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Pityriasis Rosea: BE GONE! *itch itch*

April 24, 2011

As any of my regular readers will recall, I’ve not had the best year, medically speaking. First, there was Bell’s Palsy which recovered 99% by 1 months time after a 10 day course of steroids in December. Then, in January, I had a delayed type IV-hypersensitivity reaction to a medication, where my face swelled up like it had been rubbed with poison ivy. This required more steroids. Around the same time I had my – in my opinion – totally superfluous MRI, which revealed a “incidentaloma,” a lump in my neck. This was ultrasounded which showed, as we all knew it would,  that there was nothing to fret about. Anyway, the Bell’s problem is all wrapped up… but I’m still having (somewhat comedic) issues in this chain of events.

Tinea Corporis, "ringworm"

Just after I finished the second course of prednisone,  I went away to the beautiful Kootenays to work for 2 months. Nestled in this snowy paradise amidst the rocky mountains, I was living in a basement apartment for the time being. After a shower one day, I noticed a scaly, itchy reddish-orange patch on my back about 7cm in diameter and a smaller one on my inner arm. They each kind of had a redder ring around the outside. I knew I had to have these looked at, but being in a new place, 10+hrs by road and ferry to my family doctor, I decided to ask my preceptor for help. A couple more spots had appeared in the time it took me to ask for an opinion. She, only out of residency 9 months prior, wasn’t quite sure. Neither was I. Together, we decided it was probably Tinea Corporis aka “ringworm.” That’s a fungal infection that can occur on the trunk or extremities. So as to not go to the trouble of putting me in the electronic medical record (EMR), she scribbled a prescription for an anti-fungal on an old Rx pad.

Dutifully, I collected the medication, applied it regularly, and waited. After a few days the scaliness was gone. I told her so, along with a “thanks! I think it’s working.” Well, I spoke too soon. Though it did make the patches less dry and itchy, new ones cropped up. Over the next week, they appeared all over my chest, my back, the inner parts of my arms and even a few on my bum and thighs. Itch! Itch! Our clinic’s cheekiest nurse walked by my office one day and noticed me scratching, remarking “boy, I love it! You’re so nonchalant!” Slightly embarrassed, I felt compelled to explain the itch.

Numular "coin shaped" eczema

I wondered if it could be numular eczema – coin shaped spots of eczema – but thick moisturizer was not helping. I’d never had eczema before, and no asthma or true allergies (eczema, allergies, and asthma go together in the triad of atopy). Really, I knew what it was. I just didn’t want it to be THIS THING because I knew there was no treatment. Also on the differential were syphilis and psoriasis… but no… no I did not have either of those.

Pityriasis rosea, up close

This THING is Pityriasis rosea. Dang. I’ve seen 2 cases of it before. It’s an inconvenient, at worst, quite itchy rash mainly over the trunk. Medical students around the world will remember it for its pathognemonic “herald patch,” a large salmon-red patch that appears on the trunk before the other spots appear. Being mostly unaware of my body, I had failed to notice this before the other spots started appearing. A few days after the herald patch, spots start to appear over the trunk. A textbook will tell you the red, scaly macules (flat-type of rash spots) appear in a Christmas-tree distribution. Well, they didn’t, but they were mostly symmetrical. The odd couple on my forearms were the worst because they might betray my disease to my patients if I wore short sleeves. Not really a big deal – this rash is likely caused by a virus, most likely HHV-7, but science isn’t sure. The spots worsen with heat, probably because most red things (especially inflammatory thins) on the body have increased blood flow; when hot, capillaries (small blood vessels) dilate.

Pitryriasis rosea on some guy's arm

Christmas Tree distribution - not really

This virus, or whatever it is, isn’t very contagious. Usually only one person in a household “gets” it. Maybe everyone is a carrier, but only one manifests the rash. Well my household of 1 was 100% affected, and I suspect it is because I had just been relatively immunocompromised with my recent illness and prednisone courses. The only treatment is time. It usually lasts between 6-12 weeks and just goes away on its own.

At its peak, I was willing to try anything. I had read that topical corticosteroids might help a bit, so I tried, and they didn’t. Antihistamines made no difference to the itch. I learned that in the first 2 weeks, photo-therapy may be helpful. It was winter and there was none for free outside in my snowy heaven. I drove by the tanning salon but just couldn’t bring myself to enter. Tanning salons are one of the worse human inventions and I couldn’t bear to support one, never mind the Jersey-shore culture that they are associated with.

