10/16/2015

PityriasisRosea:Background,Pathophysiology,Etiology

PityriasisRosea
Author:RobertASchwartz,MD,MPHChiefEditor:DirkMElston,MDmore...
Updated:May06,2015

Background
Pityriasisrosea(PR)isabenignrashfirstdescribedbyGilbertin1860thename
meansfinepinkscale.Itisacommonskindisorderobservedinotherwisehealthy
people,mostfrequentlychildrenandyoungadults.Othertypesofsimilarskin
eruptionsincludelichenplanus,psoriasis,andpityriasisrubrapilaris.
PRmanifestsasanacute,selflimiting,papulosquamouseruptionwithadurationof
68weeks.Itevolvesrapidly,usuallybeginningwithpatchthatheraldstheeruption,
thesocalledheraldpatch(seetheimagebelow).Itmaysometimesoccurin
atypicalvariantsormaymimicotherskindisorders,suchastineacorporisand
secondarysyphilis. [1,2,3]Guidelinesfordiagnosingsyphilis(anddistinguishingthe
roseolafrompityriasisrosea)havebeenestablished. [4]Asarule,PRrequiresonly
symptomatictreatment.

Heraldpatch.ImagecourtesyofDrexelDepartmentofDermatologyslidecollection.

See15RashesYouNeedtoKnow:CommonDermatologicDiagnoses,aCritical
Imagesslideshow,tohelpidentifyandtreatvariousrashes.

Pathophysiology
PRhasoftenbeenconsideredtobeaviralexanthem,aviewsupportedbythe
conditionsseasonaloccurrence,itsclinicalcourse,thepossibilityofepidemic
occurrence,thepresenceofoccasionalprodromalsymptoms,andthelowrateof
recurrence(seeEpidemiologyandPresentation).
PRhasbeenlinkedtouppertractrespiratoryinfections.Anincreasedincidenceis
reportedamonggroupswithclosephysicalcontact(eg,families,students,and
militarypersonnel),thoughtheconditiondoesnotappeartobehighlycontagious.
TheincidenceofPRamongdermatologistsis34timesthatamongother
physicians.
AhigherincidenceofPRisalsonotedamongpatientswithdecreasedimmunity
(eg,pregnantwomenandbonemarrowtransplantrecipients).Additionally,
ampicillinincreasesthedistributionoftheeruption,aneffectbearingastriking
resemblancetothedrugseffectontherashofinfectiousmononucleosis.
Someimmunologicdataalsosuggestaviraletiology. [5]Alackofnaturalkiller(NK)
cellandBcellactivityinPRlesionshasbeennoted,suggestingapredominantlyT
cellmediatedimmunityinthedevelopmentofthecondition.Increasedamountsof
CD4TcellsandLangerhanscellsarepresentinthedermis,possiblyreflectingviral
antigenprocessingandpresentation.AntiimmunoglobulinM(IgM)tokeratinocytes
hasbeenfoundinpatientswithPRthisfindingmaybeassociatedwiththe
exanthemphaseofthepresumedviralinfection.
Theprimaryplaqueisseenontheskinin5090%ofcasesaweekormorebefore
theonsetoftheeruptionofsmallerlesions.Thissecondaryeruptionoccurs221
dayslaterincropsfollowingthelinesofcleavageoftheskin.Ontheback,this
eruptionproducesaChristmastreepattern(seePresentation).
Atopy,seborrheicdermatitis,andacnevulgarisaremorecommoninpatientswith
PRthanincontrolsubjects.PRduringpregnancymayforeshadowpremature
deliveryandfetaldemise,especiallywhenitdevelopswithinthefirst15weeksof
gestation. [6]
RecurrencesofPRaregenerallyregardedasrareandarethoughtbysometo

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indicatealastingimmunitywhentheydooccur.

