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Tuesday, February 01, 2011

Pityriasis rosea

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Scenario: Diagnosis of pityriasis rosea

This level contains the following sections:

  • Diagnosis
  • Differential diagnosis
  • Investigations
  • View full scenario
  • View full scenario no prescriptions

How do I diagnose pityriasis rosea?

  • Make a diagnosis of pityriasis rosea based on the appearance and distribution of skin lesions — see www.dermnet.com for images.
    • Appearance of individual lesions
      • Multiple, discrete, pink-red ('salmon-coloured') or fawn-coloured, flat or slightly raised.
      • Circular or oval, and typically 0.5–1 cm in diameter.
      • Usually slightly scaly — the classical appearance is of peripheral 'collarette' scaling (scaling confined to the edge of the lesion with central clearance).
    • Distribution of lesions
      • The rash is usually symmetrical.
      • Most lesions are on the trunk and proximal limbs, with few (usually less than 10%) distal to the mid-upper arm and mid-thigh.
      • On the trunk, lesions are along the ribs, forming a 'Christmas tree' pattern on the upper back and a V-shape on the upper chest, and distributed transversely across the lower abdomen and lower back (lesions follow skin cleavage lines).
  • A diagnosis of pityriasis rosea is more likely if:
    • A 'herald patch' appeared a few days or weeks before the generalized eruption.
      • This is usually 2–10 cm in diameter, oval, erythematous, and slightly raised, with the same 'collarette' of scale at the margin as seen in subsequent lesions.
      • It usually occurs on the trunk but can occur anywhere on the body.
      • A herald patch is not always present.
    • The lesions are not vesicular and predominantly not on palmar or plantar skin surfaces.
  • Other considerations when diagnosing pityriasis rosea include:
    • Atypical forms of pityriasis rosea occur — consider referring to a dermatologist.
    • Itch may or may not be present. Severity varies from mild to severe.
    • Some people may recall an upper respiratory tract infection prior to the rash. Systemic symptoms are absent during the generalized rash stage.
    • Most people with pityriasis rosea are 10–35 years of age, but the condition can affect people of any age.
  • Consider whether the rash may be caused by an alternative condition — see Differential diagnosis.
    • The condition most commonly and easily confused with pityriasis rosea is guttate psoriasis.
    • Less common but serious conditions mimicking pityriasis rosea are secondary syphilis and HIV seroconversion.
    • Reconsider a diagnosis of pityriasis rosea if the generalized rash persists for longer than 12 weeks.
      • The rash of pityriasis rosea usually lasts for 2–12 weeks, but can take up to 5 months to disappear.
Atypical forms
  • Atypical forms of pityriasis rosea include:
    • Inverse — the extremities are affected and the trunk is (relatively) spared.
    • Localized/asymmetrical.
    • Gigantean — lesions are larger and fewer.
    • Pustular, purpuric/haemorrhagic, vesicular, or urticarial (all rare).

Basis for recommendation

Diagnosis

Atypical forms

  • The information on atypical forms of pityriasis rosea is based on expert opinion from review articles [Stulberg and Wolfrey, 2004; Chuh et al, 2005a].
  • Referral to a dermatologist if an atypical form of pityriasis rosea is suspected is recommended to exclude differential diagnoses.

What else might it be?

