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.

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.

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.

Pityriasis Rosea: Diagnosis and Treatment

Pityriasis rosea is a common self-limiting rash that usually starts with a herald patch on the trunk and progresses along the Langer lines to a generalized rash over the trunk and limbs. The diagnosis is based on clinical and physical examination findings. The herald patch is an erythematous lesion with an elevated border and depressed center. The generalized rash usually presents two weeks after the herald patch. Patients can develop general malaise, fatigue, nausea, headaches, joint pain, enlarged lymph nodes, fever, and sore throat before or during the course of the rash. The differential diagnosis includes secondary syphilis, seborrheic dermatitis, nummular eczema, pityriasis lichenoides chronica, tinea corporis, viral exanthems, lichen planus, and pityriasis rosea-like eruption associated with certain medications. Treatment is aimed at controlling symptoms and consists of corticosteroids or antihistamines. In some cases, acyclovir can be used to treat symptoms and reduce the length of disease. Ultraviolet phototherapy can also be considered for severe cases. Pityriasis rosea during pregnancy has been linked to spontaneous abortions.

Ischemic or toxic injury: A challenging diagnosis and treatment of drug-induced stenosis of the sigmoid colon

A 48-year-old woman was admitted with 15-mo history of abdominal pain, diarrhea and hematochezia, and 5-mo history of defecation difficulty. She had been successively admitted to nine hospitals, with an initial diagnosis of inflammatory bowel disease with stenotic sigmoid colon. Findings from computed tomography virtual colonoscopy, radiography with meglumine diatrizoate, endoscopic balloon dilatation, metallic stent implantation and later overall colonoscopy, coupled with the newfound knowledge of compound Qingdai pill-taking, led to a subsequent diagnosis of ischemic or toxic bowel disease with sigmoid colon stenosis. The patient was successfully treated by laparoscopic sigmoid colectomy, and postoperative pathological examination revealed ischemic or toxic injury of the sigmoid colon, providing a final diagnosis of drug-induced sigmoid colon stenosis. This case highlights that adequate awareness of drug-induced colon stenosis has a decisive role in avoiding misdiagnosis and mistreatment. The diagnostic and therapeutic experiences learnt from this case suggest that endoscopic balloon expansion and colonic metallic stent implantation as bridge treatments were demonstrated as crucial for the differential diagnosis of benign colonic stenosis. Skillful surgical technique and appropriate perioperative management helped to ensure the safety of our patient in subsequent surgery after long-term use of glucocorticoids.

Palmar initial lesion in pityriasisrosea

Pityriasisrosea is a frequently encountered skin disease associated with typical erythematous-squamous lesions. Majority of the cases relate to patients between 10 and 35 years of age. In clinically typical cases, the disease appears with the initial lesion called herald patch. The initial lesion generally locates on trunk, neck and proximal extremities. However, it can rarely be seen on other body parts such as face, scalp, and genital region. The initial lesion located on palmar region has been just once presented in literature. In this study, we present a 22-year-old female patient with palmar initial lesion who was followed up with misdiagnosis until rashes appeared on her body.

Bilateral scaly plaques in axillae: pityriasis rosea of Vidal

A 32-year-old man was referred for acute onset of pruritic scaly eruptions in the axillae of 8 days' duration, which was unresponsive to topical clotrimazole. The lesions consisted of multiple, coalescent oval plaques of 1 cm to 6 cm in longest diameter (Figure 1 and Figure 2) with central clearing and typical collarette scales at the periphery (Figure 3). Other skin areas and mucosal surfaces were unaffected. His general and systemic examinations were normal. Family and past histories were unremarkable except for a "ring worm-like patch" on his lower aspect of the abdomen 4 months ago, which rapidly regressed. On further inquiry, he gave a history of an episode of fever, coryza, and headache 3 weeks earlier to his eruption on the abdomen, which resolved with conservative remedies and one paracetamol tablet. He remained asymptomatic until axillary lesions appeared. We made a provisional diagnosis of pityriasis rosea (PR). Investigations including scrapings for potassium hydroxide examination, complete blood cell counts, urinalysis, blood sugar, VDRL test, and human immunodeficiency virus antibodies were all normal or non-reactive. As cutaneous biopsy revealed parakeratosis, epidermal spongiosis, dermal inflammatory cells, and extravasated red blood cells (Figure 4). The eruptions cleared within 8 days, following treatment with mometasone furoate cream and oral desloratidine 5 mg/d, leaving post-inflammatory hyperpigmentation. There was no recurrence for the next 6 months of observation. He was later lost to follow-up.

