The role of human herpesvirus 6, human herpesvirus 7, Epstein-Barr virus and cytomegalovirus in the aetiology of pityriasis rosea

Association between Pityriasis Rosea (PR) and HHV-6/HHV-7 Infection: Importance of Sample Selection and Diagnostic Techniques

Recent studies have focused on the role of human herpesvirus 6 (HHV-6) and human herpesvirus 7 (HHV-7) in PR etiology with varying results. In our study, with the approach that the discrepancy between the results may be related to the different samples and techniques used, we aimed to clarify the etiology by examining tissue and plasma samples using molecular methods and evaluating the results together with serological parameters. Skin biopsies and plasma samples of twenty-five PR patients were tested to detect HHV-6 and HHV-7 DNA using calibrated quantitative real-time polymerase chain reaction (CQ RT-PCR). IgG and IgM antibodies against HHV-6 and HHV-7 were tested by enzyme-linked immunosorbent assay and indirect immunofluorescence. Of the patient group, 64% were positive for HHV-6 IgG without IgM positivity. HHV-6 DNA was present in seven tissue and ten plasma samples. HHV-7 positivity was 100% and 12% for IgG and IgM antibodies, respectively. HHV-7 DNA was detected in four tissue samples and one plasma sample. Patients with HHV-7 DNA-positive plasma and tissue samples had also HHV-7 IgM antibodies. In conclusion, our results seem to support the role of HHV-6/HHV-7 in the etiology of PR. To clarify the etiology of PR and avoid confusion, the collection of different biological materials simultaneously and the usage of CQ RT-PCR as a diagnostic technique are recommended.

Interventions for pityriasis rosea

BACKGROUND

Pityriasis rosea is a scaly, itchy rash that mainly affects young adults and lasts for 2 to 12 weeks. The effects of many available treatments are uncertain. This is an update of a Cochrane Review first published in 2007.

OBJECTIVES

To assess the effects of interventions for the management of pityriasis rosea in any individual diagnosed by a medical practitioner.

SEARCH METHODS

We updated our searches of the following databases to October 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched five trials registers. We also checked the reference lists of included and excluded studies, contacted trial authors, scanned the abstracts from major dermatology conference proceedings, and searched the CAB Abstracts database. We searched PubMed for adverse effects to November 2018.

SELECTION CRITERIA

Randomised controlled trials of interventions in pityriasis rosea. Treatment could be given in a single therapy or in combination. Eligible comparators were no treatment, placebo, vehicle only, another active compound, or placebo radiation treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane. Our key outcomes were good or excellent rash improvement within two weeks, rated separately by the participant and medical practitioner; serious adverse events; resolution of itch within two weeks (participant-rated); reduction in itch score within two weeks (participant-rated); and minor participant-reported adverse events not requiring withdrawal of the treatment.