  • Guttate psoriasis is the condition most likely to be confused with pityriasis rosea — see the section on Guttate psoriasis in the CKS topic on Psoriasis.
    • It is characterized by small ('drop-like'), round or oval (2 mm to 1 cm in diameter) scaly papules, although they may not be scaly in the early stages.
      • Lesions are pink or red, but this can vary depending on the person's skin colour.
      • They occur all over the body, usually in large numbers, and particularly on the trunk and proximal limbs.
    • Differentiating guttate psoriasis and pityriasis rosea can be difficult.
      • Pityriasis rosea may be distinguished by its 'Christmas tree' distribution and peripheral 'collarette' scaling (scaling confined to the edge of the lesion with central clearance) as opposed to the more uniform scaling of guttate psoriasis.
  • Secondary syphilis is an uncommon but serious condition that can mimic pityriasis rosea.
    • Consider the possibility of secondary syphilis if there are lesions on the palms and the soles of the feet, or generalized lymphadenopathy, in people who are sexually active.
    • Lesions are non-itchy and coppery red. They are symmetrically distributed along cleavage lines (as in pityriasis rosea) and occur around 8 weeks after primary syphilis (when a chancre will have been present).
    • The rash is accompanied by fever, headache, and bone and joint pains (which are more pronounced at night).
    • Lesions are initially macular and become papular by 3 months. The macules are round or oval, and non-scaly. Papules are firm, round or oval, and less than 0.5–2 cm in diameter. Early papules tend to be shiny, but gradually a thin layer of scale forms. Older lesions tend to be pigmented and very scaly.
  • HIV seroconversion can also present with an erythematous maculopapular rash similar to pityriasis rosea.
    • The rash consists of round or oval lesions (5 mm to 3 cm in diameter), which may be slightly raised.
    • The rash is distributed symmetrically on the face, trunk, palms, and soles, and typically lasts for 1–3 weeks.
    • The rash is almost always accompanied by a febrile, influenza-like illness (whereas pityriasis rosea may be preceded by such an illness).
  • Other conditions that may be confused with pityriasis rosea include:
    • Discoid (nummular) eczema
      • Very itchy, coin-shaped plaques, which may be vesicular or crusted, occurring on the limbs (and, to a lesser extent, the trunk).
    • Drug reactions
      • Several drugs have been reported to cause pityriasis rosea-like rashes, which are often more extensive and prolonged than rashes not caused by drugs.
      • For a list of drugs, see Drug reactions.
    • Lichen planus
      • Itchy, shiny, violaceous, flat-topped polygonal papules varying in size from a pinpoint to 1 cm in diameter.
      • Lesions most commonly occur on the flexor (volar) surface of the wrists, the lumbar region, and the ankles, but can occur anywhere.
      • Mucous membrane involvement is common (this is rare in pityriasis rosea).
    • Pityriasis lichenoides
      • The more common, chronic form is characterized by small, firm, scaly papules (3–10 mm in diameter) which flatten over several weeks.
      • An acute form is characterized by oedematous pink papules, vesicles, or bullae.
      • In both forms, lesions occur on the trunk and proximal limbs (as in pityriasis rosea).
    • Pityriasis versicolor — see the CKS topic on Pityriasis versicolor.
      • Multiple round or oval macules or papules, with a fine scale that may be seen only at the edge, particularly affecting the back, chest and upper arms.
      • The colour of the lesions varies and can be fawn, pink, red, brown, or almost white.
    • Polymorphic eruption of pregnancy (also known as pruritic urticarial papules and plaques of pregnancy [PUPPP]) — see the section on Causes of itch with rash in the CKS topic on Itch in pregnancy.
      • As with pityriasis rosea, this presents with discrete itchy papules and plaques, typically sparing the face, palms, and soles of the feet.
      • It usually occurs in the third trimester of the first pregnancy and is intensely itchy.
      • It may be distinguished from pityriasis rosea by early lesions being adjacent to abdominal striae (rather than along cleavage lines as in pityriasis rosea), and by the absence of peripheral 'collarette' scaling.
    • Tinea corporis (ringworm) — see the CKS topic on Fungal skin infection - body and groin.
      • This is characterized by well-demarcated, scaly, annular, erythematous papules or plaques, which gradually enlarge over time.
      • The borders may be raised or scaly.
    • Other rashes with annular lesions
      • Erythema annulare centrifugum — expanding lesions with central clearing and scaling at the trailing edge, most commonly affecting the trunk, buttocks, and legs.
      • Erythema migrans (Lyme disease) — one expanding lesion (reaching 5 cm or more in diameter) appears 7–10 days after a tick bite, and may be followed by multiple smaller lesions; see the CKS topic on Lyme disease.
      • Erythema multiforme — a papule or plaque expands with erythematous borders; the centre may become necrotic and dusky, resulting in a target lesion.
      • Granuloma annulare — smooth, hard, non-scaly, skin-coloured annular plaques and papules usually on the extremities (hands, feet, wrists, or ankles), although they can occur anywhere on the body.
      • Leprosy (Hansen's disease).
      • Subacute lupus erythematosus — annular plaques (with or without scaling) on sun-exposed areas.

Drug reactions

  • Drugs that have been reported to cause pityriasis rosea-like rashes include:
    • Arsenic.
    • Barbiturates.
    • Bismuth.
    • Bacillus Calmette–Guérin (BCG) vaccine.
    • Captopril.
    • Clonidine.
    • Gold.
    • Hepatitis B vaccine.
    • Interferon.
    • Isotretinoin.
    • Ketotifen (an antihistamine).
    • Nonsteroidal anti-inflammatory drugs.
    • Omeprazole.
    • Terbinafine.
    • Tyrosine kinase inhibitors (for example imatinib).

Basis for recommendation

This information is based on:


What investigations should I do for a person with pityriasis rosea?

  • The diagnosis of pityriasis rosea can usually be made clinically without the need for investigations.
  • Consider doing an HIV test and VDRL (Venereal Disease Research Laboratory) or other testing for syphilis:
    • In pregnant women — check that an HIV test and VDRL (or other syphilis) testing were done at antenatal booking, and arrange tests if there are no records.
    • If the diagnosis is uncertain, especially if palms and soles are affected or there is generalized lymphadenopathy, and the person is sexually active.

Basis for recommendation

The recommendations in relation to syphilis testing are based on expert opinion in a diagnostic case-control study [Chuh, 2003], a review article [Stulberg and Wolfrey, 2004], and a case report [Chuh et al, 2005b]. The recommendations for syphilis testing are extrapolated to HIV testing because HIV seroconversion is also recognized to mimic pityriasis rosea [de Jong et al, 1991; Meys and Welsby, 2006].

View full scenario

How do I diagnose pityriasis rosea?

