Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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Anna E. Muncaster
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Pityriasis rosea is a common, self-limiting, papulosquamous disorder affecting the trunk and limbs, usually seen in the 10–35-year age group. It has a classical clinical appearance, is associated with little or no constitutional upset, but can have associated itching. Secondary syphilis and drug eruptions are diagnostic pitfalls.
Pityriasis rosea usually resolves spontaneously after approximately 6 weeks and, if asymptomatic, reassurance is all that is required. An infectious etiology, most likely viral, is strongly favored, and although several studies have suggested an association with human herpes viruses 6 and 7, an equal number have failed to show a causal link. Studies have also looked at but failed to prove an etiological role for human herpes virus 8 and there have been two case reports of a pirtyriasis rosea-like eruption occurring in patients with H1N1 influenza A virus. There have been case reports of pityriasis rosea-like eruptions after many drugs including captopril, ketotifen, and more recently adalimumab and etanercept. However, there is no evidence that true pityriasis rosea is drug induced.
For patients who do require treatment, topical corticosteroids may be helpful, although evidence for this is purely anecdotal. Emollients and oral antihistamines have also been mentioned as being of some benefit as has ultraviolet light.
Studies have shown that UVB can reduce itch and disease severity, and a study using low dose UVA1 phototherapy showed significant reduction in the severity and extent of the disease but little impact on pruritus.
For patients with more extensive severe eruptions oral prednisolone can be tried; however, this should be used with caution, as there are also reports that oral steroids can exacerbate the condition.
A trial of oral erythromycin produced complete clearance after 2 weeks in the majority of patients. The best results with all the treatments above have been obtained when treatment is started within the first 2 weeks of the appearance of the eruption. Later studies of erythromycin in pityriasis rosea have shown conflicting results. There has been one case report of vesicular pityriasis rosea responding to 10 days of oral erythromycin at a dose of 250 mg four times a day, but two further trials, one using oral erythromycin and one using azithromycin, have failed to show any benefit.
Oral acyclovir has been used in pityriasis rosea at both high and low dose. One study compared high dose acyclovir with erythromycin and found acyclovir to be more effective. There has also been one case report of pityriasis rosea clearing following oral acyclovir and one showing clearance with dapsone.
Consider mycological examination
Consider syphilis serology
Parsons JM. J Am Acad Dermatol 1986; 15: 159–67.
The author relates his own experience of using topical corticosteroids, emollients, and oral antihistamines in the treatment of pityriasis rosea. He claims all three treatments to have been of some benefit.
A comprehensive review article.
Chuh AAT, Dofitas BL, Comisel CG, Reveiz L, Sharma V, Garner SE, et al. Cochrane Database Syst Rev 2007, Issue 2: CD005068.
The authors found that good evidence for the efficacy of most treatments for pityriasis rosea was lacking, and suggest more research is needed to fully evaluate erythromycin and other treatments.
Arndt KA, Paul BS, Stern RS, Parrish JA. Arch Dermatol 1983; 119: 381–2.
Twenty patients with symptomatic and extensive pityriasis rosea were treated with UVB phototherapy in a bilateral comparison study using the left side of their body as a control. Five consecutive daily erythemogenic exposures resulted in both clinical and subjective improvement in disease severity and pruritus in 50% of the patients.
Leenitaphong V, Jiamton S. J Am Acad Dermatol 1995; 33: 996–9.
Seventeen patients with extensive pityriasis rosea were treated unilaterally with 10 daily erythemogenic doses of UVB in a bilateral comparison study using 1 J of UVA to the other half of the body as a control. This resulted in a significant reduction in disease severity in 15 out of the 17 patients, but no difference in pruritus.
Valkova S, Trashlieva M, Christova PJ. Eur Acad Dermatol Venereol 2004; 18: 111–12.
In a letter to the editor the authors describe a study of 101 patients (including children) who received broadband UVB, either to half the body (24 patients) using UVA on the other half as a control, or to the whole body (77 patients). They showed clearance of the disease in both groups, with those patients having more severe disease requiring significantly more treatments.
