Pityriasis Rosea: Diagnosis and Treatment

 

Am Fam Physician. 2018 Jan 1;97(1):38-44.

  Patient information: See related handout on pityriasis rosea written by the authors of this article.

Pityriasis rosea is a common self-limiting rash that usually starts with a herald patch on the trunk and progresses along the Langer lines to a generalized rash over the trunk and limbs. The diagnosis is based on clinical and physical examination findings. The herald patch is an erythematous lesion with an elevated border and depressed center. The generalized rash usually presents two weeks after the herald patch. Patients can develop general malaise, fatigue, nausea, headaches, joint pain, enlarged lymph nodes, fever, and sore throat before or during the course of the rash. The differential diagnosis includes secondary syphilis, seborrheic dermatitis, nummular eczema, pityriasis lichenoides chronica, tinea corporis, viral exanthems, lichen planus, and pityriasis rosea–like eruption associated with certain medications. Treatment is aimed at controlling symptoms and consists of corticosteroids or antihistamines. In some cases, acyclovir can be used to treat symptoms and reduce the length of disease. Ultraviolet phototherapy can also be considered for severe cases. Pityriasis rosea during pregnancy has been linked to spontaneous abortions.

Pityriasis rosea is a self-limiting skin condition that presents as discrete scaly papules and plaques along the Langer lines (cleavage lines) over the trunk and limbs. This generalized rash is usually preceded by a herald patch on the trunk.1,2 The incidence is 170 cases per 100,000 persons per year.2 It typically affects persons 10 to 35 years of age.2 Some studies report that males and females are equally affected,3 whereas others report that females are affected more often.2 Data on seasonal variation are conflicting, but studies show a higher prevalence during winter.2,3

WHAT IS NEW ON THIS TOPIC

Pityriasis Rosea

Although a small 2000 study of erythromycin suggested possible benefits for pityriasis rosea, subsequent studies concluded that erythromycin and other macrolides are ineffective.

Several randomized controlled trials found that acyclovir, 400 to 800 mg five times per day, improves symptoms and lesion resolution in severe cases.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Symptoms of pityriasis rosea can be managed with oral or topical corticosteroids or oral antihistamines.

C

2

Macrolide antibiotics have no benefit in the management of pityriasis rosea.

B

4144

Acyclovir is effective in the treatment of pityriasis rosea and may be considered in severe cases.

B

39, 4549


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Symptoms of pityriasis rosea can be managed with oral or topical corticosteroids or oral antihistamines.

C

2

Macrolide antibiotics have no benefit in the management of pityriasis rosea.

B

4144

Acyclovir is effective in the treatment of pityriasis rosea and may be considered in severe cases.

B

39, 4549


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Etiology

The epidemiology and clinical course of pityriasis rosea suggest an infectious etiology. Temporal case clustering, which indicates infectious transmission, has been documented in regression analysis models.4 Bacterial agents have not been linked to pityriasis rosea.5 A viral etiology was proposed after intranuclear and intracytoplasmic virus-like particles were observed by microscopy. An increase in CD4 lymphocytes and Langerhans cells in the dermis also suggest a viral etiology.6 The most common viruses linked to pityriasis rosea are human herpesvirus-6 and -7 (HHV-6 and -7). HHV-6 typically affects children by two years of age, whereas HHV-7 typically affects children by six years of age.6 Roseola infantum (exanthema subitum) is a common presentation of these viruses in children.7 The development of pityriasis rosea later in life suggests reactivation of these viruses.6,8

However, the studies linking HHV-6 and -7 with pityriasis rosea are conflicting and small. Early polymerase chain reaction studies did not detect active viral DNA in patients with pityriasis rosea, despite their having positive antibodies to HHV-6 and -7.9 A later study using a calibrated quantitative real-time polymerase chain reaction assay found active HHV-6 and -7 in plasma and skin samples.10 Only HHV-7 was found in the peripheral blood mononuclear cells. Another study using polymerase chain reaction testing with

The Author

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JOSE M. VILLALON-GOMEZ, MD, MPH, is an assistant professor in the Department of Family and Preventive Medicine at Emory University School of Medicine, Atlanta, Ga. He also serves as the assistant program director for the Emory Family Medicine Residency Program. At the time the article was written, he was a clinical assistant professor in the Department of Family Medicine at Augusta University Medical College of Georgia....

Author disclosure: No relevant financial affiliations.

Address correspondence to Jose M. Villalon-Gomez, MD, MPH, Emory Family Medicine Residency Program, 4500 N. Shallowford Rd., Dunwoody, GA 30338 (e-mail: jose.villalon-gomez@emory.edu). Reprints are not available from the author.

References

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