  • Make a diagnosis of pityriasis rosea based on the appearance and distribution of skin lesions — see www.dermnet.com for images.
    • Appearance of individual lesions
      • Multiple, discrete, pink-red ('salmon-coloured') or fawn-coloured, flat or slightly raised.
      • Circular or oval, and typically 0.5–1 cm in diameter.
      • Usually slightly scaly — the classical appearance is of peripheral 'collarette' scaling (scaling confined to the edge of the lesion with central clearance).
    • Distribution of lesions
      • The rash is usually symmetrical.
      • Most lesions are on the trunk and proximal limbs, with few (usually less than 10%) distal to the mid-upper arm and mid-thigh.
      • On the trunk, lesions are along the ribs, forming a 'Christmas tree' pattern on the upper back and a V-shape on the upper chest, and distributed transversely across the lower abdomen and lower back (lesions follow skin cleavage lines).
  • A diagnosis of pityriasis rosea is more likely if:
    • A 'herald patch' appeared a few days or weeks before the generalized eruption.
      • This is usually 2–10 cm in diameter, oval, erythematous, and slightly raised, with the same 'collarette' of scale at the margin as seen in subsequent lesions.
      • It usually occurs on the trunk but can occur anywhere on the body.
      • A herald patch is not always present.
    • The lesions are not vesicular and predominantly not on palmar or plantar skin surfaces.
  • Other considerations when diagnosing pityriasis rosea include:
    • Atypical forms of pityriasis rosea occur — consider referring to a dermatologist.
    • Itch may or may not be present. Severity varies from mild to severe.
    • Some people may recall an upper respiratory tract infection prior to the rash. Systemic symptoms are absent during the generalized rash stage.
    • Most people with pityriasis rosea are 10–35 years of age, but the condition can affect people of any age.
  • Consider whether the rash may be caused by an alternative condition — see Differential diagnosis.
    • The condition most commonly and easily confused with pityriasis rosea is guttate psoriasis.
    • Less common but serious conditions mimicking pityriasis rosea are secondary syphilis and HIV seroconversion.
    • Reconsider a diagnosis of pityriasis rosea if the generalized rash persists for longer than 12 weeks.
      • The rash of pityriasis rosea usually lasts for 2–12 weeks, but can take up to 5 months to disappear.

Atypical forms

  • Atypical forms of pityriasis rosea include:
    • Inverse — the extremities are affected and the trunk is (relatively) spared.
    • Localized/asymmetrical.
    • Gigantean — lesions are larger and fewer.
    • Pustular, purpuric/haemorrhagic, vesicular, or urticarial (all rare).

Basis for recommendation

Diagnosis

Atypical forms

  • The information on atypical forms of pityriasis rosea is based on expert opinion from review articles [Stulberg and Wolfrey, 2004; Chuh et al, 2005a].
  • Referral to a dermatologist if an atypical form of pityriasis rosea is suspected is recommended to exclude differential diagnoses.

What else might it be?

  • Guttate psoriasis is the condition most likely to be confused with pityriasis rosea — see the section on Guttate psoriasis in the CKS topic on Psoriasis.
    • It is characterized by small ('drop-like'), round or oval (2 mm to 1 cm in diameter) scaly papules, although they may not be scaly in the early stages.
      • Lesions are pink or red, but this can vary depending on the person's skin colour.
      • They occur all over the body, usually in large numbers, and particularly on the trunk and proximal limbs.
    • Differentiating guttate psoriasis and pityriasis rosea can be difficult.
      • Pityriasis rosea may be distinguished by its 'Christmas tree' distribution and peripheral 'collarette' scaling (scaling confined to the edge of the lesion with central clearance) as opposed to the more uniform scaling of guttate psoriasis.
  • Secondary syphilis is an uncommon but serious condition that can mimic pityriasis rosea.
    • Consider the possibility of secondary syphilis if there are lesions on the palms and the soles of the feet, or generalized lymphadenopathy, in people who are sexually active.
    • Lesions are non-itchy and coppery red. They are symmetrically distributed along cleavage lines (as in pityriasis rosea) and occur around 8 weeks after primary syphilis (when a chancre will have been present).
    • The rash is accompanied by fever, headache, and bone and joint pains (which are more pronounced at night).
    • Lesions are initially macular and become papular by 3 months. The macules are round or oval, and non-scaly. Papules are firm, round or oval, and less than 0.5–2 cm in diameter. Early papules tend to be shiny, but gradually a thin layer of scale forms. Older lesions tend to be pigmented and very scaly.
  • HIV seroconversion can also present with an erythematous maculopapular rash similar to pityriasis rosea.
    • The rash consists of round or oval lesions (5 mm to 3 cm in diameter), which may be slightly raised.
    • The rash is distributed symmetrically on the face, trunk, palms, and soles, and typically lasts for 1–3 weeks.
    • The rash is almost always accompanied by a febrile, influenza-like illness (whereas pityriasis rosea may be preceded by such an illness).
  • Other conditions that may be confused with pityriasis rosea include:
    • Discoid (nummular) eczema
      • Very itchy, coin-shaped plaques, which may be vesicular or crusted, occurring on the limbs (and, to a lesser extent, the trunk).
    • Drug reactions
      • Several drugs have been reported to cause pityriasis rosea-like rashes, which are often more extensive and prolonged than rashes not caused by drugs.
      • For a list of drugs, see Drug reactions.
    • Lichen planus
      • Itchy, shiny, violaceous, flat-topped polygonal papules varying in size from a pinpoint to 1 cm in diameter.
      • Lesions most commonly occur on the flexor (volar) surface of the wrists, the lumbar region, and the ankles, but can occur anywhere.
      • Mucous membrane involvement is common (this is rare in pityriasis rosea).
    • Pityriasis lichenoides
      • The more common, chronic form is characterized by small, firm, scaly papules (3–10 mm in diameter) which flatten over several weeks.
      • An acute form is characterized by oedematous pink papules, vesicles, or bullae.
      • In both forms, lesions occur on the trunk and proximal limbs (as in pityriasis rosea).
    • Pityriasis versicolor — see the CKS topic on Pityriasis versicolor.
      • Multiple round or oval macules or papules, with a fine scale that may be seen only at the edge, particularly affecting the back, chest and upper arms.
      • The colour of the lesions varies and can be fawn, pink, red, brown, or almost white.
    • Polymorphic eruption of pregnancy (also known as pruritic urticarial papules and plaques of pregnancy [PUPPP]) — see the section on Causes of itch with rash in the CKS topic on Itch in pregnancy.
      • As with pityriasis rosea, this presents with discrete itchy papules and plaques, typically sparing the face, palms, and soles of the feet.
      • It usually occurs in the third trimester of the first pregnancy and is intensely itchy.
      • It may be distinguished from pityriasis rosea by early lesions being adjacent to abdominal striae (rather than along cleavage lines as in pityriasis rosea), and by the absence of peripheral 'collarette' scaling.
    • Tinea corporis (ringworm) — see the CKS topic on Fungal skin infection - body and groin.
      • This is characterized by well-demarcated, scaly, annular, erythematous papules or plaques, which gradually enlarge over time.
      • The borders may be raised or scaly.
    • Other rashes with annular lesions
      • Erythema annulare centrifugum — expanding lesions with central clearing and scaling at the trailing edge, most commonly affecting the trunk, buttocks, and legs.
      • Erythema migrans (Lyme disease) — one expanding lesion (reaching 5 cm or more in diameter) appears 7–10 days after a tick bite, and may be followed by multiple smaller lesions; see the CKS topic on Lyme disease.
      • Erythema multiforme — a papule or plaque expands with erythematous borders; the centre may become necrotic and dusky, resulting in a target lesion.
      • Granuloma annulare — smooth, hard, non-scaly, skin-coloured annular plaques and papules usually on the extremities (hands, feet, wrists, or ankles), although they can occur anywhere on the body.
      • Leprosy (Hansen's disease).
      • Subacute lupus erythematosus — annular plaques (with or without scaling) on sun-exposed areas.