MAIN RESULTS

We included 14 trials (761 participants). In general, risk of selection bias was unclear or low, but risk of performance bias and reporting bias was high for 21% of the studies. Participant age ranged from 2 to 60 years, and sex ratio was similar. Disease severity was measured by various severity indices, which the included studies did not categorise. Six studies were conducted in India, three in Iran, two in the Philippines, and one each in Pakistan, the USA, and China. The included studies were conducted in dermatology departments and a paediatric clinic. Study duration ranged from 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding source. The included studies assessed macrolide antibiotics, an antiviral agent, phototherapy, steroids and antihistamine, and Chinese medicine. None of the studies measured participant-rated good or excellent rash improvement. All reported outcomes were assessed within two weeks of treatment, except for adverse effects, which were measured throughout treatment. There is probably no difference between oral clarithromycin and placebo in itch resolution (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.47 to 1.52; 1 study, 28 participants) or rash improvement (medical practitioner-rated) (RR 1.13, 95% CI 0.89 to 1.44; 1 study, 60 participants). For this comparison, there were no serious adverse events (1 study, 60 participants); minor adverse events and reduction in itch score were not measured; and all evidence was of moderate quality. When compared with placebo, erythromycin may lead to increased rash improvement (medical practitioner-rated) (RR 4.02, 95% CI 0.28 to 56.61; 2 studies, 86 participants, low-quality evidence); however, the 95% CI indicates that the result may also be compatible with a benefit of placebo, and there may be little or no difference between treatments. Itch resolution was not measured, but one study measured reduction in itch score, which is probably larger with erythromycin (MD 3.95, 95% CI 3.37 to 4.53; 34 participants, moderate-quality evidence). In the same single, small trial, none of the participants had a serious adverse event, and there was no clear difference between groups in minor adverse events, which included gastrointestinal upset (RR 2.00, CI 0.20 to 20.04; moderate-quality evidence). Two trials compared oral azithromycin to placebo or vitamins. There is probably no difference between groups in itch resolution (RR 0.83, 95% CI 0.28 to 2.48) or reduction in itch score (MD 0.04, 95% CI -0.35 to 0.43) (both outcomes based on one study; 70 participants, moderate-quality evidence). Low-quality evidence from two studies indicates there may be no difference between groups in rash improvement (medical practitioner-rated) (RR 1.02, 95% CI 0.52 to 2.00; 119 participants). In these same two studies, no serious adverse events were reported, and there was no clear difference between groups in minor adverse events, specifically mild abdominal pain (RR 5.82, 95% CI 0.72 to 47.10; moderate-quality evidence). Acyclovir was compared to placebo, vitamins, or no treatment in three trials (all moderate-quality evidence). Based on one trial (21 participants), itch resolution is probably higher with placebo than with acyclovir (RR 0.34, 95% CI 0.12 to 0.94); reduction in itch score was not measured. However, there is probably a significant difference between groups in rash improvement (medical practitioner-rated) in favour of acyclovir versus all comparators (RR 2.45, 95% CI 1.33 to 4.53; 3 studies, 141 participants). Based on the same three studies, there were no serious adverse events in either group, and there was probably no difference between groups in minor adverse events (only one participant in the placebo group experienced abdominal pain and diarrhoea). One trial compared acyclovir added to standard care (calamine lotion and oral cetirizine) versus standard care alone (24 participants). The addition of acyclovir may lead to increased itch resolution (RR 4.50, 95% CI 1.22 to 16.62) and reduction in itch score (MD 1.26, 95% CI 0.74 to 1.78) compared to standard care alone. Rash improvement (medical practitioner-rated) was not measured. The trial reported no serious adverse events in either group, and there may be no difference between groups in minor adverse events, such as headache (RR 7.00, 95% CI 0.40 to 122.44) (all results based on low-quality evidence).

AUTHORS' CONCLUSIONS

When compared with placebo or no treatment, oral acyclovir probably leads to increased good or excellent, medical practitioner-rated rash improvement. However, evidence for the effect of acyclovir on itch was inconclusive. We found low- to moderate-quality evidence that erythromycin probably reduces itch more than placebo. Small study sizes, heterogeneity, and bias in blinding and selective reporting limited our conclusions. Further research is needed to investigate different dose regimens of acyclovir and the effect of antivirals on pityriasis rosea.

[Significance of PCR detection of HHV6 in gastro biopsy on the course of diarrhea in patients with severe diarrhea after allogeneic hematopoietic stem cell transplantation]

目的

探讨肠黏膜人疱疹病毒6型（HHV6）检测在异基因造血干细胞移植（allo-HSCT）术后重度腹泻患者中的意义。

方法

回顾性分析2015年2月至2016年8月于北京大学血液病研究所行allo-HSCT后出现重度腹泻并行肠镜检查及肠黏膜活检的患者资料；HHV6、CMV、EBV检测采用RT-PCR方法；肠黏膜病理检查也包括免疫组化方法检测CMV早期抗原、CMV晚期抗原，原位杂交检测EBV。

结果

共有45例患者纳入研究，其中21例（46.7%）肠黏膜活检HHV6阳性，包括男13例，女8例，中位年龄29（14~54）岁；肠黏膜HHV6阳性与阴性组患者血CMV阳性检出率差异无统计学意义（76.2%对87.5%，P>0.05），但EBV血症发生率前者（6/21，28.6%）明显高于后者（1/24，4.2%）（P=0.028）；两组患者在腹泻发生的时间、次数及量方面差异无统计学意义（P值均>0.05）。45例患者中44例接受了膦甲酸钠和（或）更昔洛韦抗病毒治疗，抗病毒治疗并没有影响腹泻的进程。

结论

肠黏膜HHV6阳性在allo-HSCT术后重症腹泻患者中发生率高，未发现其对于治疗及预后有临床意义。肠黏膜HHV6阳性并不能证明HHV6在肠道的感染。

Effectiveness of acyclovir in the treatment of pityriasis rosea. A systematic review and meta-analysis

BACKGROUND

There is a lack of evidence to support acyclovir administration in pityriasis rosea.

OBJECTIVE

To determine the efficacy of acyclovir in patients with typical pityriasis rosea.