Vesicular palmoplantar pityriasis rosea

A 16-year-old young man presented with intensely itchy erythematous dermatitis on the body for 1 week and vesicular lesions on the palms and soles for 4 to 5 days. Lesions on the palms and soles were accompanied by severe burning and itching. The patient gave a history of sore throat and fever, 1 week prior to the onset of lesions. A general physical examination was normal, and cutaneous examination revealed multiple, well-defined erythematous scaly plaques with collaret scaling on the trunk and extremities (Figure 1). Vesicular lesions were seen on the palms and soles (Figure 2). The differential diagnoses we considered were pityriasis rosea and secondary syphilis. The possibility of dermatophytid, vesicular pityriasis rosea, and pompholyx was limited to the palms and sole lesions. Complete blood cell count was within normal limits. Results from antistreptolysin O titer, potassium hydroxide mount, and venereal disease research laboratory were negative. Skin biopsies were taken from the back and left palm. The biopsy specimen from the back revealed focal spongiosis, lymphocyte exocytosis, vacuolar changes in the basal layer, and perivascular lymphocytic infiltrate in the dermis (Figure 3). The biopsy obtained from the vesicular lesion on the left palm revealed an intraepidermal vesicle with no evidence of acantolytic process (Figure 4). A diagnosis of pityriasis rosea was made and the patient was started on clarithromycin 500 mg once a day for 7 days, along with antihistamines and emollients. The lesions faded dramatically in a very short period, and there was significant involution of almost all of the lesions after 7 days of clarithromycin. During the 6 months of follow-up, no recurrence was observed.

Segmental lesions in pityriasis rosea: a rare presentation

A 34-year-old nonpregnant woman noted a mildly pruritic skin lesion on her right breast for 1 week following an episode of coryza, malaise, and low-grade fever of 3 days' duration. The latter symptoms subsided without any treatment. Ketoconazole cream prescribed by her family physician did not resolve the breast eruption after 1 week, so was stopped. A week later, multiple skin lesions erupted suddenly on her right chest wall starting near the herald patch in midaxillary line and spread distally until the midback. She then consulted the authors. She denied a history of abrasion or trauma to the affected areas. Travel, contact, sexual, and drug histories were unremarkable. She categorically denied past or family history of eczema, psoriasis, contact dermatitis, and drug eruptions. On examination, the initial lesion was an annular and well-demarcated erythematous plaque on her right breast in the upper outer quadrant. Multiple small oval scaly plaques were noted, extending distally along the ribs to the midline on her back, not crossing the midline, predominantly over the distribution of right T4 dermatome (Figure 1). Peripheral collarette scaling was noted (Figure 2). A few scattered small lesions were also noted in the vicinity of this dermatome. Three isolated small plaques were also present on the trunk, one in the supramammary area and the other two on the abdomen and back, respectively. Palmoplantar and mucosal surfaces were uninvolved. The rest of the skin and systemic examination revealed no abnormalities. Complete blood cell counts, fasting glucose, and urinalysis were normal. Venereal Disease Research Laboratory (VDRL) results were nonreactive and human immunodeficiency virus (HIV) antibodies were negative. Repeat testing ofVDRL in serial dilutions and HIV antibodies after 3 months were also nonreactive and negative, respectively. Scrapings from the initial large lesion and subsequent smaller eruptions did not show any evidence of fungal infection on potassium hydroxide smear examination. The patient declined skin biopsy; however, we thought that the most diagnostic label for this condition was pityriasis rosea. Hence, we treated her with triamcinolone acetonide ointment 0.025% to be applied twice daily and desloratadine tablet 5 mg daily for 10 days. The patient demonstrated complete resolution, leaving postinflammatory hypopigmentation. There was no recurrence until 1 year after complete remission.

To treat or not to treat? Management of guttate psoriasis and pityriasis rosea in patients with evidence of group A Streptococcal infection

The association between guttate psoriasis and pityriasis rosea with Streptococcus pyogenes (S. pyogenes) is well established in the literature; however treatment guidelines and necessity have not been clarified with respect to the infectious etiology. Also, the exact role of Streptococcus in the immunopathogenesis of these entities, and the associated risk of development of scarlet fever and poststreptococcal sequelae, are not centrally reported. No single report or case series definitively establishes the coexistence between guttate psoriasis and post-streptococcal sequelae in the same patient, supporting the theories of autoimmune protection conferred between these entities. Laboratory investigations and treatment of Streptococcus in the setting of guttate psoriasis are not necessary, as anti-streptococcal treatment does not significantly modify the course of cutaneous disease, and there is no theoretical or documented risk of post-streptococcal sequelae. However, due to minimal data, antibiotics may still have a role in pityriasis rosea.