Drug reactions

  • Drugs that have been reported to cause pityriasis rosea-like rashes include:
    • Arsenic.
    • Barbiturates.
    • Bismuth.
    • Bacillus Calmette–Guérin (BCG) vaccine.
    • Captopril.
    • Clonidine.
    • Gold.
    • Hepatitis B vaccine.
    • Interferon.
    • Isotretinoin.
    • Ketotifen (an antihistamine).
    • Nonsteroidal anti-inflammatory drugs.
    • Omeprazole.
    • Terbinafine.
    • Tyrosine kinase inhibitors (for example imatinib).

Basis for recommendation

This information is based on:

What investigations should I do for a person with pityriasis rosea?

  • The diagnosis of pityriasis rosea can usually be made clinically without the need for investigations.
  • Consider doing an HIV test and VDRL (Venereal Disease Research Laboratory) or other testing for syphilis:
    • In pregnant women — check that an HIV test and VDRL (or other syphilis) testing were done at antenatal booking, and arrange tests if there are no records.
    • If the diagnosis is uncertain, especially if palms and soles are affected or there is generalized lymphadenopathy, and the person is sexually active.

Basis for recommendation

The recommendations in relation to syphilis testing are based on expert opinion in a diagnostic case-control study [Chuh, 2003], a review article [Stulberg and Wolfrey, 2004], and a case report [Chuh et al, 2005b]. The recommendations for syphilis testing are extrapolated to HIV testing because HIV seroconversion is also recognized to mimic pityriasis rosea [de Jong et al, 1991; Meys and Welsby, 2006].

View full scenario no prescriptions

How do I diagnose pityriasis rosea?

  • Make a diagnosis of pityriasis rosea based on the appearance and distribution of skin lesions — see www.dermnet.com for images.
    • Appearance of individual lesions
      • Multiple, discrete, pink-red ('salmon-coloured') or fawn-coloured, flat or slightly raised.
      • Circular or oval, and typically 0.5–1 cm in diameter.
      • Usually slightly scaly — the classical appearance is of peripheral 'collarette' scaling (scaling confined to the edge of the lesion with central clearance).
    • Distribution of lesions
      • The rash is usually symmetrical.
      • Most lesions are on the trunk and proximal limbs, with few (usually less than 10%) distal to the mid-upper arm and mid-thigh.
      • On the trunk, lesions are along the ribs, forming a 'Christmas tree' pattern on the upper back and a V-shape on the upper chest, and distributed transversely across the lower abdomen and lower back (lesions follow skin cleavage lines).
  • A diagnosis of pityriasis rosea is more likely if:
    • A 'herald patch' appeared a few days or weeks before the generalized eruption.
      • This is usually 2–10 cm in diameter, oval, erythematous, and slightly raised, with the same 'collarette' of scale at the margin as seen in subsequent lesions.
      • It usually occurs on the trunk but can occur anywhere on the body.
      • A herald patch is not always present.
    • The lesions are not vesicular and predominantly not on palmar or plantar skin surfaces.
  • Other considerations when diagnosing pityriasis rosea include:
    • Atypical forms of pityriasis rosea occur — consider referring to a dermatologist.
    • Itch may or may not be present. Severity varies from mild to severe.
    • Some people may recall an upper respiratory tract infection prior to the rash. Systemic symptoms are absent during the generalized rash stage.
    • Most people with pityriasis rosea are 10–35 years of age, but the condition can affect people of any age.
  • Consider whether the rash may be caused by an alternative condition — see Differential diagnosis.
    • The condition most commonly and easily confused with pityriasis rosea is guttate psoriasis.
    • Less common but serious conditions mimicking pityriasis rosea are secondary syphilis and HIV seroconversion.
    • Reconsider a diagnosis of pityriasis rosea if the generalized rash persists for longer than 12 weeks.
      • The rash of pityriasis rosea usually lasts for 2–12 weeks, but can take up to 5 months to disappear.

