Clinical dermatology

Concise report

Localized pityriasis rosea

I. Ahmed and R. Charles-Holmes*
Department of Dermatology, Walsgrave Hospitals NHS Trust, Coventry, and *Department of Dermatology, Warwick Hospital, Warwick, UK

Summary

Pityriasis rosea is a relatively common skin disorder. In its typical form it is easily recognizable; however, atypical forms can pose diagnostic problems. We report a 44year-old woman with an acute onset of a localized eruption on her left breast. The morphology of the rash and the time course were typical of pityriasis rosea. Localized pityriasis rosea is an unusual variant, which has been described previously.

Report
A 44-year-old woman was referred by her general practitioner with an acute eruption over her chest. It had developed over the preceding week, and was localized to the left breast. There was no prior history of drug ingestion. She had malaise and complained of a sore throat, but was not pyrexial. Her general practitioner prescribed a course of oral acyclovir, presuming that this was early shingles. On examination there was a florid macular eruption over her left breast with a few lesions on the left arm (Fig. 1). Some of the annular lesions showed scaling at the edges and fine wrinkling in the centre (Fig. 2). There was no associated lymphadenopathy and no lesions in the mucosa. Clinically the eruption was compatible with pityriasis rosea; however, the distribution was very unusual. The rash did not extend and settled over the next 4 weeks. She was prescribed clobetasone butyrate 0.05% cream in the dermatology clinic for symptomatic improvement. The following investigations were negative; throat swab, antistreptolysin O (ASO) titre, venereal disease reference laboratory (VDRL) and treponema pallidum haemagglutination assay (TPHA) and skin scrapings for mycology. A skin biopsy showed a moderate patchy mononuclear infiltrate in the upper dermis, which invaded the epidermis focally. There was spongiosis,

Correspondence: I. Ahmed, Department of Dermatology, Walsgrave Hospitals NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK. Tel.: 144 24 76538884. Fax: 144 24 76538766. Accepted for publication 10 May 2000

mild hyperkeratosis, and small areas of parakeratosis. These findings on histology were felt to be compatible with pityriasis rosea. It was not possible to look for evidence of human herpesvirus (HHV) which has recently been implicated in the pathogenesis of pityriasis rosea. Patch testing was not performed. Pityriasis rosea is a relatively common skin disease. In its typical form it is easily recognizable clinically based on the morphology and distribution of the lesions; however, atypical forms can pose diagnostic problems. The clinical features of a typical case are the appearance of a herald patch usually on the thigh, upper arm or trunk, followed by the development of disseminated, smaller papulosquamous ovoid macules after an interval of 515 days. The classical lesions consist of discrete medallions often oval in shape and dull pink in colour, covered by fine, dry silvery-grey scales. The centre tends to clear and assumes a wrinkled, appearance showing a fine colarette of scale on its margin. The long axes of these lesions follow the lines of cleavage giving a characteristic `Christmas-tree' appearance on the trunk. Although the eruption is usually asymptomatic, it can be pruritic. The eruption usually fades within 8 weeks without treatment. While the aetiology remains uncertain, there is considerable circumstantial evidence for an infectious cause. Speculation of a viral aetiology is based on the occasional presence of a prodrome, strong association with a recent upper respiratory tract infection1 seasonal variation in occurrence, clustering of cases and immunity after a single attack. A recent report implicated HHV-7 as the causative organism.2,3 Yasukawa et al. have questioned this and proposed that the HHV

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Localized pityriasis rosea

I. Ahmed and R. Charles-Holmes

Figure 1 Pityriasis rosea localized to one

breast.

findings reflect reactivation and not a causative role.4 Kempf et al. have also argued against the role of HHV-7 in the pathogenesis of pityriasis rosea.5 Pityriasis rosea may vary in its morphology, distribution and clinical course. Unusual forms have been described including vesicular, urticated and purpuric lesions.6 Lesions may be present on distal extremities, involving the hands and feet and rarely the palms.7,8 The scalp and face may be involved particularly in children.9 Pityriasis rosea unilateralis with lesions localized to one side of the body has been described.10 Pityriasis circinata et marginata of Vidal is a localized form of pityriasis rosea usually restricted to the axillae

or groin. The lesions are few and large tending to become confluent and may persist for several months.9 In our patient the lesions were typical of PR, did not coalesce and were not distributed in the axillae or groin. Our patient demonstrates a most unusual presentation of pityriasis rosea with localization largely to one breast, which has not been described previously.

References
1 Chuang T, Perry HO, Ilstrup DM et al. Recent upper respiratory tract infection and pityriasis rosea: a case

Figure 2 Close up showing typical lesions

of pityriasis rosea.

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control study of 249 matched pairs. Br J Dermatol 1983; 108: 58791. Drago F, Ranieri E, Malaguti F et al. Human herpesvirus 7 in patients with pityriasis rosea. Lancet 1997; 349: 1367 8. Drago F, Ranieri E, Malaguti F et al. Human herpesvirus 7 in patients with pityriasis rosea. Electron microscopy investigations and polymerase chain reaction in mononuclear cells, plasma and skin. Dermatology 1997; 195: 3748. Yasukawa M, Sada E, Fujita S et al. Reactivation of human herpesvirus 6 in pityriasis rosea. Br J Dermatol 1999; 140: 16970. Kempf W, Adams V, Nestle FO et al. Pityriasis rosea is not

6 7 8 9

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associated with human herpesvirus 7. Arch Dermatol 1999; 135: 10702. Rinaldi VG. Pityriasis rosea di Gibert purpurica. Minerva Dermatol 1954; 29: 38790. Imamura S, Ozaki M, Horiguchi Y, et al. Atypical pityriasis rosea. Dermatologica 1985; 171: 4747. Cairns RJ. Pityriasis rosea: some clinical variants. Trans St John's Hosp Dermatol Soc 1951; 30: 4350. Sterling JC, Kurtz JB. Viral infections. In: Champion RH, Burton JL, Burns DA, Breathnach SM, eds. Textbook of Dermatology 6th edn. Oxford: Blackwell Science Publications, 1998: 9951095. Del Campo DV, Barsky S, Tisocco L et al. Pityriasis rosea unilateralis. Int J Dermatol 1983; 22: 3123.

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