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2/24/2017 PityriasisRosea:Background,Pathophysiology,Etiology

PityriasisRosea
Updated:Jun02,2016
Author:RobertASchwartz,MD,MPHChiefEditor:DirkMElston,MDmore...

OVERVIEW

Background
Pityriasisrosea(PR)isabenignrashfirstdescribedbyGilbertin1860thenamemeansfinepink
scale.Itisacommonskindisorderobservedinotherwisehealthypeople,mostfrequentlychildren
andyoungadults.Othertypesofsimilarskineruptionsincludelichenplanus,psoriasis,and
pityriasisrubrapilaris.

PRmanifestsasanacute,selflimiting,papulosquamouseruptionwithadurationof68weeks.It
evolvesrapidly,usuallybeginningwithpatchthatheraldstheeruption,thesocalledheraldpatch
(seetheimagebelow).Itmaysometimesoccurinatypicalvariantsormaymimicotherskin
disorders,suchastineacorporisandsecondarysyphilis.[1,2,3]Guidelinesfordiagnosingsyphilis
(anddistinguishingtheroseolafrompityriasisrosea)havebeenestablished.[4]Asarule,PR
requiresonlysymptomatictreatment.

Heraldpatch.ImagecourtesyofDrexelDepartmentofDermatologyslidecollection.
ViewMediaGallery

See15RashesYouNeedtoKnow:CommonDermatologicDiagnoses,aCriticalImages
slideshow,tohelpidentifyandtreatvariousrashes.

Pathophysiology
PRhasoftenbeenconsideredtobeaviralexanthem,aviewsupportedbytheconditions
seasonaloccurrence,itsclinicalcourse,thepossibilityofepidemicoccurrence,thepresenceof
occasionalprodromalsymptoms,andthelowrateofrecurrence.Oxidativestressmayplayarole
too.[5]

PRhasbeenlinkedtouppertractrespiratoryinfections.Anincreasedincidenceisreportedamong
groupswithclosephysicalcontact(eg,families,students,andmilitarypersonnel),thoughthe

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2/24/2017 PityriasisRosea:Background,Pathophysiology,Etiology

conditiondoesnotappeartobehighlycontagious.TheincidenceofPRamongdermatologistsis
34timesthatamongotherphysicians.

AhigherincidenceofPRisalsonotedamongpatientswithdecreasedimmunity(eg,pregnant
womenandbonemarrowtransplantrecipients).Additionally,ampicillinincreasesthedistributionof
theeruption,aneffectbearingastrikingresemblancetothedrugseffectontherashofinfectious
mononucleosis.

Someimmunologicdataalsosuggestaviraletiology.[6]Alackofnaturalkiller(NK)cellandBcell
activityinPRlesionshasbeennoted,suggestingapredominantlyTcellmediatedimmunityinthe
developmentofthecondition.IncreasedamountsofCD4TcellsandLangerhanscellsarepresent
inthedermis,possiblyreflectingviralantigenprocessingandpresentation.AntiimmunoglobulinM
(IgM)tokeratinocyteshasbeenfoundinpatientswithPRthisfindingmaybeassociatedwiththe
exanthemphaseofthepresumedviralinfection.

Theprimaryplaqueisseenontheskinin5090%ofcasesaweekormorebeforetheonsetofthe
eruptionofsmallerlesions.Thissecondaryeruptionoccurs221dayslaterincropsfollowingthe
linesofcleavageoftheskin.Ontheback,thiseruptionproducesaChristmastreepattern(see
Presentation).

Atopy,seborrheicdermatitis,andacnevulgarisaremorecommoninpatientswithPRthanin
controlsubjects.PRduringpregnancymayforeshadowprematuredeliveryandfetaldemise,
especiallywhenitdevelopswithinthefirst15weeksofgestation.[7]

RecurrencesofPRaregenerallyregardedasrareandarethoughtbysometoindicatealasting
immunitywhentheydooccur.

Aclassificationbasedonpathogeneticmechanismsassociatedwththedifferentpresentationsof
PRhasbeenproposed.[8]

Etiology
Infectiousagents
AninfectiousetiologyforPRhasbeensoughtformanyyears.Ithasbeensuggestedthatthe
conditionisprecipitatedbyaviralagent.Accordingly,anumberofviruseshavebeenstudiedwith
aviewtodeterminingwhethertheyarelinkedtoPR.

PicornaviruslikeparticleshavebeenseeninthetissueofAfricangreenmonkeysinoculatedfrom
humanpityriasisrosealesions.AfollowupstudyfailedtofindpicornavirusRNAinpatientswith
pityriasisrosea.Serologyandpolymerasechainreaction(PCR)assayforviralDNAhavebeen
negativeforEpsteinBarrvirus(EBV),parvovirusB19,cytomegalovirus(CMV),humanherpesvirus
(HHV)8,[9]HHV1,andHHV2inpatientsdiagnosedwithPR.

