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. 2024 Apr 29;69(2):145–151. doi: 10.4103/ijd.ijd_1071_23

A Cross-Sectional Study of Epidemiological and Clinical Aspects of Pityriasis Rosea along with Dermoscopic Analysis and Histopathology Correlation

Aditi A Shende 1,✉, Siddhi B Chikhalkar 1
PMCID: PMC11149824  PMID: 38841213

Abstract

Background:

Pityriasis Rosea (PR) is a common, yet enigmatic, dermatological condition characterized by a distinctive clinical presentation. Despite its prevalence, the aetiology and pathogenesis of PR remain elusive.

Aims:

To study the epidemiological and clinical aspects of patients with PR. To study dermoscopic findings and carry out histopathological correlation.

Methods:

A cross-sectional study of 50 patients was conducted. A detailed clinical history was taken and an examination was done followed by a dermoscopy. Quantitative data like age and duration of disease are presented with the help of standard deviation. Qualitative risk factors, like gender, age groups, symptomatology, site of lesion, findings or cutaneous examination, dermoscopy findings, and histopathology findings, are presented with the help of frequency and percentages.

Results:

PR shows male preponderance and mean age of occurrence being 30.8 ± 15.7 years. Forty per cent of patients had an atypical clinical presentation. The most frequently seen dermoscopy findings were diffuse red background (58%), peripheral collarette scale (62%), and peripheral dotted vessels (50%). On histopathology, the most common findings were spongiosis (44%), parakeratosis (38%), irregular acanthosis (34%), perivascular lymphocytic infiltrate (56%), and red blood cell extravasation (36%).

Limitations:

Sample size was less due to COVID. As this was a corss-sectional study follow up of patients could not be done.

Conclusion:

While the diagnosis of PR is clinical, it is difficult in atypical cases where dermoscopy comes to the aid. It also helps identify the age of lesions, thus helping decide the treatment strategy for patients. Biopsy remains the gold standard in ruling out other differentials of PR.

Keywords: Dermoscopy, pityriasis rosea, spongiotic dermatitis

Introduction

Pityriasis Rosea (PR) is an acute, self-limiting disease characterized by a distinctive skin eruption with minimal constitutional symptoms.[1] The diagnosis of PR is clinical; however, atypical forms are difficult to diagnose.[2] The aetiology of PR remains unclear. Multiple hypotheses have been formulated suggesting both infectious (viral and bacterial) and noninfectious aetiology (autoimmunity, atopy, drugs, and vaccines). However, it is thought to be caused by viral agents based on clustering of cases, seasonal variation, presence of prodromal symptoms, course of rash similar to viral exanthem (herald patch followed by developing a secondary eruption), and fewer relapses.[3,4,5] There have been multiple reports on the development of PR a few weeks after SARS-COV2 infection. However, the evidence is not enough to establish a causal relationship.[6] Atypical forms of PR account for 20% of all cases.[7] Skin biopsy is needed in atypical and recurrent cases to rule out other differential diagnoses. With the growing popularity of dermoscopy, it also aids in the diagnosis of PR.[8,9]

This study aims to study the epidemiological and clinical aspects of PR along with dermoscopic analysis and histopathological correlation.

Methods

A single-centre descriptive cross-sectional observational study was conducted on patients attending the skin outpatient department for 18 months. The study was approved by the Institutional Ethics Committee (266/2020). The convenience method was used for sampling. All consenting patients irrespective of age and sex with a clinical diagnosis of PR were included. Fifty patients were enrolled in the study. Epidemiological factors (age and sex) of patients were noted. In-depth clinical history was taken which included—symptoms, prodromal features, duration between the appearance of herald patch and secondary lesions, history of atopy, drug intake, vaccine, any other comorbidity, and family history. Physical examination was done to look for the presence of herald patch, morphology, and distribution of skin lesions. This was followed by dermoscopic analysis using a video dermatoscope Dinolite premier AM4113ZT. Clinical photographs only of the lesions were taken for documentation. Relevant investigations like Venereal Disease Research Laboratory (VDRL) and skin biopsy were advised wherever relevant for confirming the diagnosis.