Oral erythromycin is ineffective in the treatment of pityriasis rosea

BACKGROUND

Despite the availability of various medical treatments for pityriasis rosea, a large percentage of patients fail to achieve satisfactory results. Erythromycin is reported to be effective in the treatment of pityriasis rosea.

METHODS

We designed a placebo-controlled study on 184 patients with pityriasis rosea attending the outpatient dermatology department at Hazrat-e-Rasul Hospital in Tehran, Iran. Adult patients were treated with 200 mg of erythromycin 4 times daily and children were treated with 20 to 40 mg/kg daily in 4 divided doses. Controls were given a placebo (an emollient cream) that was not identical in appearance. Subjects were seen at follow-up visits 2, 4, 6, and 8 weeks after starting treatment.

RESULTS

Both groups were comparable with regard to sex, age, and mean duration of disease at the time of attending the clinic. We found no significant difference between the 2 treatment groups at weeks 4, 6, and 8 after beginning of treatment. (p > .05 Chi2).

The natural history of pityriasis rosea in black American children: how correct is the "classic" description?

OBJECTIVES

To delineate the natural history of pityriasis rosea in black children and to compare our findings with those of the American, European, and African literature on pityriasis rosea. Textbook and journal article descriptions of pityriasis rosea usually offer information about the presentation and clinical course of this condition in white patients.

DESIGN

Prospective observational study.

SETTING

The general pediatric clinic, adolescent clinic, and emergency department of Children's Hospital of Michigan, Detroit, from June 2003 through May 2005.

PATIENTS

We followed up 50 black children with pityriasis rosea from the time of diagnosis through follow-up visits at 1, 2, and 4 weeks. Detailed observations were made and digital photographs taken at each visit.

MAIN OUTCOME MEASURES

Duration of illness and pigmentary sequelae.

RESULTS

Similarities with the medical literature were found regarding season of onset and prevalence of pruritus and of a herald patch. Our patients had more frequent facial involvement (30%) and more scalp lesions (8%) than usually described in white populations. One third had papular lesions. The disease resolved in nearly one half of patients within 2 weeks. Residual hyperpigmentation was seen in 48% of patients. Hypopigmentation developed in 29% of patients with purely papular or papulovesicular lesions.

CONCLUSIONS

Pityriasis rosea in black children differs in several ways from textbook descriptions. Physicians may use this information to better counsel patients about the course and potential sequelae of this condition.

Interventions for pityriasis rosea

BACKGROUND

Pityriasis rosea is a scaly rash that mainly affects young adults. It can be very itchy but most people recover within 2 to 12 weeks.

OBJECTIVES

To assess the effects of interventions for pityriasis rosea.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (December 2004), the Cochrane Central Register of Controlled Clinical Trials in The Cochrane Library (Issue 4, 2004), MEDLINE (1966 to January 2005), EMBASE (1976 to January 2005), LILACS (1982 to January 2005), BIOSIS Preview (1980 to June 2002), and ongoing trials databases. We scanned bibliographies of published studies, abstracts from dermatology conference proceedings, corresponded with trialists and contacted the pharmaceutical industry.

SELECTION CRITERIA

Randomised controlled trials evaluating interventions for pityriasis rosea.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors to retrieve missing data.

MAIN RESULTS

Three trials involving 148 people were included. One poor quality trial (23 people), compared intravenous glycyrrhizin and intravenous procaine. It found no significant difference between the two interventions for treating symptoms and rash. One fair quality trial (85 people), compared the oral antihistamine dexchlorpheniramine (4 mg), the oral steroid betamethasone (500 mcg), and a combination of betamethasone (250 mcg) and dexchlorpheniramine (2 mg). It found no significant difference in itch resolution at two weeks, as rated by the participants, between dexchlorpheniramine and betamethasone, and the combination of dexchlorpheniramine and betamethasone. However, both dexchlorpheniramine and betamethasone alone seem to be better at clearing rash than the combination of dexchlorpheniramine and betamethasone. These interventions were not compared with placebo. The small good quality trial (40 people) that compared oral erythromycin and placebo found that erythromycin was more effective than placebo in terms of rash improvement, as rated by the trialists, after two weeks (RR 13.00; 95% CI 1.91 to 88.64). It was also more effective in decreasing the itch score (difference of 3.95 points, 95% CI 3.37 to 4.53). No serious adverse effects were reported for the interventions. Two out of 17 people on oral erythromycin and 1 out of 17 on placebo reported minor gastrointestinal upset.