SomeinitialreportsusingPCRanalysissuggestedaroleforhumanherpesvirus(HHV)7and
HHV6,butsubsequentstudieshavenotbeenconfirmatory.[10,11,12,9,13,14,15,16,17,18,19,20,
21,22] ThatHHV7isfrequentlyfoundinhealthyindividualscastsfurtherdoubtonitsproposed

etiologicrole.[21]TheinfluenzavirusH1N1hasalsobeenproposedasapossiblecausative
pathogen.[23]

SomeinvestigatorshavesuggestedthatafungalinfectionisamorelikelycauseofPRthanaviral
infectionis.However,nofungushasbeenisolatedasadefinitecausalagent.Nobacterial
pathogen,suchasMycoplasma,hasbeenfoundtobecausativeeither.Thusfar,thesearchforan
infectiouscauseofPRhasbeenunsuccessful.

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2/24/2017 PityriasisRosea:Background,Pathophysiology,Etiology

Drugs

PRlikeeruptionscanalsooccurinassociationwithmanydrugs(eg,acetylsalicylicacid,
barbiturates,bismuth,captopril,clonidine,gold,imatinib,isotretinoin,ketotifen,levamisole,
metronidazole,omeprazole,Dpenicillamine,andterbinafine),aswellascertainvaccines(eg,
bacilleCalmetteGurin[BCG],humanpapillomavirus,anddiphtheria).[2,24,25]

Antitumornecrosisfactor(TNF)agentssuchasadalimumabandetanercepthavealsobeen
implicated.[26,27]PRlikedrugeruptionshavebeenreportedtoberelatedtouseofrituximab,[28]
nortriptyline,[29]andclozapine.[30]

PRlikedrugeruptionsmaybedifficulttodistinguishfromnondruginducedcases.Druginduced
PRoftenlastslongerthannondruginducedpityriasisrosea.Lesionsarealsothoughttobe
increasedinindividualswithhighstresslevels.

Epidemiology
UnitedStatesstatistics

PRisverycommoninthegeneralpopulation,andmostcasesoccurinthespringandwinterin
temperateclimates.TheestimatedfrequencyofPRintheUnitedStatesisapproximately0.13%in
femalesand0.14%inmales,witha0.33%prevalenceatdermatologiccenters.

Internationalstatistics

Worldwide,pityriasisroseahasbeenestimatedtoaccountfor2%ofdermatologicoutpatientvisits.
Thediseaseismorecommoninthespringandthefallintemperateclimatezones.However,it
maybemorefrequentinthesummerinsomeotherregions.Itfavorsthehot,dryseasonin
Australia,India,andMalaysia.

AnincreaseintheprevalenceofpityriasisroseahasbeenreportedinUganda.Nochangeinthe
prevalenceofpityriasisroseahasbeenreportedinSweden.IthasalsobeenseenintheUnited
Kingdom,Nigeria,Sudan,Brazil,Lagos,Singapore,Turkey,Kuwait,andHongKong.

Age,sex,andracerelateddemographics

PRisobservedinpeopleofallagegroups,thoughitismostcommoninpersonsaged1035years
andrareininfantsandelderlypersons.Theyoungestpatientreportedintheliteraturewasaged3
months,andtheoldestwasaged85years.

PRoccursslightlymoreofteninfemalesthaninmales.[31]Thefemaletomaleratioisreportedas
2:1or3:2intheUnitedStates.

Noracialpredominanceisreported.MoreintenselypigmentedAfricanstendtohavemore
widespreaddisease.ThelesionsinAfricanAmericansmaylackarosecolor,andtheymayappear
darkerthanthesurroundingskin.

Prognosis
PRisaselflimiting,generallybenigndisorderforwhichtheprognosisisexcellentandthe
recurrencerateislow(approximately2%).Becauseitisnotconsideredatransmissibledisease,
patientsdonotrequireisolationandmayreturntoworkorschool.PRusuallylastsfor68weeks,
butcanlastaslongas36months.ProtractedcasesofsevereeczematousordruginducedPR
arereferredtoaspityriasisroseaperstans.

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2/24/2017 PityriasisRosea:Background,Pathophysiology,Etiology

Themainmorbidityisfrompigmentarychanges,whichmaydevelopaslesionsheal,especiallyin
blackpeople.Bothpostinflammatoryhyperpigmentationandhypopigmentationmayoccur.
However,lesionsdonotresultinscars.Bacterialsuperinfectionsmayoccur,butarerare.In
pregnantwomen,PRissometimesassociatedwithmiscarriageifoccurringwithinthefirst15
weeksofpregnancy,prematuredelivery,orneonatalhypotoniaandhyporeactivity.[7,32]

PatientEducation
Patientsshouldbeinstructedtoavoidcontactwithirritants.Inaddition,patientsandfamiliesshould
beeducatedregardingthebenignandnoninfectiousnatureoftherashandtherelativelylengthy
courseofthedisease.Typically,thesecondaryrashdevelopsover2weeks,persistsforanother2
weeks,andthenfadesoveranother2weeks,withouttheneedfortreatment,thoughsomelesions
havepersistedforaslongas34months.

Forpatienteducationresources,seetheSkinConditions&BeautyCenter,aswellasEczema
(AtopicDermatitis).

ClinicalPresentation

http://emedicine.medscape.com/article/1107532overview#showall 4/4

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