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Pityriasis rosea with palmoplantar plaque lesions

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Pityriasis rosea with palmoplantar plaque lesions
I Bukhari
Dermatology Online Journal 11 (1): 27

Dermatology Department, College of Medicine, King Faisal University, Dammam, Saudi Arabia

Abstract

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.



Case 1

A 45-year-old Saudi woman presented with a 2-week history of a severely pruritic skin rash affecting the whole body including palmoplantar areas, the face, and the neck. The patient was not specific regarding the initial patch because the condition worsened quickly over 2 weeks. She denied history of fever, chills, upper respiratory tract infection, or genital lesion prior to the rash. The patient used topical steroid with no improvement. Physical examination revealed multiple, large, scattered, scaly erythematous patches on the trunk, face, upper and lower extremities. The lesions on the palms and soles were erythematous raised plaques (Fig. 1). Mucus membranes were free of lesions and lymph nodes were not palpable. At that time our differential diagnosis included severe contact dermatitis, pityriasis rosea, and secondary syphilis. Complete blood count was normal and syphilis serology was negative. Biopsy from lesions on the trunk showed features of pityriasis rosea—orthokeratosis, parakeratosis, spongiosis and exocytosis. The papillary dermis was edematous with extravasated red blood cell, eosinophils, and perivascular lymphocytic infiltrate. The patient was diagnosed with pityriasis rosea and started on oral Clarithromycin 250 mg twice daily for 2 weeks after which the lesions gradually resolved.


Case 2


Figure 1 Figure 2
Erythematous plaques affecting the palmar aspect of the both hands in both patients.

Figure 3
Typical erythematous scaly round to oval shape lesions of pityriasis rosea on the left lower extremity the second patient.

A 38-year-old Pakistani woman presented to our dermatology clinic with a 6-week history of pruritic skin rash affecting the trunk, upper and lower extremities, palmoplantar areas, and sparing the face and neck (Figs. 2 and 3) The patient recalled having an initial patch on the right thigh. She denied a history of fever, chills, upper respiratory tract infection, or genital lesion prior to the rash. The patient used topical steroid with no improvement. Physical examination revealed multiple scattered scaly erythematous 2-4-cm patches on the trunk, upper and lower extremities. The lesions on the palms and soles were erythematous raised plaques. Mucus membranes were free of lesions; lymph nodes were not palpable. Our differential diagnosis included pityriasis rosea and secondary syphilis. Complete blood count was normal and syphilis serology was negative. The patient was considered as a case of pityriasis rosea; she was treated with oral erythromycin 250 mg every 6 hours for 2 weeks after which the lesions completely resolved.


Discussion

Pityriasis rosea is an acute, self-limited papulosquamous skin disease characterized by pruritic sharply defined bright-red oval plaques covered by fine scales. It affects mostly adolescent and young adults with 75 percent of cases occurring between the ages of 10 and 35 [1]. The most common clinical presentation begins with the herald patch, a solitary erythematous oval scaly plaque ranging in diameter from 2 to 10 cm. The herald patch is sometimes preceded by a prodrome of flu-like symptoms [2]. After 1-2 weeks, a widespread eruption appears comprising multiple oval macules distributed in a Christmas-tree pattern on the trunk and proximal extremities [3]. The etiology of pityriasis rosea is unknown; viral infection has been postulated as the etiologic factor in several studies [4, 5], but not supported by others [6, 7]. The diagnosis of pityriasis rosea is based on careful history and physical examination. In the differential diagnosis, secondary syphilis should be considered and ruled out by serologic tests, especially when typical lesions are not present, when the rash is not pruritic, or when palmoplanter lesions are present [3]. The eruption usually resolves spontaneously after 2-6 weeks, but symptomatic treatment may be needed; such treatment includes topical antipruritic agents such as calamine lotion, topical corticosteroids [8], and UVB phototherapy [9]. Others have reported the effectiveness of oral erythromycin 250 mg four times daily for 2 weeks in cases of pityriasis rosea [10]. Our patients had classic presentations of pityriasis rosea except for the unusual occurrence of palmoplantar lesions, not previously reported for this disease; they responded dramatically to the 2-week course of either oral erythromycin or Clarithromycin. We believe that palmoplantar involvement should also be included among the variant forms of pityriasis rosea, other examples being pityriasis gigantean [11], pityriasis rosea with herald patch only [3], pityriasis rosea inversa, and purpuric forms of pityriasis rosea [12].


Conclusion

Pityriasis rosea is a papulosquamous pruritic skin condition that usually affects the trunk and extremities but other unusual sites could also be affected such the palmoplantar areas.

Acknowledgment: I would like to thank Dr. Nahed Mitkis for her continuous support.

[Editor's note: These are interesting cases that clinically strongly resemble secondary syphilis. However, in these patients RPR (with dilution) and MHA-TP were negative. In addition, they responded rapidly to macrolide antibiotics as would syphilis. We invite other clinicians to comment on these cases. We would also recommend follow-up syphilis serology]

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