Characterization of the inflammatory cell infiltrate in herald patches and fully developed eruptions of pityriasis rosea

A Case of Persistent Pityriasis Rosea Successfully Treated by a Short Course of Therapy with Abrocitinib

Pityriasis rosea (PR) is a common inflammatory, erythematous and scaly skin condition that usually affects individuals aged from 20 to 40 years old. The disease often exhibits a self-limiting course up to 6-8 weeks. We report a 25-year-old female patient with a six-month history of red scaly rashes on the trunk and proximal limbs, accompanied by severe pruritus that has been remained ineffective conventional treatments. She was diagnosed as persistent pityriasis rosea. As abrocitinib has been proved to be effective for many inflammatory diseases, therefore in this case, we tried abrocitinib for the patient, and a good result had been achieved.

Pityriasis rosea Gibert triggered by SARS-CoV-2 infection: A case report

RATIONALE

Pityriasis rosea Gibert is an erythematous-papulosquamous dermatosis that frequently occurs in young adults. The etiopathogenesis of PR is still unknown, but is frequently associated with episodes of upper respiratory tract infections. It is likely that a new viral trigger of pityriasis rosea is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

PATIENT CONCERNS

We present the case of a female patient in whom the diagnosis of pityriasis rosea led to the investigation and diagnosis of the SARS-CoV-2 infection. The patient presented to the Department of Dermatology for a 3 week duration of an extremely pruritic erythematous-squamous lesion, initially on the trunk and upper limbs, with extension to the lower limbs in the last week and the lesion respected the cephalic extremity, palms, and soles. One week before the rash, respiratory tract infection symptomatology was observed by the patient. At home, she underwent systemic treatment with antihistamines and topical medication with dermatocorticosteroids. The evolution was unfavorable, with the spread of the lesions and the accentuation of the pruritus.

DIAGNOSES

Considering the actual epidemiological context, we performed a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay from nasal and pharyngeal swabs for coronavirus disease 2019 (COVID-19) to investigate the PR etiology. The patient had a positive RT-PCR result, and was confirmed with SARS-CoV-2 infection.

INTERVENTIONS

Treatment was initiated with systemic corticosteroid therapy - hydrocortisone hemisuccinate 200 mg/day for 7 days, and loratadine 10 mg 2 times a day. Also, topical medication with dermatocorticosteroids and emollients was associated.

OUTCOME

Under the treatment that was initiated a partial remission of the lesions after 7 days was observed.

LESSONS

Our reported case adds to the other findings regarding the association of PR with SARS-CoV-2 infection, in the context of the pandemic, suggesting the need to test patients with PR skin lesions for SARS-CoV-2 infection.

Pityriasis Rosea: An Updated Review

BACKGROUND

Pityriasis rosea is a common acute, self-limited papulosquamous dermatosis that primarily affects children and young adults. The condition and its clinical variants may pose a diagnostic challenge, especially in the absence of the herald patch.

OBJECTIVE

This article aimed to familiarize pediatricians with clinical manifestations, evaluation, diagnosis, and management of pityriasis rosea.

METHODS

A search was conducted in March 2020 in Pubmed Clinical Queries using the key term " pityriasis rosea". The search strategy included all clinical trials (including open trials, non-randomized controlled trials, and randomized controlled trials), observational studies, and reviews (including narrative reviews and meta-analyses) published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Pityriasis rosea occurs mainly in individuals between 10 and 35 years of age with a peak during adolescence. Human herpesvirus (HHV)-7 and HHV-6 have been implicated as the causative agents in some patients with pityriasis rosea. A mild prodrome consisting of headaches, fever, malaise, fatigue, anorexia, sore throat, enlarged lymph nodes and arthralgia is present in about 5% of patients. The most common presenting sign, found in approximately 80% of patients, is a "herald" or "mother" patch which is larger and more noticeable than the lesions of the later eruption. A generalized, bilateral, symmetrical eruption develops in approximately 4 to 14 days and continues to erupt in crops over the next 12 to 21 days. Typical lesions are 0.5 to 1 cm, oval or elliptical, dull pink or salmon-colored macules with a delicate collarette of scales at the periphery. The long axes tend to be oriented along the skin lines of cleavage (Langer lines). Lesions on the back may have a characteristic "Christmas tree", whereas lesions on the upper chest may have a V-shaped pattern. There are many conditions that may mimic pityriasis rosea. Pityriasis rosea in the absence of the herald patch and its variants may pose a diagnostic challenge. The typical course is 6 to 8 weeks. In the vast majority of cases, reassurance and symptomatic treatment should suffice. Active intervention may be considered for individuals with severe or recurrent pityriasis rosea and pregnant women with the disease. Treatment options include acyclovir, macrolides (in particular, erythromycin), and ultraviolet phototherapy. If active intervention is needed, there is evidence supporting the use of oral acyclovir to shorten the duration of illness.