Atypical forms

  • Atypical forms of pityriasis rosea include:
    • Inverse — the extremities are affected and the trunk is (relatively) spared.
    • Localized/asymmetrical.
    • Gigantean — lesions are larger and fewer.
    • Pustular, purpuric/haemorrhagic, vesicular, or urticarial (all rare).

Basis for recommendation

Diagnosis

Atypical forms

  • The information on atypical forms of pityriasis rosea is based on expert opinion from review articles [Stulberg and Wolfrey, 2004; Chuh et al, 2005a].
  • Referral to a dermatologist if an atypical form of pityriasis rosea is suspected is recommended to exclude differential diagnoses.

What else might it be?

  • Guttate psoriasis is the condition most likely to be confused with pityriasis rosea — see the section on Guttate psoriasis in the CKS topic on Psoriasis.
    • It is characterized by small ('drop-like'), round or oval (2 mm to 1 cm in diameter) scaly papules, although they may not be scaly in the early stages.
      • Lesions are pink or red, but this can vary depending on the person's skin colour.
      • They occur all over the body, usually in large numbers, and particularly on the trunk and proximal limbs.
    • Differentiating guttate psoriasis and pityriasis rosea can be difficult.
      • Pityriasis rosea may be distinguished by its 'Christmas tree' distribution and peripheral 'collarette' scaling (scaling confined to the edge of the lesion with central clearance) as opposed to the more uniform scaling of guttate psoriasis.
  • Secondary syphilis is an uncommon but serious condition that can mimic pityriasis rosea.
    • Consider the possibility of secondary syphilis if there are lesions on the palms and the soles of the feet, or generalized lymphadenopathy, in people who are sexually active.
    • Lesions are non-itchy and coppery red. They are symmetrically distributed along cleavage lines (as in pityriasis rosea) and occur around 8 weeks after primary syphilis (when a chancre will have been present).
    • The rash is accompanied by fever, headache, and bone and joint pains (which are more pronounced at night).
    • Lesions are initially macular and become papular by 3 months. The macules are round or oval, and non-scaly. Papules are firm, round or oval, and less than 0.5–2 cm in diameter. Early papules tend to be shiny, but gradually a thin layer of scale forms. Older lesions tend to be pigmented and very scaly.
  • HIV seroconversion can also present with an erythematous maculopapular rash similar to pityriasis rosea.
    • The rash consists of round or oval lesions (5 mm to 3 cm in diameter), which may be slightly raised.
    • The rash is distributed symmetrically on the face, trunk, palms, and soles, and typically lasts for 1–3 weeks.
    • The rash is almost always accompanied by a febrile, influenza-like illness (whereas pityriasis rosea may be preceded by such an illness).
  • Other conditions that may be confused with pityriasis rosea include:
    • Discoid (nummular) eczema
      • Very itchy, coin-shaped plaques, which may be vesicular or crusted, occurring on the limbs (and, to a lesser extent, the trunk).
    • Drug reactions
      • Several drugs have been reported to cause pityriasis rosea-like rashes, which are often more extensive and prolonged than rashes not caused by drugs.
      • For a list of drugs, see Drug reactions.
    • Lichen planus
      • Itchy, shiny, violaceous, flat-topped polygonal papules varying in size from a pinpoint to 1 cm in diameter.
      • Lesions most commonly occur on the flexor (volar) surface of the wrists, the lumbar region, and the ankles, but can occur anywhere.
      • Mucous membrane involvement is common (this is rare in pityriasis rosea).
    • Pityriasis lichenoides
      • The more common, chronic form is characterized by small, firm, scaly papules (3–10 mm in diameter) which flatten over several weeks.
      • An acute form is characterized by oedematous pink papules, vesicles, or bullae.
      • In both forms, lesions occur on the trunk and proximal limbs (as in pityriasis rosea).
    • Pityriasis versicolor — see the CKS topic on Pityriasis versicolor.
      • Multiple round or oval macules or papules, with a fine scale that may be seen only at the edge, particularly affecting the back, chest and upper arms.
      • The colour of the lesions varies and can be fawn, pink, red, brown, or almost white.
    • Polymorphic eruption of pregnancy (also known as pruritic urticarial papules and plaques of pregnancy [PUPPP]) — see the section on Causes of itch with rash in the CKS topic on Itch in pregnancy.
      • As with pityriasis rosea, this presents with discrete itchy papules and plaques, typically sparing the face, palms, and soles of the feet.
      • It usually occurs in the third trimester of the first pregnancy and is intensely itchy.
      • It may be distinguished from pityriasis rosea by early lesions being adjacent to abdominal striae (rather than along cleavage lines as in pityriasis rosea), and by the absence of peripheral 'collarette' scaling.
    • Tinea corporis (ringworm) — see the CKS topic on Fungal skin infection - body and groin.
      • This is characterized by well-demarcated, scaly, annular, erythematous papules or plaques, which gradually enlarge over time.
      • The borders may be raised or scaly.
    • Other rashes with annular lesions
      • Erythema annulare centrifugum — expanding lesions with central clearing and scaling at the trailing edge, most commonly affecting the trunk, buttocks, and legs.
      • Erythema migrans (Lyme disease) — one expanding lesion (reaching 5 cm or more in diameter) appears 7–10 days after a tick bite, and may be followed by multiple smaller lesions; see the CKS topic on Lyme disease.
      • Erythema multiforme — a papule or plaque expands with erythematous borders; the centre may become necrotic and dusky, resulting in a target lesion.
      • Granuloma annulare — smooth, hard, non-scaly, skin-coloured annular plaques and papules usually on the extremities (hands, feet, wrists, or ankles), although they can occur anywhere on the body.
      • Leprosy (Hansen's disease).
      • Subacute lupus erythematosus — annular plaques (with or without scaling) on sun-exposed areas.