Etiology
Infectiousagents
AninfectiousetiologyforPRhasbeensoughtformanyyears.Ithasbeen
suggestedthattheconditionisprecipitatedbyaviralagent.Accordingly,anumber
ofviruseshavebeenstudiedwithaviewtodeterminingwhethertheyarelinkedto
PR.
PicornaviruslikeparticleshavebeenseeninthetissueofAfricangreenmonkeys
inoculatedfromhumanpityriasisrosealesions.Afollowupstudyfailedtofind
picornavirusRNAinpatientswithpityriasisrosea.Serologyandpolymerasechain
reaction(PCR)assayforviralDNAhavebeennegativeforEpsteinBarrvirus
(EBV),parvovirusB19,cytomegalovirus(CMV),humanherpesvirus(HHV)8, [7]
HHV1,andHHV2inpatientsdiagnosedwithPR.
SomeinitialreportsusingPCRanalysissuggestedaroleforhumanherpesvirus
(HHV)7andHHV6,butsubsequentstudieshavenotbeenconfirmatory. [8,9,10,7,
11,12,13,14,15,16,17,18,19,20]ThatHHV7isfrequentlyfoundinhealthy
individualscastsfurtherdoubtonitsproposedetiologicrole. [19]Theinfluenzavirus
H1N1hasalsobeenproposedasapossiblecausativepathogen. [21]
Someinvestigatorshavesuggestedthatafungalinfectionisamorelikelycauseof
PRthanaviralinfectionis.However,nofungushasbeenisolatedasadefinite
causalagent.Nobacterialpathogen,suchasMycoplasma,hasbeenfoundtobe
causativeeither.Thusfar,thesearchforaninfectiouscauseofPRhasbeen
unsuccessful.

Drugs
PRlikeeruptionscanalsooccurinassociationwithmanydrugs(eg,acetylsalicylic
acid,barbiturates,bismuth,captopril,clonidine,gold,imatinib,isotretinoin,
ketotifen,levamisole,metronidazole,omeprazole,Dpenicillamine,andterbinafine),
aswellascertainvaccines(eg,bacilleCalmetteGurin[BCG],humanpapilloma
virus,anddiphtheria). [2,22,23]
Antitumornecrosisfactor(TNF)agentssuchasadalimumabandetanercept
havealsobeenimplicated. [24,25]PRlikedrugeruptionshavebeenreportedtobe
relatedtouseofrituximab, [26]nortriptyline, [27]andclozapine. [28]
PRlikedrugeruptionsmaybedifficulttodistinguishfromnondruginducedcases.
DruginducedPRoftenlastslongerthannondruginducedpityriasisrosea.Lesions
arealsothoughttobeincreasedinindividualswithhighstresslevels.

Epidemiology
UnitedStatesstatistics
PRisverycommoninthegeneralpopulation,andmostcasesoccurinthespring
andwinterintemperateclimates.TheestimatedfrequencyofPRintheUnited
Statesisapproximately0.13%infemalesand0.14%inmales,witha0.33%
prevalenceatdermatologiccenters.

Internationalstatistics
Worldwide,pityriasisroseahasbeenestimatedtoaccountfor2%ofdermatologic
outpatientvisits.Thediseaseismorecommoninthespringandthefallin
temperateclimatezones.However,itmaybemorefrequentinthesummerinsome
otherregions.Itfavorsthehot,dryseasoninAustralia,India,andMalaysia.
AnincreaseintheprevalenceofpityriasisroseahasbeenreportedinUganda.No
changeintheprevalenceofpityriasisroseahasbeenreportedinSweden.Ithas
alsobeenseenintheUnitedKingdom,Nigeria,Sudan,Brazil,Lagos,Singapore,
Turkey,Kuwait,andHongKong.

Age,sex,andracerelateddemographics
PRisobservedinpeopleofallagegroups,thoughitismostcommoninpersons
aged1035yearsandrareininfantsandelderlypersons.Theyoungestpatient
reportedintheliteraturewasaged3months,andtheoldestwasaged85years.
PRoccursslightlymoreofteninfemalesthaninmales. [29]Thefemaletomaleratio
isreportedas2:1or3:2intheUnitedStates.
Noracialpredominanceisreported.MoreintenselypigmentedAfricanstendtohave
morewidespreaddisease.ThelesionsinAfricanAmericansmaylackarosecolor,
andtheymayappeardarkerthanthesurroundingskin.

