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Year:2010|Volume:55|Issue:2|Page:192194

Giantpityriasisrosea

VijayZawarShreeramSankul,Opp.HotelPanchavati,Vakilwadi,Nashik422001,Maharashtra,India

DateofWebPublication 22Apr2010

CorrespondenceAddress:VijayZawarShreeramSankul,Opp.HotelPanchavati,Vakilwadi,Nashik422001,MaharashtraIndia

SourceofSupport:None,ConflictofInterest:None

DOI:10.4103/00195154.62750

Abstract

Pityriasisroseaisafrequentpapulosquamousdiseaseandisknownforvariousatypicalclinicalpresentations.Wereportanadultfemalepatientwithaclinicaldiagnosisofgiantpityriasisrosea,whichisararityinclinicalpractice.

Keywords:Atypicalpityriasisrosea,dermatophytosis,giganticpityriasisrosea

Howtocitethisarticle:ZawarV.Giantpityriasisrosea.IndianJDermatol201055:1924

HowtocitethisURL:ZawarV.Giantpityriasisrosea.IndianJDermatol[serialonline]2010[cited2015Oct15]55:1924.Availablefrom:http://www.eijd.org/text.asp?2010/55/2/192/62750

Introduction

Pityriasisrosea(PR)isacommonpapulosquamousdisordercharacterizedbyanonsetasaheraldplaqueandfollowedbyamultipleovaltoroundsmallerscalysecondaryeruptionsdelineatingtolinesofcleavage.CurrentevidenceindicatesthatPRisatypeofviralexanthemaandtheetiologymaybepossiblylinkedtohumanherpesviruses.[1],[2],[3]

Whilemostcasespresentthetypicalpatternclinically,thereareabout20%patientsofPRpresentinginadeviated

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clinicalappearanceandmightposeadiagnosticproblem[2],[3],[4],[5]

Severalunusualvariantsarereportedintheliterature[3],[4],[5],[6]includingunilateral,[5]inverse,[3]lichenoid,[4]

vesicular,papular,[7],[8]purpuric,[7],[9]hemorrhagic,[10]erythemamultiformelike,[11]urticarial[7]andthoseinvolvingmucosae,[12]palmsandsoles,flexures,faceand,mayevenbegeneralizedhavingexfoliativedermatitis.[7]

CaseReport

A35yearoldhousewifepresentedwithmildlypruriticscalyeruptionsonthebackandfrontofchestfor2weeks.Earlier,shehadasinglelargesimilareruptiononleftbreast10daysago.Shegaveahistoryofupperrespiratoryinfection2weeksbeforetheonsetoffirstlesion,whenshehadamildfever,coryza,andmalaiselastingfor5days.Shereceivedacombinationofibuprofen+paracetamolandcetrizineorally,prescribedbyafamilypractitionerfor3days.Shehadbeentreatedwiththesamedrugsseveraltimesearlierbythesamephysician.

Therewasnohistoryofsimilarlesionsinthepast.Herpastandfamilyhealthwasunremarkable.

Therewasnohistorysuggestiveofallergicorirritantcontactdermatitisinthepresentcase.Shedidnotreceiveanyothersystemicmedicationsintherecentpast.Travelhistorywasinsignificant.Shedistinctlydeniedahistoryoftickbites.

Thefirstlesionwasalargeovalplaquemeasuringapproximately7cm6cm,almostoccupyingthewholeleftbreast,withperipheralcollarettescalingandcentralclearingwithminimalitching.Shewastreatedbyafamilyphysicianwithtopicalmiconazolecreamfor10dayswithoutsignificantresolution.Thepatientrefusedthefrontofchesttobephotographedandhence,apictureofheraldplaquecouldnotbetaken.Prescriptionsbroughtbythepatientwereverifiedspecificallyanddidnotcontaintopicalorsystemicsteroids.