Drug reactions

  • Drugs that have been reported to cause pityriasis rosea-like rashes include:
    • Arsenic.
    • Barbiturates.
    • Bismuth.
    • Bacillus Calmette–Guérin (BCG) vaccine.
    • Captopril.
    • Clonidine.
    • Gold.
    • Hepatitis B vaccine.
    • Interferon.
    • Isotretinoin.
    • Ketotifen (an antihistamine).
    • Nonsteroidal anti-inflammatory drugs.
    • Omeprazole.
    • Terbinafine.
    • Tyrosine kinase inhibitors (for example imatinib).

Basis for recommendation

This information is based on:

What investigations should I do for a person with pityriasis rosea?

  • The diagnosis of pityriasis rosea can usually be made clinically without the need for investigations.
  • Consider doing an HIV test and VDRL (Venereal Disease Research Laboratory) or other testing for syphilis:
    • In pregnant women — check that an HIV test and VDRL (or other syphilis) testing were done at antenatal booking, and arrange tests if there are no records.
    • If the diagnosis is uncertain, especially if palms and soles are affected or there is generalized lymphadenopathy, and the person is sexually active.

Basis for recommendation

The recommendations in relation to syphilis testing are based on expert opinion in a diagnostic case-control study [Chuh, 2003], a review article [Stulberg and Wolfrey, 2004], and a case report [Chuh et al, 2005b]. The recommendations for syphilis testing are extrapolated to HIV testing because HIV seroconversion is also recognized to mimic pityriasis rosea [de Jong et al, 1991; Meys and Welsby, 2006].

Scenario: Pityriasis rosea

This level contains the following sections:

  • Management
  • Referral
  • Prescriptions
  • View full scenario
  • View full scenario no prescriptions

How should I manage a person with pityriasis rosea?

  • For most people with pityriasis rosea, no treatment is required except explanation and reassurance.
    • Explain that the rash may worsen before it resolves, with new crops of skin lesions continuing to appear for up to 6 weeks.
    • Reassure the person that:
      • The rash will settle without treatment, usually within 2–3 months.
      • No treatment is required apart from symptomatic treatment for itch.
      • After the rash has disappeared, there may be some darkening (hyperpigmentation) or lightening (hypopigmentation) of the affected skin for several months, but there will be no scarring.
      • The rash does not usually recur: about 1 in every 50 people with pityriasis rosea have a recurrence.
    • Written information can be downloaded from the British Association of Dermatologists website.
  • For people with itch
    • Consider offering symptomatic treatment with one or more of the following:
    • If itch is severe (for example it is not relieved by moderately potent topical corticosteroids), reconsider the diagnosis.
    • Do not treat with oral corticosteroids.
  • Consider when to refer to a dermatology specialist.

Basis for recommendation

Explanation and reassurance

Emollients

  • Although CKS identified no evidence from randomized controlled trials (RCTs) of emollients for pityriasis rosea, they are used for the symptomatic treatment of itch in pityriasis rosea [Chuh et al, 2007] and are recommended on the basis of expert opinion in a textbook and review article [Sterling, 2004; Stulberg and Wolfrey, 2004].

Topical corticosteroids

  • Although CKS identified no evidence from RCTs of topical corticosteroids for pityriasis rosea, they are used for the symptomatic treatment of itch in pityriasis rosea [Chuh et al, 2007] and are recommended on the basis of expert opinion in a textbook and review article [Sterling, 2004; Stulberg and Wolfrey, 2004].
    • In the absence of evidence on appropriate potency, frequency of application, or duration of treatment, these recommendations are based on expert opinion from CKS reviewers and in a textbook [Sterling, 2004].

Sedating oral antihistamines

  • Although one RCT (in 85 people) included in a Cochrane systematic review [Chuh et al, 2007] found dexchlorpheniramine to be no better than low-dose oral betamethasone (a corticosteroid) in reducing itch or improving the rash at 2 weeks, the absence of a placebo group makes it impossible to determine the clinical importance of oral dexchlorpheniramine. CKS found no evidence from randomized placebo-controlled trials of oral antihistamines for pityriasis rosea.
  • In spite of this, expert reviewers for a separate CKS topic (see the section on Known cause of itch in the CKS topic on Itch - widespread), recommend a trial of sedating oral antihistamines for itch in conditions not associated with a histamine-induced process.