Prognosis
PRisaselflimiting,generallybenigndisorderforwhichtheprognosisisexcellent
andtherecurrencerateislow(approximately2%).Becauseitisnotconsidereda

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transmissibledisease,patientsdonotrequireisolationandmayreturntoworkor
school.PRusuallylastsfor68weeks,butcanlastaslongas36months.
ProtractedcasesofsevereeczematousordruginducedPRarereferredtoas
pityriasisroseaperstans.
Themainmorbidityisfrompigmentarychanges,whichmaydevelopaslesions
heal,especiallyinblackpeople.Bothpostinflammatoryhyperpigmentationand
hypopigmentationmayoccur.However,lesionsdonotresultinscars.Bacterial
superinfectionsmayoccur,butarerare.Inpregnantwomen,PRissometimes
associatedwithmiscarriageifoccurringwithinthefirst15weeksofpregnancy,
prematuredelivery,orneonatalhypotoniaandhyporeactivity. [6,30]

PatientEducation
Patientsshouldbeinstructedtoavoidcontactwithirritants.Inaddition,patientsand
familiesshouldbeeducatedregardingthebenignandnoninfectiousnatureofthe
rashandtherelativelylengthycourseofthedisease.Typically,thesecondaryrash
developsover2weeks,persistsforanother2weeks,andthenfadesoveranother2
weeks,withouttheneedfortreatment,thoughsomelesionshavepersistedforas
longas34months.
Forpatienteducationresources,seetheSkinConditions&BeautyCenter,aswell
asEczema(AtopicDermatitis).
ClinicalPresentation

ContributorInformationandDisclosures
Author
RobertASchwartz,MD,MPHProfessorandHeadofDermatology,ProfessorofPathology,Pediatrics,
Medicine,andPreventiveMedicineandCommunityHealth,RutgersNewJerseyMedicalSchoolVisiting
Professor,RutgersUniversitySchoolofPublicAffairsandAdministration
RobertASchwartz,MD,MPHisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,NewYork
AcademyofMedicine,AmericanAcademyofDermatology,AmericanCollegeofPhysicians,SigmaXi
Disclosure:Nothingtodisclose.
Coauthor(s)
RichardLichenstein,MDProfessor,PediatricEmergencyDepartment,UniversityofMarylandSchoolof
Medicine
RichardLichenstein,MDisamemberofthefollowingmedicalsocieties:AmericanMedicalAssociation,
AmericanAcademyofPediatrics
Disclosure:Nothingtodisclose.
CamilaKJanniger,MDClinicalProfessorofDermatology,ClinicalAssociateProfessorofPediatrics,Chiefof
PediatricDermatology,RutgersNewJerseyMedicalSchool
CamilaKJanniger,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology
Disclosure:Nothingtodisclose.
ChiefEditor
DirkMElston,MDProfessorandChairman,DepartmentofDermatologyandDermatologicSurgery,Medical
UniversityofSouthCarolinaCollegeofMedicine
DirkMElston,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology
Disclosure:Nothingtodisclose.
Acknowledgements
RobertAAllen,MDStaffPhysician,DepartmentofDermatology,DrexelUniversityCollegeofMedicine
HahnemannHospital
RobertAAllen,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyof
Dermatology,andAmericanMedicalAssociation
Disclosure:Nothingtodisclose.
JerryBalentine,DOProfessorofEmergencyMedicine,NewYorkCollegeofOsteopathicMedicineExecutive
VicePresident,ChiefMedicalOfficer,AttendingPhysicianinDepartmentofEmergencyMedicine,StBarnabas
Hospital
JerryBalentine,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians,
AmericanCollegeofOsteopathicEmergencyPhysicians,AmericanCollegeofPhysicianExecutives,American
OsteopathicAssociation,andNewYorkAcademyofMedicine
Disclosure:Nothingtodisclose.
KevinPConnelly,DOClinicalAssistantProfessor,DepartmentofPediatrics,DivisionofGeneralPediatricsand
EmergencyCare,VirginiaCommonwealthUniversitySchoolofMedicineMedicalDirector,PawsforHealthPet
VisitationProgramoftheRichmondSPCAPediatricEmergencyPhysician,EmergencyConsultantsInc,
ChippenhamMedicalCenter
KevinPConnelly,DOisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,
AmericanCollegeofOsteopathicPediatricians,andAmericanOsteopathicAssociation

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PityriasisRosea:Background,Pathophysiology,Etiology

