Dermatology Online Journal

Vesicular pityriasis rosea: an atypical presentation
Didem Didar Balci MD¹, Sibel Hakverdi MD²
Dermatology Online Journal 14 (3): 6

1. Mustafa Kemal University, Faculty of Medicine, Department of Dermatology, Antakya, Turkey. didemaltiner@yahoo.com 2. Mustafa Kemal University, Faculty of Medicine, Department of Pathology, Antakya, Turkey

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Abstract

Pityriasis rosea (PR) is an acute, self-limited papulosquamous dermatosis localized on the trunk and extremities. PR is seen most frequently in adolescents and young adults. Many atypical forms of the disease have been reported in the literature. We report a rare atypical type of PR with vesicles on the erythematous macules and plaques.

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Introduction

Pityriasis rosea (PR) is a self-limited, acute papulosquamous skin disorder of unknown origin. The initial lesion, also called the herald patch, is larger than the subsequent lesions. Days to weeks later crops of smaller macules, papules, and plaques begin to appear. Multiple oval scaly pale pink lesions are usually distributed in the so-called Christmas tree pattern following skin lines on the trunk [1]. Many atypical forms of the disease have been reported in the literature [2, 3, 4]. Vesicular PR seems to represent a rare atypical form of the disease characterized by a generalized eruption of vesicles [4, 5]. We present a rare atypical type of PR with vesicular lesions on the erythematous macules. The patient responded satisfactorily to topical prednicarbate cream.

Clinical synopsis

A 20-year-old young woman presented with a two-week history of an asymptomatic skin rash that was localized on her upper extremities. Dermatological examination revealed a 3 cm oval plaque with a pale central area surrounded by an erythematous border and a few 4-5 mm scaly macules and papules on the right arm (Figs. 1 & 2). We also observed 3-15 mm multiple erythematous macules, each having a number of vesicles (rosette pattern) on the left arm (Figs. 1, 3 & 4). The vesicles on the lesions had a polymorphic characteristic; in other words, there were simultaneously some ruptured vesicles with punctuate crusts and intact vesicles. The trunk, face, palms, soles and mucous membranes were uninvolved. She refused the use of any prior medication, history of fever, or upper respiratory tract infection. Complete blood count was normal and syphilis serology was negative. We performed a skin biopsy from a lesion of the left arm. The histological analysis of the biopsy specimen revealed focal spongiosis, lymphocyte exocytosis, vacuolar changes in the basal layer and perivascular lymphocytic infiltrate in the dermis (Fig. 5). The patient was diagnosed with pityriasis rosea and started on topical prednicarbate cream twice daily for four weeks. We also recommended the patient minimize scrubbing. The affected skin had fully cleared after the treatment. During 2 months of follow-up, no recurrence was observed.

Figure 1	Figure 2
Figure 1. Typical scaly oval plaques, herald patch and vesicular lesions on the upper extremities Figure 2. Herald patch and a few smaller macules and papules

Figure 3	Figure 4
Figure 3. Multiple erythematous macules, each having a number of vesicles and hemorrhagic crusts on the left arm Figure 4. Rosette pattern of vesicles

Figure 5
Figure 5. Focal spongiosis, lymphocyte exocytosis, vacuolar changes in the basal layer and perivascular lymphocytic infiltrate in the dermis (H&E; 20X)

Discussion

Pityriasis rosea is an acute, self-limited papulosquamous dermatosis localized on the trunk and extremities. PR is seen most frequently in adolescents and young adults. The disease tends to occur in the fall and winter months [1]. Although no etiology has been proven, viral agents especially human herpes virus 6 and 7, autoimmunity, many drugs and psychogenic status have been proposed as possible etiological factors [6]. Atypical variants of PR are rare, constituting approximately 20 percent of all cases [7, 8]. Atypical clinical presentations of PR may lead to difficulty in diagnosis. Atypical types can be differentiated by morphology, size, distribution, number, site, severity and course of the lesions. Additionally, drug-induced PR-like eruptions have been reported as separate clinical entities [9]. According to morphology, atypical forms of PR are described as generalized papular, vesicular, purpuric (hemorrhagic) or urticarial [2, 3, 4].

We present an atypical type of PR demonstrating vesicular lesions on the erythematous macules and plaques. Only a few vesicular PR cases have been reported in the literature. Vesicular PR is seen more frequently in children and young adults. The vesicular lesions may settle on the palms, soles, face or anterior forearm resembling varicella or dishydrosis [4, 5]. Vesicular PR lesions usually appeared as a generalized eruption of vesicles or a rosette of vesicles [2]. The vesicles are usually associated with typical papulosquamous eruptions [4, 5]. Our case demonstrates a rosette form of vesicles and typical papulosquamous lesions with the herald patch. The diagnosis was based on clinical appearance of the lesions and histopathological findings.

In conclusion, despite rarity of vesicular PR physicians should include this entity in the differential diagnosis of vesicular eruptions.

References

1. Braun-Falco O, Plewig G, Wolff HH, Burgdorf WHC. Dermatology: Springer-Verlag, 2000. pp 584-5.

2. Hendricks A, Lohr JA. Pityriasis rosea in infancia. Arch Dermatol 1979; 115: 896-897.

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4. Miranda SB, Lupi O, Lucas E. Vesicular pityriasis rosea: response to erythromycin treatment. J Eur Acad Dermatol Venereol. 2004;18:622-5.

5. Garcia RL. Letter: Vesicular pityriasis rosea. Arch Dermatol. 1976; 112: 410.

6. Gonzalez LM, Allen R, Janniger CK, Schwartz RA. Pityriasis rosea: an important papulosquamous disorder. Int J Dermatol 2005; 44 :757-64.

7. Parsons JM. Pityriasis rosea update. J Am Acad Dermatol 1986; 15: 159-167.

8. Imamura S, Ozaki M, Oguchi M, Okamoto H, Horiguchi Y. Atypical pityriasis rosea. Dermatologica. 1985;171:474-7.

9. Chuh A, Zawar V, Lee A. Atypical presentations of pityriasis rosea: case presentations. J Eur Acad Dermatol Venereol. 2005 ;19:120-6.

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