Pityriasis Rosea in Pregnancy

Pityriasis Rosea is a acute self-healing skin disease commonly seen in people between 10 and 35 of age, but can occur at any age. Although Pityriasis Rosea is harmless self-healing disease which usually resolves after 4-8 weeks, most pregnant women concern on its effects in pregnancy.

Pityriasis Rosea is reported to occur more frequently in pregnancy at a rate of 18% compared to 6% in general population. Though previous studies suggested no harm during pregnancy, current studies suggest that pityriasis rosea may result in spontaneous abortion, premature delivery with neonatal hypotonia and fetal loss especially if it develops before 15 weeks of gestation. These studies were performed on limited number of people and showed that miscarriage might be due to viral infection especially HHV-6. More large scale studies may be required in order to confirm the cause of fetal harm by pityriasis rosea in pregnancy and the cause of pityriasis rosea itself.

If you have pityriasis rosea and you are pregnant, consult your dermatologist. They would definitively give you a better suggestion. As Pityriasis Rosea required no treatment. Treatment is usually focussed on relieving the symptoms and to exclude other associated viral infection like secondary syphilis, herpesvirus, cytomegalovirus, parvovirus and Epstein-Barr which might cause harm to the fetus. For symptomatic relief your dermatologist may prescribe soothing lotions like topical zinc oxide or calamine lotion.

Remember:

  • Excess water, sweat, deodorants or deodorant soaps might irritate your skin. So, try to avoid it. use gentle soaps if needed.
  • Avoid hot water baths. Use cool water as much as possible.
  • Take an oatmeal bath. Search your local pharmacy for oatmeal bath products.
  • Keep the itchy area cool and moist. Use of moisturizing creams and soothing lotions like calamine lotion is recommended.
  • Avoid wool and synthetic fabrics. Wear cotton or silk clothing.

References:

1. Drago F, Broccolo F et al. Pregnancy outcome in patients with pityriasis rosea. J Am Acad Dermatol. 2008 May;58(5 Suppl 1):S78-83

Pityriasis Rosea

Pityriasis Rosea, also known as Pityriasis Rosea Gibert  is a common and self-limiting type of skin rash commonly seen in older children and young adults, but may occur at any age. Pityriasis Rosea may be seen at anytime of the year, but is most common during spring and fall.

Pityriasis Rosea Causes

The cause of pityriasis Rosea is unclear, but the data provided by many epidemiologic, experimental, and clinical  studies suggest an infectious origin. Pityriasis rosea is not a sign of any internal disease, nor is it caused by a fungus, a bacteria, or an allergy. All available evidence suggest that it may be more likely due to reactivation of human herpesviruses (HHV-6 and -7 ). We could say that, it is probably a multifactorial disease that can be induced by various infectious agents.

Pityriasis Rosea Symptoms:

Prodromal Symptoms
Though not reported in every patients, most of the patients may complain of nausea, malaise, loss of appetite, headache, fever, irritability, upper respiratory symptoms ( sore throat), gastrointestinal symptoms, joint pain and swelling of lymph nodes before the cutaneous sign appear.

Cutaneous Eruption

Primary Eruption:
Usually, Pityriasis rosea rash begins with a single, large, round or oval, scaly, pink patch on the chest, neck, abdomen, back or extermities which is called a “herald” or “mother” patch. But sometimes it may also occur as multiple lesions or in atypical locations, which may be often confused with other infection like tinea, psoriasis or secondary syphilis. The Herald patch is paler and slightly depressed or wrinkled in the centre and slightly elevated, dark red and scaly in the periphery. The patch enlarge progressively reaching 3 cm or more in diameter and remains isolated for about 2 weeks or more after which secondary generalized eruption appears.

Secondary Eruption:
This secondary eruptive phase starts 1-2 weeks after the herald patch is seen. (Although in few cases it may occur from hours to months after herald patch is seen). This phase is characterized by eruption of patches that looks similar to the initial one and are smaller and symmetrically oriented seen predominantly on the trunk, the abdomen, back, and the proximal upper extremities. These are salmon-colored, oval macules or patches ranging from 0.5 to 1.5 cm in diameter, with collarette scale, often described as cigarette paper like appearance. They may usually form a christmas tree like pattern at the back. Pruritus may occurs in 75% of patients and may be severe in 25%. Warm environment, bathing in hot water or physical activities like running may worsen the itching and the rashes.