CONCLUSION

Pityriasis rosea is a common, acute, self-limiting exanthematous skin disease that primarily affects children and young adults. The condition is characterized by a "herald patch" after which oval erythematous squamous lesions appear along Langer's lines of cleavage on the trunk and proximal extremities, giving it a "Christmas tree" appearance. The disease presenting in its classical form can easily be diagnosed. Clinical variants of the disease may pose a diagnostic challenge for the general pediatrician. Knowledge of the disease is essential to allow prompt diagnosis and to avoid unnecessary investigations.

Evaluation of thiol/disulfide homeostasis in patients with pityriasis rosea

Purpose: Pityriasis rosea (PR) is a common, self-limiting, inflammatory skin disease with an acute onset. The etiology of PR is not yet clearly known but the defect in the oxidation system involved in many papulosquamous skin diseases may play a role. Thiol/disulfide homeostasis is a new marker of oxidative stress and has been studied in many diseases in recent years. The aim of this study to investigate thiol/disulfide homeostasis in PR patients. Material and methods: Thirty-four patients (18 females, 16 males; median age 26 years) that presented to the Dermatology Clinic of Istanbul Medipol Mega University Hospital between November 2017 and December 2018 and were clinically and/or histopathologically diagnosed with PR, and 30 healthy individuals (16 females, 14 males; median age 27 years) were included in the study. The serum native thiol and total thiol were measured by a novel colorimetric, automated method. The disulfide levels and disulfide/native thiol ratios were also calculated from these measured parameters. Results: There was no statistically significant difference in the serum native thiol and total thiol concentration between the PR and control groups (p = 0.711 and 0.788, respectively). Disulfide, disulfide/native thiol, and disulfide/total thiol levels were significantly higher in patients with PR (p = 0.002, 0.006 and 0.006, respectively). Conclusions: The thiol-disulfide balance shifted toward disulfide in patients with PR. This demonstrates the importance of oxidative stress in the etiopathogenesis of PR using a new marker.

Subsets of T lymphocytes in the lesional skin of pityriasis rosea

BACKGROUND

Pityriasis rosea is a common papulosquamous disorder. However, its etiology and pathogenesis remain unclear.

OBJECTIVE

We investigate the types of inflammatory cells infiltrating the lesional skin of pityriasis rosea and demonstrate whether T-cell-mediated immunity is involved in the pathogenesis of this condition or not.

METHODS

The biopsies were taken from the lesional skin of 35 cases of patients diagnosed with pityriasis rosea. The specimens were prepared in paraffin sections, then submitted to routine immunohistochemistry procedures using monoclonal antibodies directed against CD3, CD4, CD8, CD20 and CD45RO and horseradish peroxidase-labeled goat anti-human antibodies. The positive sections were determined by the ratio and staining intensity of positive inflammatory cells.

RESULTS

The mean score of positive CD3, CD4, CD8, and CD45RO staining was respectively 3.74±3.88, 5.67±4.40, 2.94±3.42 and 7.68±4.33 in these pityriasis rosea patients (P<0.001). The percentage of positive staining was 54.29% (19/35), 69.7% (23/33), 40% (14/35) and 79.41% (27/34) (P<0.05). However, the staining of CD20 was negative in all samples. The mean score of CD3 staining in patients with time for remission ≤60 days (4.90±4.21) was higher than that in patients with time for remission >60 days (2.00±2.5) (P<0.05), whereas no statistical difference in the mean score of CD4, CD8 and CD45RO staining was observed. study liMitations: The sample size and the selected monoclonal antibody are limited, so the results reflect only part of the cellular immunity in the pathogenesis of pityriasis rosea.

CONCLUSION

Our findings support a predominantly T-cell mediated immunity in the development of pityriasis rosea.

Double-blind randomized placebo-controlled trial to evaluate the efficacy and safety of short-course low-dose oral prednisolone in pityriasis rosea

PURPOSE

To evaluate the efficacy and safety of short-course low-dose oral prednisolone in symptomatic pityriasis rosea (PR) of onset <5 days and compare it with placebo.

MATERIAL AND METHODS

Placebo-controlled randomized double-blind study design with the treatment group receiving tapering doses of oral prednisolone over 2 weeks and the control group receiving a placebo. Outcome measures evaluated were subsidence of patient-perceived pruritus, improvement in rash quantified by a specific score, adverse effects and relapse at 12 weeks.