Well, it’s been 9 weeks for me and only the last-to-appear spots have yet to disappear. I am much less itchy now.

Since you’ve read this far, maybe you’ll heed my plea: the next time your doctor has trouble figuring out your spots, please try to be a patient patient. Your GP may have had their share of spots too! There are a few scary rashes, but most skin changes do not signal doom; rather, they are just a bit annoying to have – and tricky to diagnose.

These rashes all friggin’ look the same! No?


If you are lucky enough to get this or just want to learn more about it, the best article I found was from the American Academy of Family Physicians (AAFP).

28 Comments leave one →
  1. April 24, 2011 6:01 am

    sometimes it lasts up to 6 or 8 months… but usually is gone after 3 months.
    in my 35 years at this trade i’ve seen clusters of outbreaks occur in communities.
    This link of a case reported in 1950 may interest you.
    An association of pityriasis rosea with Bell’s palsy. Hmmm. Maybe this needs further investigation.
    Might help to figure out the etiology.

  2. April 24, 2011 6:19 am

    The metamere distribution of pityriasis rosea suggests nerve root inflammation to me.
    Neuropathy is also the manifestation of Bell’s Palsy.
    And Herpes Virus infections like zoster take up residence and do their evil in nerve root ganglia as do many other viruses like Poliovirus.
    My gut feel is that the Human Herpes Virus 7 is a likelihood for all this stuff.
    But its only anecdotal.
    Steve

    • April 24, 2011 6:57 am

      Another rather convoluted but interesting article re HHV-6 and 7

      http://jmm.sgmjournals.org/cgi/content/full/52/1/5

    • April 24, 2011 9:55 am

      Interesting. Of course with all this viral stuff (before the Bell’s I had recurrent swab -ve Monospot -ve tonsillitis necessitating hospitalization then tonsillectomy) I wonder if I’m just a viral magnet.

      You’ll see in the AAFP paper that they found no increased prevalence of HHV7 in pts with pityriasis (although it had been found in the pityriasis biopsy sites).

      All this mystery is what makes our job so cool – just a little less cool when you are the spotty itchy one! Glad mine isn’t lasting 6 months or I’d have to change the name if my blog to “Spotty Otte.”

  3. April 24, 2011 11:30 pm

    Its cool when the exact etiology of things can be figured out and then something can actually be done to prevent of cure it. Plus your name becomes some famous disease solving entity. Something better than Spotty Otte Disease. (Cute). I think that an activation cofactor is involved to trigger the Herpes family of disease flare-ups from what I’m reading. A couple years ago I got H. zoster in my Right neck and arm. No treat!

    • April 25, 2011 5:51 am

      Yowtch! I was telling someone that zoster was going to be next on my body’s sick list and I distinctly hope not! Sorry you had to go through that.

      Not sure how far down the rabbit hole I want to go with all this. Might be easier for me to be thankful I’m better and just hope for no new ‘treats’!

  4. April 25, 2011 10:40 am

    Could it get any worse? You really deserve a break. Honestly. You really don’t have to experience EVERYTHING to be a good doctor, you know! wow.

    As an aside, I find it slightly humorous that the commentaries by the MDs on here are less *sympathetic* and more *interested curiosity* with suggestions re: diagnostics … :)

    • April 25, 2011 3:19 pm

      thanks :)

      I never thought about it that way. I’ve had some bad luck but I certainly don’t write about it looking for pity – it’s more of an educational opportunity.

      I’d be likely to react as Dr. Mlawsky has if a colleague were to write a similar post. Physicians and other health care people seem to have a pathological fascination with, well, pathology and figuring it out. It’s not insensitivity, it’s just how we’re wired.

      That said, your goofy well-wishes are very much appreciated – even doctors can use a little sympathy, a pat on the back, or even a hug once in a while.

    • April 28, 2011 3:18 am

      I really didn’t think they were “insensitive” – just struck me as amusing that no offers of sympathy were doled out….which is usually what the general public would do. :)
      Just different….and an observation only :)

  5. April 25, 2011 4:41 pm

    Wow, what a random medical roller coaster you’ve been on lately! Yikes!

