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Chapter 11: Pityriasis Rosea

Reinie Thomas; Grace Hile; Johann Gudjonsson

PITYRIASIS ROSEA

Therapeutic Approach

Pityriasis rosea (PR) is a benign, self-limiting skin disease characterized by the sudden appearance of multiple, discrete patches of skin in a distinctive pattern on trunk and limbs. A solitary larger lesion or “herald patch” usually precedes the widespread rash with lesions oriented along Langer’s cleavage lines in a “Christmas tree pattern.” The disease duration is typically 2 to 12 weeks but may last up to 7 months. Less common clinical variants include inverse, vesicular, purpuric, and pustular. A viral etiology has been postulated with attention focused on human herpesvirus-7 (HHV-7) and less so HHV-6, but this remains unproven. Patient education and reassurance is often a satisfactory treatment plan. However, several therapeutics (see treatment table) can be considered in severe or recurrent disease. See Table 11-1.

Table 11-1Pityriasis Rosea Treatment Table
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Table 11-1 Pityriasis Rosea Treatment Table
MEDICATION NAME MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Corticosteroids Anti-inflammatory Various formulations, low-mid strength BID 2-4 wk Skin atrophy, telangiectasia, striae, purpura None None
Systemic Therapy
Acyclovir Antiviral 400 mg 5×/d; 800 mg 5×/d Increased sleep, headache, nausea, vomiting, dysgeusia None IA2-4
Erythromycin Anti-inflammatory, antimicrobial

1 g in 4 equally divided doses for 2 wk in adults; 25-40 mg/kg in 4 doses in children;

400 mg QID for 10 d

 Mild nausea None IIA5-6
Azithromycin Anti-inflammatory, antimicrobial 12 mg/kg QD for 5 d Mild abdominal pain not necessitating treatment None IB7
Clarithromycin Anti-inflammatory, antimicrobial 500 mg BID for 1 wk in adults; 250 mg BID for 1 wk in children 10-12 yo None None IB8
Prednisolone Anti-inflammatory 20 mg/d for 5 d, 15 mg/d for 5 d, 10 mg/d for 5 d—total tx 15 d Mild gastric hyperacidity, transient anxiety and palpitations, erythema, thermalgia, itch, diarrhea None IB9
Procedural Therapy
UVB phototherapy Anti-inflammatory 311-313 nm, dose varies based on MED or skin type Hyper-/hypopigmentation, burning None IA/IB12-13
UVA phototherapy Largely unknown; 300-400 nm, 2-3 times per week until partial improvement Erythema, pruritus, burning sensation and polymorphous light eruption (PMLE) None III14

Levels of evidence are based on the Journal of the American Academy of Dermatology guidelines: level IA evidence includes evidence from meta-analysis of randomized controlled trials; level IB evidence includes evidence from ≥1 randomized controlled trial; level IIA evidence includes evidence from ≥1 controlled study without randomization; level IIB evidence includes evidence from ≥1 other type of experimental study; level III evidence includes evidence from nonexperimental descriptive studies, including comparative studies, correlation studies, and case control studies; and level IV evidence includes evidence from expert committee reports or opinions or clinical experience of respected authorities, or both.

REFERENCES

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Goldstein  A, Goldstein  B. Pityriasis rosea. In: UpToDate, Dellavalle  R (Ed.), Levy  M (Ed.), Ofori ...

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