RESULTS

The improvement in the pruritus score as well as objective rash score were much better in the prednisolone-treated group. No adverse effects reported in either group. The relapse rate at 12 weeks was much higher in the prednisolone treated group.

CONCLUSIONS

Oral corticosteroids, even if used in low-dose and for a short tapering course should not be the first line of therapy for PR. The only justified indication may be extensive and highly symptomatic lesions of PR.

'Hints' in the horn: diagnostic clues in the stratum corneum

The stratum corneum or horny layer is the uppermost layer of the epidermis, and is mainly responsible for the skin's barrier function. In spite of its complexity at the ultrastructural and molecular level, the features accessible to visualization on conventional histology are relatively limited. Nevertheless, knowledge of subtle clues that one may observe in the stratum corneum can prove useful in a wide range of situations in dermatopathology. We herein review a selection of common and rare entities in which the horny layer may reveal significantly important hints for the diagnosis. These clues include parakeratosis and its different patterns (focal, confluent, alternating, associated with spongiosis, epidermal hyperplasia or lichenoid changes), subcorneal acantholysis, infectious organisms in the stratum corneum (including fungal, bacterial and parasitic), thickening or thinning of the stratum corneum and the presence of different kinds of pigment. Even when normal, the horny layer may prove to be useful when seen in association with severe epidermal damage, a combination of features testifying to the acute nature of the underlying pathological process.

The role of interleukin-22 in pityriasis rosea

BACKGROUND

Pityriasis rosea (PR) is an exanthematous disease related to reactivation of human herpes virus (HHV) types 6 and 7. The pathogenesis and cytokine profile of PR are still poorly understood.There is a large amount of evidence indicating a viral aetiology for PR.

AIM

To measure the serum level of interleukin (IL)-22, a cytokine expressed by T helper (Th)17 cells in patients with PR to explore the possible association of IL-22 with the pathogenesis of the disease.

METHODS

This case-control study enrolled 25 patients with PR (mean ± SD age 20 ± 12 years) and a control group of 25 apparently healthy individuals (mean age 18 ± 12.1 years). Blood samples were collected from both patients and controls to measure serum IL-22. Scoring of PR was performed using the Pityriasis Rosea Severity Score (PRSS).

RESULTS

There was a statistically significant difference in IL-22 serum level between the patient and control groups. The IL-22 serum level increased with increase in disease severity (PRSS), extent and duration.

CONCLUSION

Through its proinflammatory cytokines, IL-22 plays a role in the inflammatory process of PR.

Pityriasis rosea in pregnancy: report of a spousal occurrence and craniosynostosis in the healthy newborn

BACKGROUND

Pityriasis rosea is a papulosquamous disease. It may occur during pregnancy; in this setting, it has occasionally been associated with adverse outcomes.

PURPOSE

A woman who developed pityriasis rosea at the beginning of her eighth week of gestation is described. The outcomes in newborns delivered by pregnant women who developed pityriasis rosea during gestation are summarized.

METHOD

A 28-year-old woman developed pityriasis rosea during her eighth week of pregnancy. Her husband had pityriasis rosea two months earlier. PubMed was searched for the following terms: conjugal, craniosynostosis, newborn, pityriasis, pregnancy, rosea, sagittal, spouse. The papers were reviewed and the references cited were evaluated.

RESULTS

Our patient delivered a healthy male infant after 41 weeks of gestation. He had normal weight, height, and Apgar scores. Isolated sagittal craniosynostosis was diagnosed and was successfully treated at nine weeks after birth without complications.

CONCLUSION

Several retrospective studies have investigated the possibility of adverse outcomes in infants born to women who developed pityriasis rosea during pregnancy, such as stillbirth, low gestational weight, hypotonia, and premature delivery. However, there are also reports of healthy newborns in women who have had pityriasis rosea during gestation. Our patient carried the fetus one week post-term and delivered a healthy boy via C-section; isolated sagittal craniosynostosis was later diagnosed and successfully repaired. The occurrence of craniosynostosis in a woman who developed pityriasis rosea during her first trimester of pregnancy may be two coincidental events.

The Oxidant and Antioxidant Status in Pityriasis Rosea

Background:

Pityriasis rosea (PR) is usually an asymptomatic and self-limiting papulosquamous skin disease with acute onset. The etiology has not been clarified yet. Recently, increased oxidative stress was found to play a role in etiopathogenesis of multiple cutaneous diseases with T cell-mediated immune response. However, there are no studies demonstrating the oxidative stress status in PR.

Aim:

The aim of the study is to determine the status of oxidative stress (OS) and paraoxonase (PON) 1/arylesterase enzyme activities in PR.