Data analysis was done with the help of Microsoft Excel 2016. Quantitative data like age and duration of disease are presented with the help of Mean±Standard Deviation. Qualitative factors like gender, age groups, symptomatology, site of lesion, findings or cutaneous examination, dermoscopy findings, and histopathology findings are presented with the help of frequency and percentages.

Results

Demographic profile: PR showed male preponderance (60%, n = 30) and was common amongst the age group 18–25 years (26%, n = 13), with the youngest patient being eight years old and the oldest being 66 years old (mean age was 30.8 ± 15.7 years). There was a single case of PR in a pregnant female in first trimester.

Seasonal variation: Incidence was more in the rainy and spring seasons, though sporadic cases were seen throughout the year.

Family history: None of the patients had any positive history of similar complaints in the family. There was no clustering of cases in any locality.

Risk factors: A history of atopy was seen in 38% (n = 19) of cases. Four per cent (n = 2) of patients had a history of wearing new synthetic garments, 10% (n = 5) had a history of gastrointestinal infection, 8% (n = 4) had a history of stress, and 6% (n = 3) had a past history of PR.

Drug or vaccine history: Nine patients had a history of prior drug intake and vaccine, they presented with atypical PR. Three cases were seen after receiving chemotherapeutic drugs and three cases were reported post receiving vaccines against the novel SARS-COV2 virus (2 due to Covaxin and 1 post-Covishield vaccine). These patients had developed PR two days after taking 1st dose of Covaxin and 20 days after taking the Covishield vaccine. One patient who had the lichenoid type of PR (biopsy proven) had a history of chronic intake of amlodipine for hypertension. EM-like PR was seen in a patient post-Covaxin and another patient of Ewing’s sarcoma who was on chemotherapy with cyclophosphamide and vincristine.

Prodromal symptoms: Sixty per cent (n = 30) had no prodromal symptoms. The most common prodromal symptom was fever (18%, n = 9). Other symptoms are given in Table 1.

Table 1.

Distribution of prodromal symptoms amongst patients

Symptoms Frequency Percentage (%)
Fever 9 18
Myalagia 3 6
Arthralgia 5 10
Cough and cold 1 2
Diarrhoea 2 4
Upper respiratory tract infection (URTI) 2 4
Headache 1 2
None 30 60
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Symptoms: Usually, PR is asymptomatic, but 82% (n = 41) of cases complained of mild itching in our study, while one patient had a burning sensation.

Presence of herald patch: Herald patch was seen in only 72% (n = 36) of the patients. Back was the most common site involved.

The time duration between the appearance of the herald patch and secondary eruptions: 40% (n = 20) of patients developed secondary eruption within five days of the appearance of the herald patch.

Clinical examination: 60% (n = 30) of cases had classic PR, while the rest of the 40% (n = 20) were atypical. Fifty-two per cent (n = 26) of patients had a central distribution of lesions showing the characteristic ‘Christmas tree pattern’. Plaque was the most common morphology (82%, n = 41) of the secondary eruption followed by papules. Four cases had targetoid lesions (EM-like PR), one patient had developed vesicles on the palms and soles. Two patients had purpuric lesions.

Atypical PR: Forty per cent (n = 20) of cases had atypical PR. The most common were inverse PR, followed by papular PR. Other types seen were EM-like PR [Figure 1] and lichenoid PR.

Figure 1.

Figure 1

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Image showing targetoid lesions over the abdomen (EM-like PR)

Dermoscopic findings

The most frequently seen dermoscopy findings were diffuse red background (58%, n = 29), peripheral collarette scale (62%, n = 31), and peripheral dotted vessels (50%, n = 25). Amongst classic PR, these findings were consistent. Apart from these, brown globules were seen in 50% (n = 25) of cases. Atypical PR cases also showed a diffuse red background (65%, n = 13) and peripheral collarette scaling (45%, n = 9); however, scattered dotted vessels (45%, n = 9) were the most common finding.