    Thanks for the post though, I’d never heard of that before and now it will be tucked in the (nearly empty) derm file in my brain. :)

    I had a similar incident a few years ago in Pond Inlet: this weird rash which was insanely itchy and strange feeling…both the doc and I thought it was poison ivy from a climbing tumble, so she gave me steroid cream…yeah…the next morning I woke up and figured out it was SHINGLES!!

    Yeah, that was what I got for 30 days on call in a row with not one full nights sleep.

  6. medrunner permalink
    April 26, 2011 2:31 pm

    Hey Dr. Otte,
    I feel your pain. You’ve had a run of bad luck when it comes to random ailments. Let’s hope that it turns and you win the lottery… or something.

    I’ve been having a bit of bad luck with my skin too… I developed vitiligo when I was 16 and ever since then my skin has decided it’s sensitive to a whole bunch of stuff. Silly skin!

    • April 27, 2011 12:54 am

      ooh vitiligo, that’s a funky one! sorry it bears sequelae. I guess we all just start collecting problems as we get older :/

      Jess

  7. Julie permalink
    December 10, 2011 12:16 am

    Nice and informative for a parent of a child that just got diagnosed with Pityriasis Rosea. Yes, it’s almost winter, but I’m hoping the sun might do him some good. I’m hoping to avoid the virus that causes this since my immune system is supressed with the antithyroid drug I’m on and the prednisone I’m having to take thanks to my sinus infection. Does pityriasis rosea get worse before it gets better? So far his rash is contained to just his torso. Here’s hoping it stays that way. Thanks for sharing your personal experience with pityriasis rosea.

    • December 10, 2011 11:12 am

      thanks Julie. I don’t know if it gets worse before better – my experience was just that it took a long time to go away. Hope your little one is not too itchy!

  8. Ike permalink
    April 7, 2012 1:28 pm

    Stumbled across your blog while reviewing for Step 1. Great entry, but I’m sorry it was at your itchy expense. Looking forward to reading more in the future…

  9. isthisusernametaken permalink
    April 10, 2012 9:18 am

    I somewhat understand why doctors have such a hard time diagnosing rashes now. I was diagnosed last week with impetigo on my thigh but when I went back for more bacterial cream the new doctor thought I was having a reaction to lamotrigine. I was taken off that and told to see a doctor if it worsened. When it did I went to another doctor, who called in a colleague to consult. Both independently thought it was pityriasis rosea. Today, yet another doctor has said it is too florid for pityriasis rosea (though he kept saying pityriasis rosea is fungal?) and gave me steroid cream and antibiotics, but not before pointing to the much finer rash on my stomach and saying to his student “this is a classic example of a viral rash”. I am unbelievably confused! And having seen how similar rashes look to each other I am also quite glad I’m not a doctor trying to work these things out!

  10. Cris permalink
    September 24, 2012 9:23 am

    Why this is happening to me, first, my PR is really fading away, like Im already healed, only scars are left but now, its coming back again, anyone who experienced this?? its only 2weeks after my PR is gone and then re-occuring again. Please help

  11. Britt permalink
    December 24, 2012 1:30 am

    Hi I currently have PR and its an absolute mess!!! My dermo says it’s going to go away but it seems as though it starts fading and going away they all flare back up. I had over 100 spots on my body and the worst part on my scalp 100% covering my head! Now all my scalp does is either flake, bleed, burn and hurt! And I can feel it swollen. Not to mention the bald spots :(

  12. sasa fierce permalink
    June 26, 2013 10:27 pm

    How long did it take to go away

  13. Dynagirl permalink
    July 5, 2013 12:04 pm

    I was diagnosed almost 3 weeks ago and was in PR hell for 2 weeks. I read through the message boards and have tried a lot of things. I finally gave in and use HEAD AND SHOULDERS shampoo as a body wash (cold shower). OMG what a difference and relief it made even with just the first use. The itching and redness was reduced dramatically specially the itching which was my biggest problem. After just a few showers (twice a day), the rash started fading and drying and scaling. It really saved me. The active ingredient pyrithione Zinc is used to cure sebhoreic dermatitis. I apply Aveeno eczema cream after my shower. The shampoo really saved me.

