Pityriasis Rosea Pityriasis rosea is an acute self-limiting papulosquamous disorder. It is characterized by a herald patch followed by scaly oval patches on the trunk and proximal extremities in a “Christmas tree” appearance. Pityriasis rosea means rose- colored scale. Pityriasis rosea is also known as pityriasis circinata, roseola annulata, and herpes tonsurans maculosus. The skin eruption usually lasts 6 to 8 weeks and begins with a herald patch (Litchman et al., 2022). The exact cause of pityriasis rosea is unknown, but features like seasonal variation and community clustering suggest it is infectious. Infections like viruses, bacteria, spirochetes, and noninfective causes like atopy and autoimmunity are known causes. Upper respiratory tract infections that precede pityriasis rosea suggest a role of Streptococcus. Eruptions have also been seen with drugs like gold, captopril, barbiturates, D-penicillamine, and clonidine. In temperate regions, it is more common in the winter season, while in tropical areas, some seasonal variation is noted (Litchman et al., 2022). Pityriasis rosea is clinically characterized by a herald patch or mother patch followed by scaly oval plaques on the trunk and proximal extremities along the Langer’s lines of cleavage, giving a characteristic Christmas-tree appearance. Collarette scaling is common. A prodrome of a sore throat, gastrointestinal disturbance, fever, and arthralgia usually precedes the eruption. Pruritus is severe in 25% of cases. Herald patch is seen in 50% to 90% of cases and is located on the trunk, followed by the neck or proximal extremity (Litchman et al., 2022). A generalized eruption occurs, in which numerous lesions develop in crops for 1 to 2 weeks after the onset of the herald patch. The eruptions are symmetric and most commonly involve the thorax, back, abdomen, and adjoining areas of the neck and extremities. These secondary lesions occur as macules and papules that are elliptical or ovular in shape. Fine scaling and central wrinkling are seen with a cigarette paper aspect. Figure 4. Pityriasis Rosea
Pityriasis rosea is a self-limiting, exanthematous disease. Most patients need emollients, antihistamines, and topical steroids. Macrolides and acyclovir lead to faster resolution of lesions and help to relieve pruritus. Narrowband ultraviolet B therapy is also used. It alters the immune response in the skin (Litchman et al., 2022). Differentials Diagnosis The age of the patient often assists in narrowing the differential diagnosis. Exanthems associated with a variety of viral illnesses are classically seen in the pediatric age group. The constellation of symptoms and a characteristic rash often allow for a clinically based diagnosis (Lopez & Sanders, 2021). The NP needs to have a keen eye and ask appropriate questions to differentiate from systemic urgent or emergent presentations. Some differentials to consider are the following. ● Measles (rubeola) : Measles is associated with a blanching erythematous “brick-red” maculopapular rash beginning in the head and neck area and spreading centrifugally to the trunk and extremities. Patients also typically have a fever, cough, coryza, conjunctivitis, and Koplik’s spots. ● Chickenpox (varicella) : Chickenpox is characterized by classic vesicular lesions on an erythematous base that appear in crops and are present in different stages from papules through vesicles to crusting. ● Rubella : Rubella has a rash resembling measles; however, the patient does not appear sick. Prominent postauricular, posterior cervical, and/or suboccipital adenopathy may also assists in the diagnosis. Forchheimer spots, or punctate soft palate macules, can be a helpful clue. ● Erythema infectiosum (fifth disease) : Erythema infectiosum is due to human parvovirus B19. Children, unlike adults, often develop a characteristic rash with a “slapped cheeks” appearance followed by an erythematous maculopapular rash that spreads from arms to trunk and a rash in a reticular pattern. ● Roseola infantum (exanthem subitum; sixth disease) : Roseola infantum, an illness of infants most commonly caused by human herpesvirus 6, is characterized by high fever for 3 to 4 days, followed by seizures and a generalized maculopapular rash that starts on the neck and trunk and spreads to the face and extremities.
From Aceofhearts1968. (2008). Pityriasis rosea-3 https://commons.wiki - media.org/wiki/File:Pityriasis_rosea-3.jpg. In public domain. Viral exanthem Fever with an accompanying skin eruption is a common patient presentation in primary care offices and urgent care settings. Skin manifestations may provide the only early clue to an underlying infection, may be the hallmark of contagious disease, and/or may be an early sign of a life-threatening infection or serious noninfectious disorder (Lopez & Sanders, 2021). The differential diagnosis of fever and rash is extremely broad. However, this symptom complex allows the diligent clinician
to establish a probable etiology through a careful history and physical examination. The term exanthem is derived from the Greek exanthema , which translates to “breaking out” and is used to describe cutaneous eruptions that arise abruptly and on several skin surfaces at once. During spring and winter, numerous viruses can cause a nonspecific skin eruption. Parainfluenza, respiratory syncytial, rhinovirus, and type A and B influenza viruses can cause fever
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