Early lesion of PR showed a diffuse red background with collarette scaling at the centre and peripheral dotted vessels. A dermoscopy of a well-established lesion showed a diffuse red background with peripheral collarette and peripheral dotted vessels. In comparison, late lesions of PR showed a diffuse yellow background with the absence of scale and brown globules and brown structureless areas. [Figures 2–4]

Figure 2.

Figure 2

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Dermoscopy of early lesion showing diffuse red background with central collarette scaling (red arrow) and few peripheral dotted vessels (blue circles) (Dinolite premier AM4113ZT, 50×, polarized light)

Figure 4.

Figure 4

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Dermoscopy of old lesion showing diffuse yellow background with brown structureless areas (black circles) with mild scaling (red arrows) and no vessels (Dinolite premier AM4113ZT, 50×, polarized light)

Figure 3.

Figure 3

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Dermoscopy of well-established lesion showing diffuse red background with a peripheral collarette (red arrow) and peripheral dotted vessels (blue circles) (Dinolite premier AM4113ZT, 50×, polarized light)

Dermoscopy of different variants of PR is summarized in Table 2.

Table 2.

Dermoscopy findings of PR and its variant

Type of PR Background Scaling Vascular structure Other findings
Classic PR (early lesion) Diffuse red Collarette scale at centre Peripheral dotted –
Classic PR established lesion Diffuse red Peripheral collarette Peripheral dotted –
Classic PR late lesion Diffuse yellow Absent scale – Brown globules and brown structureless areas
Acral PR Diffuse red Peripheral collarette and scaling over dermatoglyphic lines Scattered dotted –
EM-like PR Diffuse red and central yellow with peripheral red Peripheral collarette and irregular distributed scale Peripheral dotted, scattered dotted and scattered linear Brown globules
Inverse PR Diffuse red Absent Scattered dotted vessels –
Lichenoid PR Diffuse red Irregular distributed scales Scattered dotted vessels Brown globules and structureless areas
Purpuric PR Diffuse red Irregular distributed scales (50%) and absent scaling (50%) Scattered dotted and linear vessels Red globules
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Histopathology findings

Biopsy was done from secondary eruptions and atypical lesions in 28 patients. On histopathology, the most common epidermal change was spongiosis (44%, n = 22), followed by parakeratosis (38%, n = 19) and irregular acanthosis (34%, n = 17). The most common dermal changes included perivascular lymphocytic infiltrate seen in 56% (n = 28) of cases, followed by red blood cell extravasation in 36% (n = 18) of cases. [Figure 5] The intraepidermal vesicle was seen in a single patient. Other findings included the presence of melanophages, mucin in the papillary dermis, eosinophils, and dermal oedema. Classical cases of PR showed hyperkeratosis, focal parakeratosis, irregular acanthosis, and mild spongiosis with sparse perivascular lymphocytic infiltrate.

Figure 5.

Figure 5

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Biopsy showing parakeratosis (Salute sign), spongiosis, irregular acanthosis, increased basal layer melanisation, and superficial perivascular lymphocytic infiltrate (H and E, 10×)

Histopathology of lichenoid PR had similar findings and necrotic keratinocytes and dermal melanophages. Five cases showed the characteristic salute sign showing a parakeratotic mound lifting from the stratum corneum. It correlated with the collarette scale present over the lesions. Biopsy of EM-like PR showed focal parakeratosis, irregular acanthosis, thinning of the granular layer, spongiosis, perivascular lymphocytic infiltration, RBC extravasation, and hyalinization of the papillary dermis. Characteristic findings of EM-like basal layer vacuolization or keratinocyte necrosis were absent.