    • July 5, 2013 7:37 pm

      It is possible that you had seborrheic dermatitis which can be on the trunk as well. That would typically respond to the anti-fungal shampoo. Pyrithione Zinc is used occasionally for inflammatory dermatitis like eczema and psoriasis. Suppose there’s little harm in trying it for pityriasis, save whatever side effects it might have in any application.

  14. Janette permalink
    July 9, 2013 6:31 pm

    My 12 year old son got a rash in Nov 2012. I thought it was eczema. The doctor diagnosed him with Pityriasis Rosea and prescribed a steroid. It started to look better but never completely went away. It’s been 8 months and I’m taking him in again because it seems to be flaring up and looking worse not better. I’m worried why this has gone on so long.

  15. August 29, 2013 1:11 am

    Hey i’m glad i stumbled at your blog. 27F here from the Philippines. I’m having ptyriasis rosea now :( and it takes so long to go away. Does any one here have any clue as to what we can do? It’s extending in my arms and legs now and I feel so helpless. Some are even climbing up my neck :( And yes it is concentrated in the trunk area too. it’s so stressful :(

  16. Jeanie permalink
    April 15, 2014 5:19 pm

    This is probably bout number 12 and only compares to the first outbreak. Miserable horrible itching. Found myself to the ER. Prednizsone is killing it and things are fading. I just hope it stays away. every year between Dec and May outbreak. The itch is all consuming and sweating adds more fuel. No over the counter took it away. Odd note did first contract it when I lived in a Very moldy house. It seems like a parasite that breaks out and breeds at a certain time of year. Scary and weird when you keep getting something and your only suppose to have it ONCE. It covers my whole trunk. Herold appeared end of Feb. Then total outbreak all of April. What Could be the infective agent?
    Sun does seem to hamper it. I live in Washington. Tho it isn’t a fungus, because anti fungus med inside and out side does not relieve it. I still think it is an offspring of mold, We have to figure the unknown reason because I Never want it again. Stress is a factor as well I believe. Before outbreak, I was tired stressed felt like a truck hit me( sore) and my limphnode swollen, a slight ongoing head ache. Still have head ache and feeling not well.Come to think of it I still have dry cough.
    I wish us all Luck, it seriously is a bad thing we go through.
    (sorry about my spelling)

    • April 15, 2014 7:20 pm

      12 times! and seasonal! it could certainly be something else. I would suggest seeing our family doctor. Sometimes when we aren’t sure what a rash is, we do a small sampling called a punch biopsy. Your doctor might suggest that.

      Good luck

    • jeanie permalink
      April 15, 2014 9:21 pm

      Dermatologist may deffently going with or without insurence. But story book simptoms already had that test. Unknown. Great huh? Thanks for the care.

  17. Erin permalink
    August 22, 2014 8:15 pm

    I have it now and want to die a little bit (I realize how dramatic that sounds). I’m just SO SO SO DAMN ITCHY!!! My herald patch appeared on my inner thigh about 3 weeks ago. I didn’t really think anything of it – thought it was dry skin, put lotion on it, forgot about it. The next week, the rash exploded all over my inner thighs and my armpits. Somewhat itchy, but not insane. Made an appointment with the doctor as it looked like the pictures of ringworm when I Google searched rash images. Doctor thought it looked fungal and gave me a topical cream to apply twice daily. I did – diligently – and the rash not only did not get better, it started to spread EVERYWHERE, heavily and started to itch like crazy. It’s now EVERYWHERE on my body except for the elbows to the fingers, the knees to the toes or on my face. Went back to the doctor this week and she was shocked at how much it had spread and changed, diagnosed PR, told me to take Claritin during the day and gave me a script for hydroxyzine to take at night to help me sleep a bit (the itching keeps me up all night). Neither are seeming to do much of anything for me. I’m starting to feel desperate. Think I’m going to try the Head and Shoulders shampoo as soap remedy that someone mentioned above. A friend suggested trying using Sarna lotion and Aveeno baths. I’m also going to head to a tanning salon tomorrow as many articles I’ve read suggest this can help (I know how bad they are, but right now I just don’t care – I need the itching to stop). My doctor told me to lay out in the sun, but since it’s been cool and cloudy here lately and I just cannot wait, tanning bed here I come!

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