METHODS

A systematic review and meta-analysis of experimental studies was performed in MEDLINE, SCOPUS, EMBASE and others, from January 1990 to October 2016 on acyclovir for pityriasis rosea. Random effect model was used to find the pooled Risk Ratio. Outcomes, evaluated between weeks 1 to 8, were regression of lesions, cessation of lesions, decrease of symptoms and duration of disease. Comparisons were acyclovir vs. placebo; acyclovir vs. symptomatic treatment; acyclovir vs. antibiotic; acyclovir vs. observation and combined therapy (acyclovir plus symptomatic treatment) vs. symptomatic treatment alone.

RESULTS

Seven papers were analyzed with 324 participants, of which 159 received acyclovir and 165 were controls. Acyclovir was superior to placebo for complete regression of lesions at week 1 (Risk Ratio 5.72, CI95% 2.36-13.88). However, combined therapy was not superior to symptomatic treatment at week 4 (Risk Ratio 1.46, CI95% 0.93-2.29). Individual studies showed the superiority of acyclovir for the control of symptoms and pruritus.

STUDY LIMITATIONS

We faced differences designs of trials and inconsistency between reports.

CONCLUSION

Symptomatic treatment is a reasonable option for pityriasis rosea, and the addition of acyclovir is justified for the control of symptoms and pruritus.

Histopathology of Cutaneous Inflammatory Disorders in Children

Inflammatory dermatoses encompass a variety of histologic patterns that affect different portions of the skin. In spongiotic, psoriasiform, lichenoid, pityriasiform, and blistering disorders, there are predominately epidermal and junctional activities with variable superficial dermal inflammation. Hypersensitivity reactions can show either epidermal or mostly dermal changes depending on whether the exposure of the exogenous allergen occurs through an external or internal route, respectively. Exceptions include erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis, where the etiology is often due to infection or ingested medications, but the histologic features are almost exclusively confined to the epidermis and dermoepidermal junction. Autoimmune disorders are unique in that lesions typically incorporate a mixture of epidermal and dermal inflammatory patterns with periadnexal inflammation, while the vast majority of vasculitis/vasculopathy and alopecia have changes limited to only the vessels and hair follicles, respectively. It is critical to recognize that a relatively limited number of histologic patterns are seen in a large array of clinical entities. Therefore, clinicopathologic correlation and careful examination of histologic details are of the utmost importance when evaluating skin biopsies for inflammatory disorders.

Atypical Case of Pityriasis Rosea in a Child Following Streptococcal Erythema Nodosum

Introduction:Pityriasis rosea (PR) is a widespread skin erythemato-squamous eruption, occurring mostly in young adults.

Case presentation:A 9-year-old patient presented with multiple lesions developed after streptococcal pharyngitis and erythema nodosum diagnosed and treated with penicillin prior to the PR.

Conclusion:This unique case should be considered a coincidence of two consecutive diseases.

Red Cell Distribution Width and Mean Platelet Volume in Patients With Pityriasis Rosea

Background

Pityriasis rosea (PR) is an inflammatory skin disorder of unknown etiology. However, it is suggested to be related with the reactivation of human herpes virus 7 (HHV-7) and/or HHV-6. It is sometimes diffucult to distinguish PR from PR-like drug eruptions and other inflammatory disorders, so we need new parameters which are cheap and easy in determining PR. Red blood cell distribution width (RDW) and mean platelet volume (MPV) have been studied as inflammatory markers in recent studies. However, the RDW and MPV in PR patients have not been investigated. This is the first study investigating RDW and MPV parameters in PR.

Methods

This was a retrospective study of 127 patients and 127 healthy controls. MPV, RDW and the other laboratory tests were recorded.

Results

RDW levels of patients with PR were significantly lower than those of the controls (13.66 ± 2.68 and 14.00 ± 1.39, P < 0.01). The other inflammatory markers such as MPV (9.97 ± 0.99 and 10.0 ± 1.06, P = 0.7) and platelet (2.66.29 ± 62.85 and 277.41 ± 63.50, P = 0.3) were studied and statistically significant differences were not obtained. There were no significant differences found between the patient group and healthy controls in terms of hemoglobin, hematocrite, C-reactive protein (CRP), sedimentation, mean corpuscular volume (MCV), aspartate aminotransferase (AST), red blood cell (RBC), alanine aminotransferase (ALT), blood urea nitrogen (BUN), and creatinine parameters (P > 0.05).

Conclusion

RDW can be used as a marker in diagnosing PR.

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.

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.

Applicability of proposed diagnostic criteria of pityriasis rosea: results of a prospective case-control study in India

BACKGROUND

The diagnosis of pityriasis rosea (PR) is generally clinical. Previous studies usually recruited relatively small numbers of patients and control subjects, leading to low power of study results. Systematic reviews and meta-analyses cannot be readily performed, as the inclusion and exclusion criteria of these studies were not uniform. We have previously validated a set of diagnostic criteria (DC) in Chinese patients with PR.