Materials and Methods:

Study included 51 patients with active PR lesions, and 45 healthy volunteers. Serum levels of total oxidant status (TOS), total antioxidant status (TAS), and PON1/arylesterase (ARES) activity were determined and oxidative stress index (OSI) was calculated in all patients and controls.

Results:

TAS levels and ARES activities in the patient group were significantly lower than the control group. On the other hand, TOS and OSI levels were significantly higher in patients compared with controls. There was no significant correlation between the duration of disease and TAS, TOS, OSI levels, and ARES activities.

Conclusion:

A systemic oxidative stress exists in PR, which suggests that OS may be involved in the etiopathogenesis of disease.

The Role of Cytokines, Chemokines, and Growth Factors in the Pathogenesis of Pityriasis Rosea

Introduction. Pityriasis rosea (PR) is an exanthematous disease related to human herpesvirus- (HHV-) 6/7 reactivation. The network of mediators involved in recruiting the infiltrating inflammatory cells has never been studied. Object. To investigate the levels of serum cytokines, growth factors, and chemokines in PR and healthy controls in order to elucidate the PR pathogenesis. Materials and Methods. Interleukin- (IL-) 1, IL-6, IL-17, interferon- (IFN-) γ, tumor necrosis factor- (TNF-) α, vascular endothelial growth factor (VEGF), granulocyte colony stimulating factor (G-CSF), and chemokines, CXCL8 (IL-8) and CXCL10 (IP-10), were measured simultaneously by a multiplex assay in early acute PR patients' sera and healthy controls. Subsequently, sera from PR patients were analysed at 3 different times (0, 15, and 30 days). Results and discussion. Serum levels of IL-17, IFN-γ, VEGF, and IP-10 resulted to be upregulated in PR patients compared to controls. IL-17 has a key role in host defense against pathogens stimulating the release of proinflammatory cytokines/chemokines. IFN-γ has a direct antiviral activity promoting NK cells and virus specific T cells cytotoxicity. VEGF stimulates vasculogenesis and angiogenesis. IP-10 can induce chemotaxis, apoptosis, cell growth, and angiogenesis. Conclusions. Our findings suggest that these inflammatory mediators may modulate PR pathogenesis in synergistic manner.

Evaluation of clinico-epidemiological and histopathological features of pityriasis rosea

Introduction

Pityriasis rosea is a sudden-onset and self limiting disease with specific skin rash. The exact etiology is still not clear.

Aim

To determine epidemiological, etiological, clinical and histopathological features in pityriasis rosea (PR).

Material and methods

Fifty two patients (older than 18 years) with PR were included in this study. Patients were examined for epidemiological and etiological features. Biopsy specimens obtained from secondary eruptions were histopathologically evaluated with hematoxylin-eosine and immunohistochemically evaluated with CD3 and CD20 monoclonal antibodies.

Results

Age range of patients was 18–53, mean age was 29.3 ±9.5 and women-to-men ratio was 1.08/1. Thirty-nine (75%) patients had a history of wearing new clothes, 27 (51.9%) patients had a history of recent respiratory tract infection, 15 (28.8%) patients had a history of recent gastrointestinal infection. Eczematous changes were detected in biopsy materials by histopathological evaluation, and cellular infiltrate was positively stained with pan T-cell marker CD3 and negatively stained with B lymphocyte marker CD20 in all biopsy materials in immunohistochemical examination.

Conclusions

In our study, frequency of pre-disease infection and prodromal symptoms history were determined to be higher than the results of similar studies in the literature. These higher results suggest that PR may be delayed-type hypersensitivity to an infectious factor. However, positive staining of all biopsy materials with pan T lymphocyte marker CD3 supports the association with cellular immunity. We believe that more extensive studies are needed on this issue.

Pityriasis rosea of Gibert: immunological aspects

More than 200 years after first description and 150 years after complete definition by Gibert, pityriasis rosea (PR) is still a clinical entity with many obscure aspects. Although great interest was focused on aetiology, studies on immunological mechanisms associated with this disease were rather discontinuous. We present a review of the literature on immunological features of PR, aimed to outline a unified picture of currently available knowledge in this field and create a useful starting point for future research.

An atypical case of pityriasis rosea gigantea after influenza vaccination

Pityriasis rosea is a common erythematosquamous eruption, typically presenting along the cleavage lines of the skin. A wide spectrum of atypical manifestations may challenge even the most experienced physician. Here we report a rare case of a suberythrodermic pityriasis rosea with gigantic plaques after an influenza vaccination, and we discuss the possible triggers of atypical manifestations of such a common dermatological disease in the setting of an altered immunity.