they may not remember having a
herald patch. This may be because the herald patch is
asymptomatic and, when located on the back or flank,
may not be noticed by the patient. One study found that
only 17% of patients develop the herald patch [6].
Although this number is probably low, as it reflects
patients with atypical pityriasis rosea seen in a dermatology clinic rather than a primary care clinic, it is helpful to
remember that the presence of a herald patch by history is
not necessary in making a diagnosis of pityriasis rosea.
Days to weeks later, numerous smaller scaly patches
DOI:10.1097/MOP.0b013e32832db96e
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482 Dermatology
Figure 1 Numerous erythematous scaly macules on the back
following the skin cleavage lines
Cause
develop on the trunk along the lines of skin cleavage.
This has often been described as a Christmas tree pattern
because skin-cleavage lines run diagonally on the back
[7]. Because of this diagonal pattern, the lesions of
pityriasis rosea often have a spindled or football shape
to them. The individual patches have a light pink color
with slight scale. They are not bright red, as would be
seen in a drug eruption, or thick and lichenified, as would
be expected with nummular eczema.
Pityriasis rosea lasts on average 68 weeks, although
longer and shorter courses have been reported.
In some individuals, pityriasis rosea affects the face and
extremities more than the trunk and is referred to as
inverse pityriasis rosea (Fig. 2). Pityriasis rosea in patients
with darker skin often follows an inverse pattern and may
involve the scalp and face, leaving residual pigmentary
changes in a majority [8]. Pityriasis rosea may rarely
present as a vesicular eruption [9] or similar to erythema
multiforme. [10]. Pityriasis rosea has also been known to
involve the oral mucosa [11], although this is quite rare.
There have been reports of purpuric pityriasis rosea
[12,13] and unilateral pityriasis rosea [14]. Pityriasis rosea
is often mildly pruritic, although in some cases it may be
highly pruritic or asymptomatic [7].
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Update on pityriasis rosea and other similar childhood exanthems Browning 483
pregnant women with pityriasis rosea should have serologic testing for syphilis [21].
Diagnosis
Diagnosing pityriasis rosea is nearly always made by history
and physical exam alone. In certain atypical cases, a skin
biopsy performed by a dermatologist may prove useful in
differentiating pityriasis rosea from other exanthems.
Histologically, acanthosis with mild psoriasiform hyperplasia and overlying focal parakeratosis may be seen [22].
Treatment
Treatment for pityriasis rosea is not necessary since the
rash eventually resolves in 13 months. Pityriasis rosea is a
benign disease, with the exception of potential risks during
pregnancy as discussed earlier. However, in certain cases
patients may request treatment due to pruritus or cosmetic
concerns. One of the most important parts of treatment is
to inform the patient and family of the usual 13-month
course of the rash, its benign and noncontagious nature,
and the fact that it is not a reason to be excluded from
school or other activities. There has been some evidence
that acyclovir may be useful [23]. However, despite its
effectiveness against herpes simplex virus, several studies
have shown acyclovir to be ineffective against HHV-6 and
HHV-7 and instead have shown ganciclovir and foscarnet
to be effective antiviral agents [24,25]. This is logical, as
HHV-7 lacks the thymidine kinase gene and acyclovir is
thymidine kinase-dependent. Interestingly, there has also
been one case report of pityriasis rosea occurring during
acyclovir therapy [26]. There are no studies investigating
the use of foscarnet or ganciclovir in treating pityriasis
rosea. In the past there has been support for erythromycin
as a treatment for pityriasis rosea [27]. It has been hypothesized that the anti-inflammatory component of erythromycin, rather than the antibiotic effect, is helpful in
reducing the inflammation in pityriasis rosea. Recently,
however, another study found erythromycin not to be
useful in pityriasis rosea [28]. A separate study did not
show any benefit in using azithromycin [29]. In response to
these studies, a letter to the editor recently commented on
unpublished data using clarithromycin in treating pityriasis rosea [30]. Specifically, the author states that 50 out of
52 patients with pityriasis rosea showed improvement
during the first week of clarithromycin therapy. The author
plans to submit the results of the study in the near future.
There has been support in using narrow-band UVB phototherapy [31,32] as well as natural sunlight. Ultraviolet light
works by suppressing the cutaneous immune system.
Topical steroids offer limited benefit but may be helpful
when pruritus is present [33]. Systemic steroids have not
been shown to be effective, and the risk of systemic
steroids precludes their use in this benign condition.
Antihistamines may be of benefit when pruritus is present.
Differential diagnosis
As mentioned earlier, other exanthems may be mistaken
for pityriasis rosea. Pityriasis lichenoides chronica (PLC)
has a similar distribution and morphology to pityriasis
rosea but does not resolve within the same time period. It
can be thought of as pityriasis rosea that does not go
away. PLC can often last for months or years before full
resolution. Unlike pityriasis rosea, PLC does not begin
with a herald patch, although it tends to primarily involve
the trunk (Fig. 3). Histologically, PLC can be differentiated from pityriasis rosea by biopsy, when needed. PLC
is characterized histologically by a superficial lymphocytic infiltrate, occasional degenerate keratinocytes, and
occasional extravasated erythrocytes [34]. Narrowband
UVB phototherapy has been shown to be useful in
treating PLC. The acute form of pityriasis lichenoides
known as pityriasis lichenoides et varioliformis acuta
(PLEVA) lasts for a shorter duration than PLC. PLEVA
is characterized by erythematous papules with overlying
crusting; it should not be confused with pityriasis rosea.
Guttate psoriasis is a form of psoriasis often seen in
children following streptococcal illness. It is characterized by round and ovoid scaly, erythematous macules on
the trunk. Guttate means drop-like because the macules
Figure 3 Pityriasis lichenoides chronica
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484 Dermatology
Conclusion
Capillaritis is an idiopathic condition in which inflammation of the capillary vessels can lead to leakage of red
blood cells into the skin. Clinically this is characterized
by nonblanching erythematous patches. There are two
subtypes in particular that can be mistaken for pityriasis
rosea: Schambergs disease and eczematoid-like purpura
of Doucas and Kapetanakis. Schambergs disease is
characterized by nonblanching erythematous patches
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Update on pityriasis rosea and other similar childhood exanthems Browning 485
Gilbert CM. Traite pratique des maladies de la peau et de la syphilis. 3rd ed.
Paris: H. Plon; 1860. p. 402.
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11 Vidimos AT, Camisa C. Tongue and cheek: oral lesions in pityriasis rosea.
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31 Arndt KA, Paul BS, Stern RS, Parrish JA. Treatment of pityriasis rosea with UV
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18 Broccolo F, Drago F, Careddu AM, et al. Additional evidence that pityriasis
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19 Rajpara SN, Ormerod AD, Gallaway L. Adalimumab-induced pityriasis rosea.
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