AIM

Our aim is to evaluate the validity and applicability of the DC of PR in Indian patients with PR.

STUDY DESIGN

Prospective unblinded pair-matched case-control study.

MATERIALS AND METHODS

The setting is a dermatology clinic in India served by one board-certified dermatologist. We recruited all 88 patients seen by us during five years diagnosed to have PR to join our study. For each study subject, we recruited the next patient who consulted us with differential diagnoses of PR as control subjects. We applied the DC of PR on all study and control subjects.

RESULT

The sensitivity, specificity, positive predictive value, and negative predictive value of the DC were all 100%. Two-tailed Fisher's exact probability test result was 0.036. Φ was 1.00.

CONCLUSION

The set of DC can be validly applied to Indian patients with PR.

Pityriasis rosea associated with pegylated interferon alfa and ribavirin treatment in a patient with chronic hepatitis C

BACKGROUND

Pityriasis rosea is an acute inflamatory skin disease that the etiology is unknown but some viral agents like human herpes virus-6 and 7 and drugs are suspected.

CASE REPORT

A-58-year-old man with chronic hepatitis C was being followed up in our hospital. Pegylated interferon (PEG-IFN) alfa-2b (100 μg per week) and ribavirin (1000 mg/day) was started. In the third month of this treatment, the patient was diagnosed with pityriasis rosea (PR), which was confirmed by skin biopsy. PEG-IFN alfa-2b treatment for chronic hepatitis C was maintained and no therapy was given for PR. The lesions spontaneously improved within 5 weeks.

CONCLUSION

Interferon and ribavirin have several cutaneous side effects. Our case is the first case of PR, emerged in a patient with chronic hepatitis C while receiving PEG-IFN alfa 2b and ribavirin.

Concurrence of lichen striatus and localised pityriasis rosea: Cutaneous mosaicism

Cutaneous mosaicism has always been an intriguing subject. A 15-year-old boy presented to us with a unilateral band of lesions of pityriasis rosea and lichen striatus. The case is discussed in the light of the concept of genetic mosaicism.

Gianotti-Crosti syndrome, pityriasis rosea, asymmetrical periflexural exanthem, unilateral mediothoracic exanthem, eruptive pseudoangiomatosis, and papular-purpuric gloves and socks syndrome: a brief review and arguments for diagnostic criteria

Several exanthems including Gianotti-Crosti syndrome, pityriasis rosea, asymmetrical periflexural exanthem, eruptive pseudoangiomatosis, and papular-purpuric gloves and socks syndrome are suspected to be caused by viruses. These viruses are potentially dangerous. Gianotti-Crosti syndrome is related to hepatitis B virus infection which is the commonest cause of hepatocellular carcinoma, and Epstein-Barr virus infection which is related to nasopharyngeal carcinoma. Pityriasis rosea has been suspected to be related to human herpesvirus 7 and 8 infections, with the significance of the former still largely unknown, and the latter being a known cause of Kaposi's sarcoma. Papular-purpuric gloves and socks syndrome is significantly associated with human B19 erythrovirus infection which can lead to aplastic anemia in individuals with congenital hemoglobinopathies, and when transmitted to pregnant women, can cause spontaneous abortions and congenital anomalies. With viral DNA sequence detection technologies, false positive results are common. We can no longer apply Koch's postulates to establish cause-effect relationships. Biological properties of some viruses including lifelong latent infection, asymptomatic shedding, and endogenous reactivation render virological results on various body tissues difficult to interpret. We might not be able to confirm or refute viral causes for these rashes in the near future. Owing to the relatively small number of patients, virological and epidemiology studies, and treatment trials usually recruit few study and control subjects. This leads to low statistical powers and thus results have little clinical significance. Moreover, studies with few patients are less likely to be accepted by mainstream dermatology journals, leading to publication bias. Aggregation of data by meta-analyses on many studies each with a small number of patients can theoretically elevate the power of the results. Techniques are also in place to compensate for publication bias. However, these are not currently feasible owing to different inclusion and exclusion criteria in clinical studies and treatment trials. The diagnoses of these rashes are based on clinical assessment. Investigations only serve to exclude important differential diagnoses. A wide spectrum of clinical features is seen, and clinical features can vary across different populations. The terminologies used to define these rashes are confusing, and even more so are the atypical forms and variants. Previously reported virological and epidemiological results for these rashes are conflicting in many aspects. The cause of such incongruence is unknown, but low homogeneity during diagnosis and subject recruitment might be one of the factors leading to these incongruent results. The establishment and proper validation of diagnostic criteria will facilitate clinical diagnosis, hasten recruitment into clinical studies, and allow results of different studies to be directly compared with each another. Meta-analyses and systematic reviews would be more valid. Diagnostic criteria also streamline clinical audits and surveillance of these diseases from community perspectives. However, over-dependence on diagnostic criteria in the face of conflicting clinical features is a potential pitfall. Clinical acumen and the experience of the clinicians cannot be replaced by diagnostic criteria. Diagnostic criteria should be validated and re-validated in response to the ever-changing manifestations of these intriguing rashes. We advocate the establishment and validation of diagnostic criteria of these rashes. We also encourage the ongoing conduction of studies with a small number of patients. However, for a wider purpose, these studies should recruit homogenous patient groups with a view towards future data aggregation.