Atypical Pityriasis Rosea:

Atypical pityriasis rosea occurs in 20% of patients. They may be atypical for their size, number, distribution, morphology, location, severity and course. These atypical pityriasis rosea may be associated with missing herald patch or multiple herald patch, peripheral distribution, and may be localized in a area like abdomen, axilla, face, groin, distal extremities, the palm and the soles. Atypical presentations are usually seen in younger children then in adults.

Oral Involvement
Oral lesions are not commonly seen in PR. If there is oral involvement, hemorrhagic spots, ulcers, papules, vesicles, bullae, or erythematous plaques may be seen. Study suggests that they may be more common to occur in dark skinned people. They usually disappear along with the cutaneous lesion or few days later.

Pityriasis Rosea in Pregnancy
Pityriasis Rosea has been reported to occur more frequently in pregnancy than in the general population (18% vs 6%). PR may result in spontaneous abortion, premature delivery with neonatal hypotonia, especially if it develops before 15 weeks of gestation.

Laboratory Findings in Pityriasis Rosea:

Laboratory findings in PR may usually be in normal range, so it will not help in diagnosis. If its an atypical case or hard to differentiate one can perform lab test to rule out other possible disease.
Syphilis: Screening rapid Plasma Reagin ( RPR) test or VDRL , if required HIV test can be performed.
Tinea: KOH test
Nummular dermatitis, Guttate psoriasis : perform a biopsy.

Other possible diagnosis one may consider:

  • Guttate Psoriasis
  • Lichen Planus
  • Nummular Dermatitis
  • Seborrheic Dermatitis
  • Secondary Syphilis
  • Pityriasis lichenoides
  • Tinea Corporis
  • Erythema Dyschromicum Perstans
  • Other Viral exanthems
  • Primary human immunodeficiency viral infection
Excluding Common disease

Secondary syphilis: In secondary syphilis there may be history of primary chancre, no herald patch are seen, lesion usually involves palms and soles, condyloma lata may be present and they are usually associated with other systemic complaints and lymphadenopathy. It can be confirmed by serology test like RPR or VDRL
Tinea corporis: In Tinea corporis scale is usually at periphery of plaques, plaques are usually not oval and distributed along the lines of cleavage. It can be confirmed by KOH examination.
Nummular dermatitis: In Nummular dermatitis, plaques are usually circular and not oval, no collarettes of scale occurs, tiny vesicles are common. It can be excluded by biopsy
Guttate psoriasis: In Guttate psoriasis, plaques usually are smaller than PR plaques and do not follow lines of cleavage, scale is thick and not fine. It can be excluded by Biopsy
Pityriasis lichenoides chronica: It has longer disease course, smaller lesions, thicker scale, with no herald patch and more common on extremities. It can be excluded by biopsy.
PR-like drug eruption: It can be excluded by obtaining drug history.

Association of Pityriasis Rosea:

PR has been associated with prior history of upper respiratory infection, asthma and eczema. Several research papers have associated PR like eruption in neoplasms ( those of gastric, bronchogenic), T-cell lymphomas, hodgkin disease, bone marrow transplantation. PR is a common disease, so these association may just be a coincidence by chance or it may also be due to the reactivation of latent virus triggered by the immunologic changes.

Pityriasis Rosea Treatment

In most cases, Pityriasis rosea will usually go away on its own within four to six weeks. No specific treatment are recommended on the basis of evidence based medicine. In some atypical and severe cases treatment can be prescribed accordingly. So treatment modalities are mainly focused on controlling itching and symptomatic relief.

Controlling the itch:

  • Oral Antihistamines: Cetrizine, fexofenadine, chlorpheniramine, loratadine.
  • Soothing lotions like calamine lotions.
  • Low or mild potent steroids Creams or ointments. ( in some cases topical steroids may cause the eruption to generalize to erythroderma).
  • Steroids and antihistamines doesn’t speedup the disease recovery but will control discomfort.
  • Avoiding soaps, avoiding hot water bath and use of moisturizing creams is needed.