AUTHORS' CONCLUSIONS

We found inadequate evidence for efficacy for most treatments for pityriasis rosea. Oral erythromycin may be effective in treating the rash and decreasing the itch. However, this result should be treated with caution since it comes from only one small RCT. More research is necessary to evaluate the efficacy of erythromycin and other treatments.

Use of high-dose acyclovir in pityriasis rosea

BACKGROUND

The association of human herpesvirus 6 (HHV-6) and HHV-7 with pityriasis rosea suggests that systemic drugs directed against HHV may hasten recovery of patients with pityriasis rosea.

OBJECTIVE

The purpose of this study was to verify the efficacy of oral acyclovir in the treatment of pityriasis rosea.

METHODS

Eighty-seven consecutive patients were treated for 1 week with either oral acyclovir (800 mg 5 times daily) or placebo. In all patients, the time of lesion clearing and the number of new lesions appearing during treatment were recorded.

RESULTS

On the 14th day of treatment, 79% of treated patients fully regressed compared with 4% of the placebo group. The lesions cleared in 18.5 days in treated patients and in 37.9 days in the placebo group. Clearance was achieved in 17.2 days in patients treated in the first week from onset and in 19.7 days in the patients treated later. On the 7th day, there were significantly fewer new lesions in patients treated in the first week than in those treated later.

LIMITATIONS

This trial was neither randomized nor double blind. Objectivity was achieved by counting the lesions.

CONCLUSION

Acyclovir may be effective in the treatment of pityriasis rosea, especially in patients treated in the first week from onset, when replicative viral activity of HHV is probably very high.

Azithromycin does not cure pityriasis rosea

OBJECTIVES

Pityriasis rosea (PR) is a common skin disorder in children. Its cause is unknown. A recent publication reported a 73% cure rate in patients with PR after treatment with erythromycin. To duplicate this result using a drug with fewer adverse effects and greater biological half-life, we set out to study the effect of azithromycin on PR. Azithromycin is an azalide antibiotic with a spectrum of antimicrobial activity very similar to that of erythromycin.

DESIGN

We randomly assigned 49 children with PR to receive either azithromycin (12 mg/kg per day, up to a maximum of 500 mg/day) for 5 days or a similar-appearing placebo. Study physicians were blinded to patients' treatment type. Two pediatricians had to agree on the diagnosis of PR before patients could be enrolled. Subjects were seen at follow-up visits 1, 2, and 4 weeks after starting treatment.

OUTCOME MEASURES

We measured the appearance of new lesions and resolution of lesions.

RESULTS

Rates of cure and of partial resolution were similar in the azithromycin and placebo groups.

CONCLUSION

Azithromycin does not cure PR.

Atypical presentations of pityriasis rosea: case presentations

Atypical cases of pityriasis rosea (PR) are fairly common and less readily recognized than typical eruptions. We present four patients for whom we believe atypical PR is the most likely diagnosis. A 33-year-old man had purpuric lesions bilaterally on the legs with classical rash on the trunk. A 28-year-old woman had intensely pruritic and urticarial lesions. A 10-year-old girl had hundreds of small papular lesions 1-3 mm in size. A pregnant woman aged 26 had oral haemorrhagic ulcers with classical PR eruption on her trunk. The oral ulcers erupted and remitted at the same time as the generalized eruption. We reviewed the literature and proposed a classification based on rash morphology, rash size, rash distribution, number of lesions, site of lesions, severity of symptoms and course of the eruption. We believe that it is difficult to make a clear division to define typical and atypical PR, and that it is important not to ascribe any unusual or atypical skin eruption with PR unless other dermatoses have been excluded.

Pityriasis rosea with palmoplantar plaque lesions

Pityriasis rosea is a skin disease characterized by sharply defined pruritic red patches covered by fine scales. It affects mostly adolescent and young adults. Typical lesions usually affect the trunk in a Christmas-tree pattern. The eruption usually resolves after 6 weeks but symptomatic treatment may be needed. Two patients are reported with classic presentation of pityriasis rosea except for the unusual associated palmoplantar lesions; both patients had negative RPR (with dilutions) and MHA-TP. They responded to 2-week courses of either oral erythromycin or Clarithromycin with complete resolution.