The comparison between the efficacy of high dose acyclovir and erythromycin on the period and signs of pitiriasis rosea

Background:

Pityriasis Rosea (PR) is an acute inflammatory and self-limiting skin disorder, sometimes with troublesome symptoms. To date, there are few treatments available for this disorder.

Aim:

Compare the traditional treatment with erythromycin to a newly introduced antiviral treatment acyclovir for PR.

Materials and Methods:

Patients with clinically confirmed diagnosis of PR, matching our exclusion criteria, were enrolled. They were randomized in two groups that received high-dose oral acyclovir or erythromycin. The participants were evaluated two, four, and eight weeks after commencement of the study and followed for one year.

Results:

A total of 30 patients including 15 males and 15 females completed the study. After eight weeks, 13 patients in the acyclovir group experienced complete response, while in the erythromycin group only six patients had complete response (P < 0.05). Also, patients in the acyclovir group experienced faster resolution of pruritus in comparison with the erythromycin group (not significant). No adverse drug reaction was detected in both groups.

Conclusion:

It seemed that a high-dose of oral acyclovir was a safe and effective therapy for PR, although this remained to be confirmed in larger studies.

Human Herpesvirus 6 Infection in Hemodialysis and Peritoneal Dialysis Patients

Background

Human herpesvirus 6 (HHV-6) infection occurs worldwide and can be reactivated from latency during periods of immunosuppression, especially after organ transplantation. No previous study has evaluated the influence of dialysis type on HHV-6 infection. The aim of the present study was to determine the prevalence of HHV-6 antibodies in hemodialysis (HD) and peritoneal dialysis (PD) patients.

Methods

W e studied 36 PD patients, 35 HD patients, and 20 healthy subjects, all with no history of organ transplantation. After systematic inquiries and a physical examination, blood was drawn for determination of biochemical parameters, cytomegalovirus immunoglobulin M (IgM) and immunoglobulin G (IgG), hepatitis B surface antigen, and the hepatitis C and human immunodeficiency virus antibodies. Titers of HHV-6 IgM and IgG antibodies were determined by ELISA.

Results

Titers for HHV-6 IgM antibody were positive in 9 HD patients (25.7%), 8 PD patients (22.2%), and 2 control subjects (10.0%, p > 0.05). More HD patients (20.0%) than PD patients (5.6%, p = 0.07) or control subjects (0.0%, p =0.03) were positive for HHV-6 IgG antibody. In HD patients, HHV-6 IgG seropositivity and duration of dialysis were positively correlated (R = 0.33, p = 0.05).

Conclusions

Infection with HHV-6 is not rare in PD and HD patients. In addition, HHV-6 IgG seropositivity was significantly higher in H D patients than in control subjects and approached significance when compared with seropositivity in PD patients. Moreover, in HD patients, HHV-6 IgG seropositivity correlated with duration on HD. These preliminary findings provide insight into the pre-transplantation period for patients and may aid our understanding of how to best protect patients against HHV-6 after transplantation.

Hematopoietic cell transplantation and emerging viral infections

Viral infections remain important causes of morbidity and mortality in hematopoietic cell transplant recipients. More recent developments in preparative regimens and graft manipulations, as well as the control of well-recognized post-transplant infections by the introduction of prophylaxis and preemptive strategies, have influenced the timing and the epidemiology of infections. As new pathogens, such as human metapneumovirus (HMPV), human bocavirus, human coronaviruses HCoV-NL63 and HCoV-HKU1, human herpesviruses HHV-6 and HHV-7, and polyomaviruses, have emerged, it is fundamental to determine the significance of the newly discovered viruses and their role in the transplantation field. This article summarizes recent data on epidemiology and laboratory diagnosis of new pathogens, as well as clinical features and management of the associated infectious complications. J. Med. Virol. 82:528-538, 2010. (c) 2010 Wiley-Liss, Inc.