Shesuddenlydevelopedthesubsequentlesionsasmultiple,sharplydemarcated,largescalylesionsofirregularshapeonfrontandbackoftrunkaswellaslateralthighsextendinguptothehipsonbothsidessomewhatinsymmetricaldistribution.Thesizeofindividuallesionsvariedfrom5to7cminlongestdiameters.Theperipheryoffewoftheselesionsstillshowedcollarettescalingatplaces.Onlytheplaqueonrightupperbackshowedtobeplacedalongthelineofcleavageandotherswerenotsoclassical[Figure1],[Figure2].

Alltheeruptionsconsistedofscalyplaqueswithcentralclearingandperipheralscales.Collarettescalingwasseenatplacesontheaffectedareas.Therepalmsandsolesandmucosalsurfaceswereuninvolved.

Hergeneralandsystemicexaminationsrevealednoabnormality.Investigationsincludingcompletebloodcounts,bloodsugarlevels,urinalysis,HIVantibodies,andVDRLtest(doneinrepeateddilutions)werenegativeornormal.Thefungalscrapingswererepeatedtwiceanddidnotrevealanyevidenceoffungalelements.Shedidnot,however,agreeforskinbiopsy.

Shewasprescribedtopicalbetamethasonedipropionate0.025%ointmenttwiceadaytopicalapplicationanddesloratidinetablet5mgonceaday.Thelesionsslowlyresolvedwithin2weeks,withslighthypopigmentation.Therewasnorecurrencefor6monthsoffollowup.

Discussion

AtypicalorunusualpresentationsinPRareoftenseeninclinicalpractice.Diagnosticdilemmapersistsinsuchpatientsunlessacarefulclinicalobservationandfollowuparemade.[1],[2],[3],[6]Suchpatientsmayoftenbeoverinvestigated.Moreover,beingthediseasenotmuchbothersomewithatendencyofselfresolution,thepatientsareoftenlosttofollowupandremainundiagnosed.

Consideringclinicalcourse,typicalheraldplaquewithcollarettescaleattheinitiallesionandcompleteresolutionwithin3weeks,webelievethiscasedeservesadiagnosticlabelofgiganticPR.Otherpossibilitiessuchassecondarysyphilis,pityriasislichenoides,erythemaannularecentrifugum,erythemachronicummigrans,tineacorporis,psoriasis,anddruginducedPRwereunlikelyinourpatient.Multipleheraldplaquesmaycausediagnosticconfusioninsuchsituations.However,eventhiswasnotlikelyinourcaseconsideringprimarylesiononleftbreast10daysearliertosuddenonsetofsecondarylesions.Moreover,classicalcollarettescalingonthebreastandatplacesonthetruncalandthighlesionsandresolutionwithinaspanoffewweekswithoutrecurrencefurthersupportsourviewofgiganticPR.

Scalyannular,largereruptionsareknowntooccurinanotherrarevariantknownasPRofVidal,whichpresentsatlimbgirdlesinvolvingaxillaandinguinocruralareas.[1],[2],[3],[6]Ourpatientdidnothaveanylesionsintheseareas.PRlikeeruptionsarereportedafteringestionofantiinflammatoryandantipyreticdrugs.[13]But,adetailedhistoryandfollowupinourpatientdidnotpointtootheralternativediagnosessuchasdrugeruption,dermatophytosis,andcontactdermatitis.Unfortunately,skinbiopsywasnotpossibleinourcase.However,histopathologicalfeaturesaregenerallynotdiagnosticinPRandtheyusuallypresentswithnonspecificdermatitis.SkinbiopsyisnotroutinelyperformedfordiagnosisofPRinIndia.Itmaybehelpfultoruleoutotherdiagnosiswhenindoubt.Inourexperience,intheabsenceofskinbiopsy,ameticulousfollowupofclinicalcourseinthegivenpatientishelpfulinarrivingataproperdiagnosis.