Disclosure:Nothingtodisclose.
BurkeACunha,MDProfessorofMedicine,StateUniversityofNewYorkSchoolofMedicineatStonyBrook
Chief,InfectiousDiseaseDivision,WinthropUniversityHospital
BurkeACunha,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofChestPhysicians,
AmericanCollegeofPhysicians,andInfectiousDiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
PamelaLDyne,MDProfessorofClinicalMedicine/EmergencyMedicine,UniversityofCalifornia,LosAngeles,
DavidGeffenSchoolofMedicineAttendingPhysician,DepartmentofEmergencyMedicine,OliveViewUCLA
MedicalCenter
PamelaLDyne,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
MarkWFourre,MDProgramDirector,DepartmentofEmergencyMedicine,MaineMedicalCenterAssociate
ClinicalProfessor,DepartmentofSurgery,UniversityofVermontSchoolofMedicine
Disclosure:Nothingtodisclose.
RajendraKapila,MD,MBBSProfessorofMedicine,DepartmentofMedicine,UniversityofMedicineand
DentistryofNewJerseyNewJerseyMedicalSchool
RajendraKapila,MD,MBBSisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,
AmericanMedicalAssociation,InfectiousDiseasesSocietyofAmerica,andInfectiousDiseasesSocietyofNew
Jersey
Disclosure:Nothingtodisclose.
ThomasMKerkering,MDChiefofInfectiousDiseases,VirginiaTechCarilionSchoolofMedicine
ThomasMKerkering,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
CollegeofPhysicians,AmericanPublicHealthAssociation,AmericanSocietyforMicrobiology,AmericanSociety
ofTropicalMedicineandHygiene,InfectiousDiseasesSocietyofAmerica,MedicalSocietyofVirginia,and
WildernessMedicalSociety
Disclosure:Nothingtodisclose.
MarkGLebwohl,MDChairman,DepartmentofDermatology,MountSinaiSchoolofMedicine
MarkGLebwohl,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology
Disclosure:Amgen/PfizerHonorariaConsultingGlaxoSmithKlineNoneInvestigatorNovartisHonoraria
ConsultingRanbaxyNoneConsultingPfizerNoneConsultingBioLineRX,Ltd.HonorariaConsultingCelgene
CorporationConsultingClinuvelNoneInvestigatorEliLilly&Co.HonorariaConsultingGenentechNone
Consulting
DanielRLucey,MD,MPHChief,FellowshipProgramDirector,DepartmentofInternalMedicine,Divisionof
InfectiousDiseases,WashingtonHospitalCenterProfessor,DepartmentofInternalMedicine,Uniformed
ServicesUniversityoftheHealthSciences
DanielRLucey,MD,MPHisamemberofthefollowingmedicalsocieties:AlphaOmegaAlphaandAmerican
CollegeofPhysicians
Disclosure:Nothingtodisclose.
AmalMattu,MD,FACEP,FAAEMProfessorandViceChair,DepartmentofEmergencyMedicine,Universityof
MarylandSchoolofMedicine
AmalMattu,MD,FACEP,FAAEMisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine,AmericanCollegeofEmergencyPhysicians,andSocietyforAcademicEmergency
Medicine
Disclosure:Nothingtodisclose.
JeffreyMeffert,MDAssistantClinicalProfessorofDermatology,UniversityofTexasSchoolofMedicineatSan
Antonio
JeffreyMeffert,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AmericanMedicalAssociation,AssociationofMilitaryDermatologists,andTexasDermatologicalSociety
Disclosure:Nothingtodisclose.
GiuseppeMicali,MDHead,Professor,DepartmentofDermatology,UniversityofCataniaSchoolofMedicine,
Italy
GiuseppeMicali,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology
Disclosure:Nothingtodisclose.
MariaRNasca,MD,PhDAssistantProfessor,DepartmentofDermatology,UniversityofCataniaSchoolof
Medicine,Italy
Disclosure:Nothingtodisclose.
RobertLRogers,MDStaffPhysician,DepartmentsofInternalMedicineandSurgery,DivisionofEmergency
Medicine,UniversityofMaryland
RobertLRogers,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency

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Medicine,AmericanCollegeofEmergencyPhysicians,andAmericanCollegeofPhysiciansAmericanSocietyof
InternalMedicine
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
RichardPVinson,MDAssistantClinicalProfessor,DepartmentofDermatology,TexasTechUniversityHealth
SciencesCenter,PaulLFosterSchoolofMedicineConsultingStaff,MountainViewDermatology,PA
RichardPVinson,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AssociationofMilitaryDermatologists,TexasDermatologicalSociety,andTexasMedicalAssociation
Disclosure:Nothingtodisclose.
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.

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