Treatments that are not recommended

  • Oral corticosteroids
    • Although one RCT (in 85 people) included in a Cochrane systematic review [Chuh et al, 2007] found low-dose oral betamethasone to be no better than oral dexchlorpheniramine (an antihistamine) in reducing itch or improving the rash at 2 weeks, the absence of a placebo group makes it impossible to determine the clinical importance of oral betamethasone. CKS identified no evidence from randomized placebo-controlled trials on the efficacy and safety of oral corticosteroids for pityriasis rosea.
    • One case series of 18 people with pityriasis rosea suggests that oral corticosteroids may exacerbate symptoms [Leonforte, 1981].
  • Antibiotics
    • Evidence on antibiotics for pityriasis rosea is lacking and inconsistent.
      • Although one small, unpublished RCT included in a Cochrane systematic review [Chuh et al, 2007] found erythromycin to be effective compared with placebo in reducing itch (difference in mean itch score 3.95 points; 95% CI 3.37 to 4.53) and in achieving excellent rash improvement (77% compared with 6%; relative risk 13; 95% CI 1.91 to 88.64), one subsequent small RCT concluded that azithromycin had no impact on the clinical course of pityriasis rosea in children (rate of complete resolution 60% compared with 42%, p = 0.275; rate of complete or partial resolution, p = 0.171) [Amer and Fischer, 2006].
  • Antiviral drugs
    • CKS identified no evidence from RCTs of antiviral drugs for pityriasis rosea.

When should I refer a person with pityriasis rosea?

  • Refer to a dermatology specialist if:
    • The diagnosis is uncertain.
    • An atypical form of pityriasis rosea is suspected.
    • The person has extensive disease or severe itch not controlled by simple treatments.

Basis for recommendation

Referral if the diagnosis is uncertain

  • In the absence of published evidence or expert opinion, this recommendation is based on what CKS considers to be good clinical practice.

Referral if an atypical form is suspected

  • This is recommended to exclude differential diagnoses of pityriasis rosea.

Referral for extensive disease or severe itching not controlled by simple treatments

  • This is recommended so that the person can be offered phototherapy. Although there is no evidence from randomized controlled trials, non-randomized controlled trials discussed in review articles suggest some benefits [Stulberg and Wolfrey, 2004; Drago and Rebora, 2009], leading the author of one review article to recommend this treatment for extensive disease [Stulberg and Wolfrey, 2004].

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Emollient creams

Age from 1 month onwards
Aqueous cream
Aqueous cream
Apply to skin frequently and liberally, as often as required. Use as a soap substitute.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £1.86
OTC cost: £2.60
Licensed use: yes
Patient information: Apply gently in direction of hair growth, and avoid vigorous rubbing of skin.
Diprobase® cream
Diprobase cream
Apply to skin frequently and liberally, as often as required.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £4.89
OTC cost: £11.91
Licensed use: yes
Patient information: Apply gently in direction of hair growth, and avoid vigorous rubbing of skin.
E45® cream
E45 cream
Apply to skin frequently and liberally, as often as required. Use as a soap substitute.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £6.20
OTC cost: £9.69
Licensed use: yes
Patient information: Apply gently in direction of hair growth, and avoid vigorous rubbing of skin.
Cetraben® cream
Cetraben emollient cream
Apply to skin frequently and liberally, as often as required. Use as a soap substitute.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £5.61
OTC cost: £9.89
Licensed use: yes
Patient information: Apply gently in direction of hair growth, and avoid vigorous rubbing of skin.
Unguentum M® cream
Unguentum M cream
Apply to skin frequently and liberally, as often as required. Use as a soap substitute.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £8.48
OTC cost: £14.95
Licensed use: yes

Emollient ointments

Age from 1 month onwards
Emulsifying ointment
Emulsifying ointment
Apply to skin frequently and liberally, as often as required. Use as a soap substitute.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £2.22
OTC cost: £4.30
Licensed use: yes
Patient information: Apply gently in direction of hair growth, and avoid vigorous rubbing of skin.
Hydrous ointment
Hydrous ointment
Apply to skin frequently and liberally, as often as required. Use as a soap substitute.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £3.06
OTC cost: £3.58
Licensed use: yes
Patient information: Apply gently in direction of hair growth, and avoid vigorous rubbing of skin.
Liquid and white soft paraffin
Liquid paraffin 50% / White soft paraffin 50% ointment
Apply to skin frequently and liberally, as often as required. Use as a soap substitute.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £6.09
OTC cost: £8.72
Licensed use: yes
Patient information: Apply gently in direction of hair growth, and avoid vigorous rubbing of skin.
Hydromol® ointment
Hydromol ointment
Apply to skin frequently and liberally, as often as required. Use as a soap substitute.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £4.74
OTC cost: £8.35
Licensed use: yes
Patient information: Apply gently in direction of hair growth, and avoid vigorous rubbing of skin.
Epaderm® ointment
Epaderm emulsifying ointment
Apply to skin frequently and liberally, as often as required. Use as a soap substitute.
Supply 500 grams.
Age: from 1 month onwards
NHS cost: £6.26
OTC cost: £10.00
Licensed use: yes
Patient information: Apply gently in direction of hair growth, and avoid vigorous rubbing of skin. If used as a bath additive, take care to avoid slipping.