GiganticPRisrarelyreportedintheliteratureandwasnamedafterDarier.Inhisproposedclinicalclassificationin1924,KlauderdescribedPRgiganteanintoconfluentanddiffusevariantaccordingtomorphology.[14]PringleearlierdescribedthatPRgiganticisveryrareandconsistsofplaquesandcirclesofverylargesizewhereintheindividuallesionsmayreachthesizeofpalmofthepatient.[14]Thesizehedescribedrangedbetween5cmand6.3cm.Oneofthelesionsontheleftsideofbackinourpatientappearedaspearshaped,asdescribedinPringle'sreport.TheclinicalcourseinourpatientwassimilartotheclassicalPR,assuggestedbyPringle.[15]

OurcaseillustratesthatPRcanpresentasmultiple,largescalyplaques.Insuchpatients,goodclinicalobservationandfollowuparekeystodiagnosis.Withoutknowledgeofthisentity,thediagnosismaybemissed.CliniciansneedtobealertedtothisrarevariantofPR.Thiscaseisbeingreportedhereforitsextremerarity.Tothebestofourknowledge,thisisthefirstreportofgiganticPRintheIndianliterature.Thevariantmaybeunderreported.

Acknowledgements

TheauthorthankfullyacknowledgesDrSudhirSankalecha,MD,ConsultantPathologist,Nashik,forhissupportinlaboratoryinvestigations.

References

1. DragoF,BroccoloF,ReboraA.Pityriasisrosea:anupdatewithacriticalappraisalofitsPossibleherpesviraletiology.JAmAcadDermatol200961:30318.

2. AllenR,SchwartzRA.Pityriasisrosea.Availablefrom:http://emedicine.medscape.com/article/1107532.[lastaccessedon2009Jul12].

3. GonzlezLM,AllenR,JannigerCK,SchwartzRA.Pityriasisrosea:Animportantpapulosquamousdisorder.IntJDermatol200544:75764.

4. ChuhA,LeeA,ZawarV,SciallisG,KempfW.PityriasisroseaAnupdate.IndianJDermatolVenereolLeprol200571:3115. [PUBMED]

5. BrarBK,PallA,GuptaRR.Pityriasisroseaunilateralis.IndianJDermatolVenereolLeprol200369:423.[PUBMED]

6. BjornbergA,HellgrenL.Pityriasisrosea.Astatistical,clinical,andlaboratoryinvestigationof826patientsandmatchedhealthycontrols.ActaDermVenereolSuppl(Stockh)196242:168.

7. ChuhA,ZawarV,LeeA.Atypicalpresentationsofpityriasisrosea:Casepresentations.JEurAcadDermatolVenereol200519:1206.

8. MiljkovicJ,BercicM,BelicM.Pityriasisroseawithunusualpapulovesicularpresentation.ActaDermVenerol19965:613.

9. SezerE,SaracogluZN,UrerSM,BildiriciK,SabuncuI.Purpuricpityriasisrosea.IntJDermatol200342:13840.

10. PallerAS,EsterlyNB,LuckyAW,MilstoneEB,HigginsTP.Hemorrhagicpityriasisrosea:Anunusualvariant.Pediatrics198270:3579.

11. FriedmanSJ.Pityriasisroseawitherythemamultiformelikelesions.JAmAcadDermatol198717:1356. 12. SciubbaJJ.Orallesionsassociatedwithpityriasisrosea.ArchDermatol1986122:5034. 13. YosipovitchG,KupermanO,LivniE,AvinoachI,HalevyS.Pityriasisrosealikeeruptionafteranti

inflammatoryandantipyreticmedication.Harefuah1993124:198200,247. 14. KlauderJV.Pityriasisroseawithparticularreferencetoitsunusualmanifestations.JAMA192482:17883.

15. JJ.Casepresentation,sectionondermatology,RoyalSocietyofMedicine.BrJDermatol191527:309.

Figures

[Figure1],[Figure2]

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3 CurrenttrendsinpityriasisroseaZawar,V.,Jerajani,H.,Pol,R.ExpertReviewofDermatology.20105(3):325333[Pubmed]



4 CurrenttrendsinpityriasisroseaVijayZawar,HemangiJerajani,ReshmaPolExpertReviewofDermatology.20105(3):325[Pubmed]

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