Treatment of Pityriasis Rosea Rash

  • Low to mild potency steroids may be used.
  • Systemic steroids are not recommended, until and unless required for some very severe cases.
  • Systemic steroids will not shorten the disease progression, in fact they might even prolong or exacerbate the disease.
  • Patients with associated flu-like symptoms or with extensive skin rash may be given early course of oral Acyclovir or its derivatives . This may reduce the duration of PR by one or two weeks.
  • Light therapy either Ultraviolet B or brief introduction to sunlight may be beneficial to some patients. But are are few possibility of post-inflammatory pigmentation with light therapy.
  • Antibiotics like erythromycin and azithromycin and other macrolides have been tried without much success. They were thought to shorten the disease course.

Study Finds No Association Between Streptococcus Pharyngitis And Pityriasis Rosea

A study at Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research, India suggests that there is no association between streptococcus pharyngitis and pityriasis rosea.

Pityriasis rosea is self limited skin condition of uncertain etiology. The exact cause of pityriasis rosea is not known but various hypotheses have been postulated incriminating infective agents such as viruses, bacteria, spirochete and noninfective etiologies such as atopy and autoimmune causes have also been investigated.

They undertook a study to investigate the role of Streptococcus haemolyticus in the causation of pityriasis rosea and study the levels of C-reactive protein (CRP) and ASLO titer in patients with pityriasis rosea.

The study included 20 patients with pityriasis rosea attending the outpatient dermatology department at JIPMER hospital during the period from June to December 2004. Corresponding number of age- and sex-matched controls were chosen from amongst healthy individuals and patients attending skin OPD with dermatological disorders other than pityriasis rosea.

On analyzing the data collected from 20 cases of pityriasis rosea, the average age was found to be 15.3 years and ranged from 5 years to 30 years. The male to female ratio was found to be 1.5:1. The average duration of illness was 14.5 days (median) and 29.3 days (mean). CRP was negative in all the cases as well as the controls. ASLO titer was found to be raised in 2 (10%) cases, while it remained below the critical value in all the controls. On comparing the cases and controls, the raised ASLO titer in the cases was found to be not statistically significant (p = 0.147). From the throat swab culture, Streptococcus haemolyticus was isolated from only one case and none of the controls. This finding was not statistically significant (p = 0.310).

As per the findings of the present study, They arrived at conclusion that there is no association between streptococcus pharyngitis and pityriasis rosea.

Source:

Parija M, Thappa DM. Study of role of streptococcal throat infection in pityriasis rosea. Indian J Dermatol [serial online] 2008 [cited 2009 Jan 3];53:171-3. Available from: http://www.e-ijd.org/text.asp?2008/53/4/171/44787

What Is Pityriasis Rosea ?

Pityriasis Rosea is mild  self limited skin condition seen predominantly in adolescents and young adults especially during spring and fall. It usually begins with a large, scaly, pink patch on the chest, abdomen or back then spread.  The patches are oval or round with a central, wrinkled, salmon-colored area and a dark red peripheral zone  that resembles the outline as of Christmas tree. It is frequently confused with ringworm, but antifungal creams do not help because it is not a fungus.

Although a viral origin has often been suggested, there has not been supporting laboratory evidence. So causes remains unknown. Some earlier study had suggested relation with human herpes virus-7 but  no serologic or tissue based evidence were found in patients with Pityriasis Rosea. Some drugs like  barbiturates, metronidazole, isotretinoin,  ketotifen,  bismuth, captopril, gold, organic mercurials and methoxypromazine may cause drug induced Pityriasis Rosea.

Pityriasis rosea does not spread from person to person and  usually occurs only once in a lifetime. Pityriasis Rosea may be asymptomatic, but many of the patients will experience itching, especially when they become warm. Other symptoms like fatigue and aching or upper respiratory infection might occur. The rash usually fades and disappears within six to eight weeks, but can sometimes last much longer.

As this disease is self limited, most of the patients doesn’t require treatment. Main treatment is focussed on controling itching. Anti-itch medications and soothing medicated lotions like topical zinc oxide and calamine lotion be applied. But if the disease is severe and widespread topical or oral steroids may be used. Some oral antiviral drugs like acyclovir and famciclovir and some antibiotic like erythromycin might reduce its duration if taken early to one to two weeks, but are not usually necessary as its self limited.Ultravoilet radiation therapy might be useful, but it may leave postinflammatory pigmantation at the site.

So just remember Pityriasis Rosea is a mild skin disorder which is self limited and do not usually needs treatment.If you have any queations regarding Pityriasis Rosea ask us at DermaTalk Skin Care Forums