The role of human herpes virus 6 and 7 in the pathogenesis of pityriasis rosea

Pityriasis rosea (PR) is an acute exanthematous inflammatory skin disease in which many epidemiological studies suggest a viral infection in its pathogenesis. Several viruses such as picornaviruses, parvoviruses and herpes viruses were accused as causative agents in PR. Human herpes virus-6 (HHV-6) and HHV-7 are newly discovered members of herpesviridae family. Several diseases including roseola infantum and PR have been linked with HHV-6 and HHV-7 in dermatology. We aimed to investigate the role of HHV-6 and HHV-7 in the pathogenesis of PR. Blood samples from 35 patients with acute PR and 30 healthy volunteers were examined to obtain titres for HHV-6 and HHV-7 antibodies. Anti-HHV-6 and -HHV-7 immunoglobulin (Ig) G antibodies were detected by IFA. The high titres of anti-HHV-6 IgG were determined in four patients and anti-HHV-7 IgG in only two of four patients. In our study, we haven't found any significant relationship between HHV-6, HHV-7 and PR. Our results were supported with the data of several previous studies.

Atypical pityriasis rosea and Hodgkin's disease+

Pityriasis rosea (PR)-like eruptions have been associated with several neoplasms and drugs. These eruptions may be atypical. To date, the association of Hodgkin's disease with PR-like eruptions has rarely been reported. We report a 37-year-old patient with clinical lesions of PR-like, systemic symptoms and lymphadenopathies, who was subsequently diagnosed with Hodgkin's disease.

Pityriasis rosea-like eruption due to pneumococcal vaccine in a child with nephrotic syndrome

A pityriasis rosea-like eruption can occur as a consequence of treatments with gold compounds and captopril. It has rarely been reported to have an association with vaccinations such as smallpox, BCG, hepatitis B, and diphtheria toxoid. It has not previously been documented to develop after pneumococcal vaccination. We report a case of pityriasis rosea-like eruption that developed following pneumococcal vaccination in a child with nephrotic syndrome.

Localized pityriasis rosea

Pityriasis rosea is a relatively common skin disorder. In its typical form it is easily recognizable; however, atypical forms can pose diagnostic problems. We report a 44-year-old woman with an acute onset of a localized eruption on her left breast. The morphology of the rash and the time course were typical of pityriasis rosea. Localized pityriasis rosea is an unusual variant, which has been described previously.

Erythromycin in pityriasis rosea: A double-blind, placebo-controlled clinical trial

BACKGROUND

The study stemmed from an incidental observation of improvement in 2 patients with pityriasis rosea while receiving erythromycin.

OBJECTIVE

The purpose of the study was to evaluate the efficacy of erythromycin in patients with pityriasis rosea.

METHODS

A double-blind, placebo-controlled clinical study was performed in an outpatient setting in a major hospital. Ninety patients over a period of 2 years were alternatively assigned to treatment group or placebo group. Patients in the treatment group received erythromycin in divided doses for 14 days. The response was categorized as complete response, partial response, or no response. All patients were followed up for 6 weeks.

RESULTS

Both groups were comparable with regard to age at presentation, sex, and average duration of disease at the time of reporting to the clinic. Upper respiratory tract infection before the appearance of skin lesions was reported in 68.8% of all patients. Complete response was observed in 33 patients (73.33%) in the treatment group and none in the placebo group (P <.0001).

CONCLUSION

Oral erythromycin was effective in treating patients with pityriasis rosea.

Immune-mediated pathology following hepatitis B vaccination. Two cases of polyarteritis nodosa and one case of pityriasis rosea-like drug eruption

The association of hepatitis B virus infection and vasculitis or other immune-mediated manifestations is well documented. Reports on such manifestations in relation to hepatitis B vaccination are scarce, however. We report 2 patients who developed polyarteritis nodosa following vaccination against hepatitis B. In one patient this resulted in an ischemic and necrotic digital ulcus, necessitating surgical amputation. The other patient presented with typical cutaneous polyarteritis nodosa which responded well to corticosteroid treatment. A third patient developed a severe pityrias rosea-like eruption. He was treated with topical steroids with healing of the lesions, leaving only post-inflammatory hyperpigmentation. The literature on these associations is reviewed.