Age from 1 month onwards
Hydrocortisone 1% ointment (30g)
Hydrocortisone 1% ointment
Apply thinly to the affected area(s) once or twice a day.
Supply 30 grams.
Age: from 1 month onwards
NHS cost: £5.96
Licensed use: yes
Hydrocortisone 1% cream (30g)
Hydrocortisone 1% cream
Apply thinly to the affected area(s) once or twice a day.
Supply 30 grams.
Age: from 1 month onwards
NHS cost: £5.14
Licensed use: yes

Age from 1 month onwards
Alclometasone 0.05% cream: apply once or twice a day
Alclometasone 0.05% cream
Apply thinly to the affected area(s) once or twice a day.
Supply 50 gram.
Age: from 1 month onwards
NHS cost: £2.68
Licensed use: yes
Betamethasone valerate 0.025% cream (100g)
Betamethasone valerate 0.025% cream
Apply thinly to the affected area(s) once or twice a day.
Supply 100 grams.
Age: from 1 month onwards
NHS cost: £3.34
Licensed use: yes
Clobetasone 0.05% cream (30g)
Clobetasone 0.05% cream
Apply thinly to the affected area(s) once or twice a day.
Supply 30 grams.
Age: from 1 month onwards
NHS cost: £1.86
Licensed use: yes
Fluocinolone 0.00625% cream: apply once or twice a day
Fluocinolone 0.00625% cream
Apply thinly to the affected area(s) once or twice a day.
Supply 50 gram.
Age: from 1 month onwards
NHS cost: £4.40
Licensed use: yes
Fluocortolone hexanoate 0.25%/fluocortolone pivalate 0.25% cr
Fluocortolone hexanoate 0.25% / Fluocortolone pivalate 0.25% cream
Apply thinly to the affected area(s) once or twice a day.
Supply 50 gram.
Age: from 1 month onwards
NHS cost: £2.95
Licensed use: yes
Fludroxycortide 0.125% cream: apply once or twice a day
Fludroxycortide 0.0125% cream
Apply thinly to the affected area(s) once or twice a day.
Supply 60 gram.
Age: from 1 month onwards
NHS cost: £3.26
Licensed use: yes

Moderately potent corticosteroid ointments

Age from 1 month onwards
Alclometasone 0.05% ointment: apply once or twice a day
Alclometasone 0.05% ointment
Apply thinly to the affected area(s) once or twice a day.
Supply 50 gram.
Age: from 1 month onwards
NHS cost: £2.68
Licensed use: yes
Betamethasone valerate 0.025% ointment (100g)
Betamethasone valerate 0.025% ointment
Apply thinly to the affected area(s) once or twice a day.
Supply 100 grams.
Age: from 1 month onwards
NHS cost: £3.15
Licensed use: yes
Clobetasone 0.05% ointment (30g)
Clobetasone 0.05% ointment
Apply thinly to the affected area(s) once or twice a day.
Supply 30 grams.
Age: from 1 month onwards
NHS cost: £1.86
Licensed use: yes
Fluocinolone 0.025% ointment: apply once or twice a day
Fluocinolone 0.025% ointment
Apply thinly to the affected area(s) once or twice a day.
Supply 50 grams.
Age: from 1 month onwards
NHS cost: £3.76
Licensed use: yes
Fluocortolone hexanoate 0.25%/fluocortolone 0.25% oint
Fluocortolone 0.25% / Fluocortolone hexanoate 0.25% ointment
Apply thinly to the affected area(s) once or twice a day.
Apply thinly to the affected area(s) once or twice a day.
Supply 50 grams.
Age: from 1 month onwards
NHS cost: £2.95
Licensed use: yes
Fludroxycortide 0.125% oint: apply once or twice a day
Fludroxycortide 0.0125% ointment
Supply 60 gram.

Sedating antihistamine (for itch at night) (chlorphenamine [off-label] or hydroxyzine [licensed])

Age from 1 year to 1 year 11 months
Chlorphenamine 2mg/5ml oral solution: 1mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml at night when required for relief of itching.
Supply 50 ml.
Age: from 1 year to 1 year 11 months
NHS cost: £0.79
OTC cost: £3.99
Licensed use: no - off-label indication
Age from 1 year to 5 years 11 months
Hydroxyzine syrup: 5 to 15 mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 2.5ml to 7.5ml at night when required for relief of itching.
Supply 100 ml.
Age: from 1 year to 5 years 11 months
NHS cost: £0.89
Licensed use: yes
Age from 2 years to 5 years 11 months
Chlorphenamine 2mg/5ml oral solution: 1-2mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml to 5ml at night when required for relief of itching.
Supply 100 ml.
Age: from 2 years to 5 years 11 months
NHS cost: £1.59
OTC cost: £3.99
Licensed use: no - off-label indication
Age from 6 years to 11 years 11 months
Chlorphenamine oral 2mg/5ml solution: 2-4 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take one to two 5ml spoonfuls at night when required for relief of itching.
Supply 100 ml.
Age: from 6 years to 11 years 11 months
NHS cost: £1.59
OTC cost: £3.99
Licensed use: no - off-label indication
Hydroxyzine syrup: 15mg to 25mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 7.5ml to 12.5ml at night when required for relief of itching.
Supply 200 ml.
Age: from 6 years to 11 years 11 months
NHS cost: £1.78
Licensed use: yes
Age from 12 years onwards
Chlorphenamine tablets: 4 mg at night when required
Chlorphenamine 4mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Age: from 12 years onwards
NHS cost: £0.50
OTC cost: £3.15
Licensed use: no - off-label indication
Hydroxyzine tablets: 25mg at night when required
Hydroxyzine 25mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Age: from 12 years onwards
NHS cost: £0.55
Licensed use: yes


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