Ptyriasis rosea

Clinical features Ptyriasis rosea is a mild inflammatory exanthema characterized by salmoncolored popular and macular lesions that are at first discrete but may become confluent. The individual patch are oval or circinate, and are covered with finely crinkled, dry epidermis, which often desquamates, leaving a collarette of scaling. When stretched across the long axis, the scales tend to fold across the lines of stretch, the so-called hanging curtain sign. The disease most frequently begins with a single herald or mother patch, usually large than succeeding lesions, which may persist or longer before other appear. By the time involution of the herald patch has begun, the efflorescence of new lesions spread rapidly, and after 38 weeks they usually disappear spontaneously. Relapses and recurrences are observed infrequently. the incidence is highest between the ages of 15 and 40, and the disease is most prevalent in the spring and autumn. Women are more frequently affected than men. The fully developed eruption has a striking appearance because of the distribution and definite characteristics of the individual lesions. These are arranged so that the long axis of the macules runs parallel to the lines of cleavage. The eruption is usually generalized, affecting chiefly the trunk and sparing sun exposed surfaces. At times is localized to a certain area, such as the neck, thighs, groins or axillae. In this regions confluent circinate patches with gyrate borders may be formed; these may strongly resemble tinea corporis. Rarely, the eyelids, palms and soles, scalp, or penis may be involved. Oral lesions are relatively uncommon. They are asymptomatic, erythematous macules with raised borders and clearing centers or aphthous ulcer-like lesions. They involute simultaneously with the skin lesions. Moderate pruritus may be present,

particularly during the outbreak, and there may be mild constitutional symptoms before the onset. Variations in the mode of onset, course, and clinical manifestations are extremely common. An unusual form, common in children under age 5, is popular pityriasis rosea, occurring in the typical sites and running a course similar to that of the common form of pityriasis rosea. Black children are particularly predisposed to this popular variant, and are also more prone to facial to facial and scalp involvement. The lesions often heal, leaving hypopigmented macules. An inverse distribution, sparing covered areas, in not rare and is common in popular cases. A vesicular variant has also been described. Purpuric pytiriasis rosea may manifest with petechiae and ecchymoses along Langer lines of the neck, trunk, and proximal extremities, and may occasionally be a sign of an underlying acute myeloid leukemia. Pityriasis rosea occurring during pregnancy may be associated with premature delivery, neonatal hypotonia, and fetal loss, especially if the eruption occurs within the first 15 weeks of gestation. Etiology Watanabe el al have provided evidence for the long-held belief that pityriasis rosea is a viral exanthema. They demonstrated active replication of human herpes Virus (HHV)-6 and 7 in mononuclear cells of lesional skin, as well as identifying the viruses in serum samples of patients. Although these viruses are nearly universally acquired in early childhood and remain a latent phase as mononuclear cells, the eruption is likely secondary to reactivation leading to viremia. A pityriasis rosea-like eruption may occur as a reaction to captopril, imatinib mesylate, interferon, ketotifen, arsenicals, gold, bismuth, clonidine,

methoxypromazine, tripelennamine hydrochloride, ergotamine, lisinopril, acyclovir, lithium, alaimumab, or barbiturates. Histology The histology features of pityriasis rosea include mild acanthosis, focal parakeratosis, and extravasation of erythrocytes into the epidermis. Spongiosis may be present in acute cases. A mild perivascular infiltrate of lymphocytes is found in the dermis. Histologic evaluation is especially helpful in excluding the conditions with which pityriasis rosea may be confused. Differential diagnosis Pityriasis rosea may closely mimic seborrheic dermatitis, tinea corporis, macular syphilid, drug eruption, other viral exanthema, and psoriasis. In seborreich dermatitis, the scalp and eyebrows are usually scaly; there is a predilection for the sternal and interscapular regions, and the flexor surfaces of the articulations, where the patches are covered with greasy scales. Tinea corporis is rarely so widespread. Tinea versicolor may also closely simulate pityriasis rosea. A positive KOH examination serves well to differentiate these last two. In macular syphilid, the lesions are of a uniform size and assume a brownish tint. Scaling and itching are absent or slight, and there are generalized adenopathy, mucous membrane lesions, palmoplantar lesions, positive nontreponemal and treponemal tests, and often the remains of a chancre. Scabies and lichen planus may be confused with the papular type. Most patients require no therapy, as they are asymptomatic; however, the duration of the eruption may be notably reduced by several interventions. A Cochrane database review cited inadequate evidence for efficacy for most published treatments, but it should be noted that lack

of evidence does not equate to lack of efficacy. They cited some evidence that oral erythromycin may be effective for both the rash and the itch, although this is based on only one small randomized controlled trial (see below). UVB in erythema exposures may be used to expedite the involution of the lesions after the acute inflammatory stage has passed. The erythema produced by UV treatment is succeeded by superficial exfoliation. In a comparison study by Leenutaphong et al, using a placebo of 1 J UVA on the untreated side compared with the UVB-treated side, there was significant improvement in the severity of the disease on the treated side. However, there was no difference in itchiness or the course of the disease. Corticosteroid lotions or creams provide some relief from itching. One study found erythromycin, 250 mg four times a day for adults and 2540 mg/kg in four divided doses a day for children, over a 2-week period resulted in complete clearance of all lesions. This response in 33 of 45 patients contrasted with the fact that none of the 45 placebo patients had the same response. Other studies have challenged the effectiveness of erythromycin, and more research is needed. For dryness and irritation, simple emollients are advised.