Lim SH, Kim SM, Oh BH, Ko JH, Lee YW, Choe YB, Ahn KJ. Ann Dermatol 2009; 21: 230–6.
Fifteen patients were treated with UVA1 starting at doses of 10–20 J/cm2 using 20% increments up to 30 J/cm2 given two to three times a week until complete clearance was achieved. Twelve out of the 15 patients showed complete clearance and the other three showed significant improvement with less than 25% of lesions persisting. The mean number of treatments was 6.5.
Tay YK, Goh CL. Ann Acad Med Singapore 1999; 28: 829–31.
In this retrospective case note study of 368 patients, 20 with extensive pruritic disease were treated with short reducing courses of prednisolone over 2 to 3 weeks, with improvement.
Leonforte JF. Dermatologica 1981; 163: 480–1.
This was a case series of 18 patients, all of whom had received oral corticosteroids for pityriasis rosea. Five were observed while they received their corticosteroid course, and the other 13 were seen after completing their course. In those patients who did report an exacerbation this was worse the higher the dose of corticosteroid received, the longer the course of treatment, and in those who were treated earlier on in their disease.
Sharma PK, Yadav TP, Gautam RK, Taneja N, Satyanarayana L. J Am Acad Dermatol 2000; 42: 241–4.
Ninety patients, including children, were randomly assigned to a treatment or a control group. Those in the treatment group received 2 weeks of oral erythromycin 250 mg four times a day for adults, or 25–40 mg/kg in four divided doses for children. Of patients in the treatment group, 73% had a complete response, compared to none of the controls.
Miranda SB, Lupi O, Lucas E. J Eur Acad Dermatol Venereol 2004; 18: 622–5.
A case report of a 32-year-old woman with a 6-week history of biopsy-proven vesicular pityriasis rosea who achieved almost complete clearance after 10 days of oral erythromycin at a dose of 250 mg four times a day. No recurrence was observed during a four-month follow-up period.
Eshani A, Esmaily N, Noormohammadpour P, Toosi S, Hosseinpour A, Hosseini M, Sayanjali S. Indian J Dermatol 2010; 55: 246–8.
In this randomized controlled trial 15 patients with pityriasis rosea were treated with erythromycin 400 mg four times a day for 10 days and the other 15 with acyclovir 800 mg, five times a day for 10 days. When evaluated at 8 weeks, 13 out of the 15 patients treated with acyclovir had complete responded compared with only six of the patients on erythromycin which was statistically significant. No patients achieved complete response within the first 2 weeks.
Drago F, Veccio F, Rebora A. J Am Acad Dermatol 2006; 54: 82–5.
In this placebo-controlled trial, 87 consecutive patients were treated with either oral acyclovir (800 mg five times daily) or placebo for 1 week. At 14 days 78.6% of treated patients achieved complete regression, compared to only 4.4% of the placebo group.
Rassai S, Feily A, Sina N, Abtahian SA. J Eur Acad Dermatol Venereal 2011; 25: 24–6.
Sixty-four patients with pityriasis rosea were enrolled in this randomized, comparative, investigator blinded trial. Patients were randomized to receive acyclovir 400 mg five times a day for 1 week or control. Fifty-four patients completed the study. At the 4-week follow-up 92.8% of patients in the acyclovir group had significant reduction of erythema compared with 61.5% of patients in the control group.
Castanedo-Cazares JP, Lepe V, Moncada B. Photodermatol Photoimmunol Photomed 2004; 20: 110.
In a letter to the editor the authors relate the successful treatment of a case of pityriasis rosea with a short course of oral acyclovir. Dosage and length of treatment were not stated.
Anderson CR. Lancet 1971; 2: 493.
A case report of a 55-year-old man with histologically proven pityriasis rosea, resistant to oral prednisolone, responding to dapsone 100 mg twice daily for one month.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Topical corticosteroids
Emollients
Oral antihistamines
UVB
UVA1
Oral prednisolone
Oral erythromycin
Oral acyclovir
Dapsone
