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Pityriasis Rosea: Not Just a Seasonal Rash

By: Risa Caldoza, MD, FPAMS, FPAPSHPIPityriasis Rosea: Not Just a Seasonal Rash

Jonah, a 26-year-old flight attendant, woke up one morning and saw a pink rough oval patch of slightly raised skin, the size bigger than a one-peso coin in her chest. It wasn’t itchy or anything so she let it be. More than a week later, the patch was growing and a bunch of small spots that peel off to scales have sprouted across her chest and tummy and this time, it was really itchy. The spots were almost identical on both sides of her body. Quite anxious, she went to me for consultation and after a lengthy interview and physical examination, I diagnosed her with pityriasis rosea. “So you have what we call a Christmas tree rash. The pink rash is the herald or mother patch, the smaller round ones with a crinkly center are her daughters,” I said.

These characteristic symptoms of mother and daughter patches are typical of pityriasis rosea. The herald pink patch is surrounded by a rim or ‘collarette’ of scales. Sometimes this patch is absent in up to 30 percent of cases. The daughter patches sweep out and form drooping pine tree branches or an inverted V pattern, thus the term Christmas tree rash. The rashes appear on the trunk, back, upper arms, thighs or neck and usually spares the soles of the feet, face, palms or scalp. They normally follow the skin lines. Surprisingly, a recent study found that almost two of 10 patients have lesions in their mouths.

Almost 200 years ago, in 1798, British physician Robert Willan first described a self-healing skin eruption and called it roseola annulata. However, in 1860, an eminent French physician named Camille Gilbert described this benign rash in medical literature and renamed it to pityriasis rosea or ‘fine pink scale’.  In his third treatise, Gilbert wrote: “There are small branny patches, very slightly colored, irregular, of a size which seldom exceeds that of the size of the nail.” Pityriasis comes from the Greek word for bran (pityron) since the flakes of skin shed from the lesions resemble small pieces of wheat bran. Rosea hails from a Latin word that means ‘rose-colored’ or ‘pink’.

The condition is universal and accounts for about two per 100 dermatological patients. It can affect anyone, most especially those in the 10 to 35 age group and slightly more common in the fairer sex. Half of the cases occur before the age of 20. It rarely affects the elderly and infants. Jonah disclosed that about a week before she had the mother patch, she was feeling under the weather. She had headache and body pain and thought she was going to have the flu. She took ibuprofen but it did not work. Other patients complain of stuffy nose, sore throat and fever, loss of appetite, swollen lymph nodes, and symptoms resembling an upper respiratory infection before the herald patch appears. This is called prodromal symptoms.

“How did I get this?” asked Jonah. The answer is ‘idiopathic’ (medicalese for unclear) as we are still trying to figure it out. Research shows that it is not an allergy, not a sign of an internal disease, nor caused by fungi or bacteria. Studies show it might be triggered by a viral infection, a reactivation of certain strains of the human herpes virus 6 and 7 (No, it’s not THAT herpes virus that causes STD or cold sores!). The fact that it is accompanied by mild flu-like symptoms and because it occurs in clusters like in schools, army barracks, and families bolster this theory. High levels of emotional stress are said to increase the severity of the skin lesions in some patients.

Some researchers say that the immune system plays a role. Other studies implicate drugs that may lead to drug-induced pityriasis rosea, including barbiturates (sedatives), bismuth, captopril (used in high blood pressure), gold (used in rheumatoid arthritis), metronidazole (antibiotic), D-penicillamine (chelating agent), and isotretinoin (anti-aging skin preparation). 

It may look and sound worse than it really is but it’s not benign and not contagious. It goes away on its own within two to three months in eight of 10 cases. More good news: it’s a one-off event, it doesn’t return after it goes away.

Pityriasis rosea may appear during pregnancy. This is when we worry because complications might be serious for moms-to-be. You have to see your OB-GYN immediately. A small study has shown that pityriasis rosea during the first 15 weeks pregnancy is linked with premature birth or fetal death. Studies are conflicting about this, saying the condition is so benign pregnant women shouldn't be worried. I say, better safe than sorry.

“Will it leave marks?” the beautiful Jonah worried. On darker skin, brown spots or lighter pigmentation may be left behind after the rash has healed. These may last for months but eventually fade. It rarely leaves scars. Even if it did leave unsightly marks, you can come to me so I can laser them off!

Stop the itch!

Many cases require no treatment at all and only takes reassuring the patient that it is self-limiting and she can’t spread it to another person. However, as supportive treatment, we often recommend topical medications to help alleviate symptoms. These medications are mostly geared to reduce or stop the itch, which is severe in a quarter of patients, while waiting for the rash to resolve.

Topical corticosteroids are medications you apply directly to the skin. I’m sure you’ve heard of some common corticosteroids such as hydrocortisone, mometasone, betamethasone, and clobetasol. They are used to treat different skin conditions ranging from allergy, eczema to psoriasis and also address inflammation or swelling and redness and suppress the immune system. It may come as cream, lotion, gel, mousse, and ointment. They’re available in different strengths ­– mild, moderate, potent, and very potent. Like with everything else, the greater the strength, the greater the risk.

For Jonah, I prescribed a medium-strength topical cream applied thinly and evenly only to the affected areas once or twice a day for several weeks. I prefer cream since ointments are more greasy and sticky. Creams can be spread easily on larger areas of the body and absorbed quicker than ointments. Applying it thinly minimizes the amount absorbed through the skin into the body. She can’t use it long-term though because of potential adverse effects.

Antihistamines, often taken for allergies, also treat rashes and itching. In some cases, your doctor may want you to take prescription drugs such as corticosteroids, which lessen itching and swelling, or acyclovir, an antiviral used for herpes disease. However, there is no evidence that antiviral agents are effective.

You may also do these things:

  • Avoid scratching. An itch-scratch cycle may develop where the more you scratch, the more you itch and vice versa.
  • Take lukewarm showers or soak in oatmeal baths. Hot baths may make the itching worse.
  • Some suggest you get natural or artificial sunlight. The ultraviolet (UV) rays are said to slash the time you have the rash. Mild early morning or late afternoon sunshine may be beneficial but be careful not to get sunburnt. UV therapy is best when done in the first week of the eruptions.
  • Put cold compresses on itchy spots.
  • Avoid clothes made of wool or acrylic fabrics.
  • Avoid harsh soaps, deodorants, and perfumes.
  • Avoid strenuous physical activity, which can aggravate existing rashes.
  • If the rash does not clear up after 3 months, go back to your skin care physician.
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