Discussion

The diagnosis of PR is largely clinical based on the characteristic clinical findings. A recent study has reported an incidence of 0.64 per 100 dermatologic patients.[10] The current study showed the predominance of PR cases in young adults in the age group 18 to 25 years old, which is similar to that reported in the literature.[3] In our study, male predominance was seen which is similar to that reported in the literature.[11] PR shows a seasonal variation with most frequently occurring cases in colder months, owing to the common occurrence of viral illness in these seasons.[4] Our study was consistent with the above finding, with more patients seen during the rainy (July to September) and spring season (February to March). Less commonly, there can be familial cases and clustering of cases.[4] But in our study, no such cases were observed. The history of atopy in PR in the literature is reported in 30% of cases.[4] In our study, atopy was slightly higher in around 38% of cases.

Various risk factors are associated with the development of PR mentioned in the literature like pregnancy, stress, new clothes, drugs, vaccines, and infections like streptococcus and other viral aetiology.[4,5,12,13,14,15,16,17,18,19] In the present study, one case of a pregnant female developed PR in the first trimester. Other risk factors reported were infection in 10% of cases, history of new clothes in 4% (in contrast to that reported by Ganguly S in his study 23%), and stress in 8% of cases.[11] There is an exhaustive list of drugs causing PR mentioned in the literature.[4,5] Saha et al.,[18] in their study of cutaneous drug reaction profiles in Eastern India, reported 1.89% PR-like drug rash. In our study, nine out of 50 cases, 18%, were drug-induced PR. Three patients developed PR post-chemotherapeutic drugs like imatinib, cyclophosphamide, vincristine, and trastuzumab. Six cases of PR have been reported to occur post vaccination against SARS-COV2. PR occurring post-vaccine has been reported in multiple case reports.[13,14,19,20,21,22,23,24,25,36] The possible hypothesis could be a high cytokine response to the vaccine, leading to immune deregulation and reactivation of latent HHV6 and HHV7.[14]

Prodromal illness before the appearance of the herald patch is reported in 69% of patients.[15] Of our patients, only 46% had a history of prodromal illness, with the most common being fever (18%) and arthralgia (10%). Other less commonly seen symptoms included myalgia, upper respiratory tract infection (URTI), diarrhoea, headache, cough, and cold. While PR is asymptomatic, mild pruritus was observed in 82% of cases. A clinical profile on PR from central India also reported similar findings with pruritus in 75% of cases.[26]

In the literature, herald patch is reported in up to 80% of cases, but they may not always be present.[27] In our study, 72% of patients had a history of herald patch. The most common site of occurrence of herald patch was the back followed by the abdomen. The time interval between the herald patch and the secondary eruptions was less than five days in 40% of cases. Similar findings were reported in a one-year review of PR.[28]

Atypical variants of PR based on the morphology of lesions, size, distribution, number, orientation, symptoms, and clinical course are reported in 20% of cases.[7] Different morphologies include vesicular, purpuric, urticarial, generalized papular, lichenoid, erythrodermic, and EM-like PR.[29] In our study, we observed atypical PR in 40% of cases based on both the morphology and site of lesions. The most common was inverse PR (six cases) followed by papular PR (five cases). EM-like PR is reported in the literature by Sharma et al. (1 case with targetoid lesions) and Sinha et al. (co-existing with papular PR) and Relhan et al.[30,31,32] In our study, we had three cases with EM-like lesions. Recently, a PR distributed symmetrically in a blaschkolinear configuration was reported in a child.[37]

Facial involvement is seen mainly in children.[26,33] In our study, one of our 8-year-old patients had lesions over the face, both arms, chest, and upper back. [Figure 6].

Figure 6.

Figure 6

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Facial lesions in a child with PR

Palmo plantar involvement was seen in one patient in the form of vesicles, followed by the development of annular scaly lesions. [Figure 7] VDRL was negative in this patient. Such cases have been reported in the literature by other authors Mahajan et al.[5] and Zawar.[34]

Figure 7.

Figure 7

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Palmar lesions of PR

Oral mucosa is involved in 16% of cases, but no such case was seen in our study.[4] No systemic involvement was noted in our study, consistent with the literature.

Lallas et al.[9] were the first to review dermoscopic features of PR. Later on, in 2019, Elmas conducted a study on the dermoscopic profile of PR, further adding to the findings. In this study, they studied the dermoscopic findings of 100 lesions from 25 different patients. The most frequent finding was the peripheral collarette scale (84%), followed by central yellow with a peripheral reddish background (40%) and peripheral dotted vessels with patchy distribution (35%). Other less common findings were diffuse reddish background (31%), scattered dotted vessels (30%), and irregular distributed scales and red globules (20%).[8] In our study, we followed the same classification as Elmas et al.[8] The most common findings were diffuse reddish background (58%), peripheral collarette scale (62%), and peripheral dotted vessels (50%). Also, no scaling was evident even on dermoscopy in 8% of cases, and these correlated with the inverse distribution of lesions, and lack of scaling may be due to moisture and sweat.

Elmas et al.[8] described three additional findings blood spots, brown dots, and brown structureless areas. In addition to these, we also observed combined findings in the same lesions in 18% of patients. We also observed dermoscopy findings of palmar lesions of PR [Table 2], which have not been described previously.

We also found that 14% of cases had two types of background that correlated with the lesion’s age.

Early lesions of PR showed a diffuse red background with a collarette of scale and centre of the lesion and peripheral dotted vessels. As the lesion evolved, the central collarette moved peripherally with the development of scattered dotted vessels. As the lesions resolve, central redness decreases, leading to a central yellow and peripheral red background which eventually became diffuse yellow, scaling decreases, and vessels become less prominent. In addition, brown globules and structureless areas are more prominently seen.

The histopathological features of PR are nonspecific but essential to rule out other differentials of PR, especially in atypical cases. In our study, we performed a biopsy of patients with atypical morphology and cases in which the clinical diagnosis was questionable. PR shows a predominantly spongiotic tissue reaction pattern. Other findings include parakeratosis, irregular acanthosis, RBC extravasation, perivascular dermal lymphocytic infiltrate, necrotic keratinocyte, dermal melanophages, mucin in the papillary dermis, presence of eosinophils, and dermal oedema. Salute sign was seen in five cases which correlated clinically with collarette scaling. Prasad, in his histopathological study of PR, described delling that is depression in the surface of the epidermis filled with keratin and pinkish exudates.[35] We observed no such changes in histopathology.

The correlation of dermoscopic findings with histopathology revealed a diffuse red background correlated with vascular dilation, collarette scaling with salute sign, and patchy scaling with focal parakeratosis. Peripherally distributed dotted vessels in patchy distribution showed nonuniform dilatation of capillaries in dermal papillae. Miscellaneous findings like brown structureless areas corresponded with increased basal layer melanization and dermal melanophages, red globules corresponded to RBC extravasation, and brown spots correlated with hemosiderin deposits from extravasated RBCs.

Limitations

The main limitation was the fact that the study was conducted in a tertiary care centre which was a COVID hospital due to which sample size was less and biopsy was not done in all patients. Since ours was a cross-sectional study, there was no follow-up of cases to assess response to treatment and recurrence. Since the biopsy was not done in all patients, these findings could not be compared in all patients.

Conclusion

Pityriasis rosea is a mild papulosquamous disorder with varied clinical presentations. While diagnosis is clinical, it is difficult in atypical cases. Dermoscopy has been proven to be a novel diagnostic tool in dermatology. It helps in distinguishing various inflammatory disorders. This study adds to dermoscopic findings of PR, thus helping in distinguishing it from other inflammatory papulosquamous diseases like guttate psoriasis. It also helps identify the age of lesions, thus helping decide the treatment strategy for patients. Biopsy remains the gold standard in ruling out other differentials of PR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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