Clinicopathologic features of pityriasis rosea-like drug eruption secondary to imatinib: A case report and review of the literature.

Pityriasis rosea is an acute, self-limited exanthem that typically occurs in adolescence and young adulthood, classically featuring ovoid erythematous and scaly lesions on the trunk and proximal extremities. While its cause is not definitively known, the classic form of pityriasis rosea may result from the reactivation of latent human herpesvirus (HHV) infections (HHV-6 and HHV-7). Interestingly, drug eruptions that clinically and/or histopathologically resemble pityriasis rosea have also been reported. These pityriasis rosea-like drug eruptions tend to occur at an older age and have a shorter duration than the classic type. As there are different management paradigms, the distinction between classic pityriasis rosea and the mimicking drug eruption is important to recognize. Herein, we report a case of a pityriasis rosea-like drug eruption that occurred in association with imatinib mesylate treatment for chronic myeloid leukemia. We also review the clinicopathologic features of reported cases of pityriasis rosea-like drug eruption, including those due to imatinib. While the clinical morphology of the cutaneous drug-related eruption mimics the lesions seen in classic pityriasis rosea, the presence of unique histopathologic findings, including necrotic keratinocytes, interface dermatitis, and eosinophils, may aid in distinction.

Utility of IL-36 immunostaining in distinguishing psoriasis from pityriasis rosea and pityriasis lichenoides.

BACKGROUND: Psoriasis is an inflammatory skin disease driven by upregulation of cytokines in the Th17 pathway, including interleukin-36 (IL-36). Previous studies have highlighted the utility of IL-36 immunostaining for psoriasis compared to spongiotic dermatitis and other psoriasiform dermatoses; however, no study has examined the role of IL-36 staining in distinguishing psoriasis from pityriasis rosea (PR) and pityriasis lichenoides (PL), known histologic mimickers of psoriasis. METHODS: We compared the immunostaining pattern of IL-36 for 21 PR cases, 22 PL cases, and 10 psoriasis cases. We graded the immunostaining as 0, negative; 1, focal weak; 2, diffuse weak; 3, focal, strong; or 4, diffuse strong. We further categorized stains as negative (0-2 score) or positive (3-4 score) and utilized Fisher's exact test to compare the immunostaining pattern of these entities. RESULTS: All psoriasis specimens were positive for IL-36, whereas all PR specimens were negative (p = 0.00000002). Twenty PL specimens were negative (p = 0.000001). Nine of 10 pityriasis lichenoides et varioliformis acuta cases were negative (p = 0.00012), and 11 of 12 cases of pityriasis lichenoides chronica were negative (p = 0.00003). CONCLUSIONS: Our findings highlight the potential role of IL-36 immunostaining in distinguishing psoriasis from other psoriasiform dermatoses, including PR and PL.

Atypical plaque psoriasis: a clinicopathological study of 20 cases.

BACKGROUND: Plaque psoriasis is relatively straightforward to identify. When diagnostic concerns arise in atypical cases, a biopsy is needed. It is widely accepted that the Munro microabscess and the spongiform pustule of Kogoj are diagnostic pathological features. However, the diagnostic dilemma is likely to arise in cases without these specific pathological changes and typical clinical features. This study aimed to investigate clinical and pathological clues in distinguishing atypical plaque psoriasis from its mimics. METHODS: We evaluated the clinicopathological features of 20 cases of atypical plaque psoriasis and 40 cases of psoriasis mimics as controls including pityriasis rosea (n = 10), pityriasis lichenoides chronica (n = 8), and subacute dermatitis (n = 22). RESULTS: A retrospective analysis of the clinicopathological characteristics of patients with atypical plaque psoriasis and controls was performed. Pathologically, there were significant differences between the two groups in the types of parakeratosis (P = 0.046), epidermal capture of extravasated erythrocytes (P = 0.011), focal basal liquefied degeneration (P = 0.017), types of inflammatory cells (P = 0.000), and depth of inflammation (P = 0.000). Clinically, we found the presence of scales and crusts was significantly different between the two groups. CONCLUSION: This study offers insight into the clinicopathological features of atypical plaque psoriasis. These differential diagnostic features, compared with its mimics, are proposed to assist the clinician in the diagnosis and treatment of atypical plaque psoriasis.

Pityriasis rosea: dermoscopic features in Uganda.

PURPOSE: The study aimed to describe the dermoscopic features of pityriasis rosea among patients attending the skin clinic at Mbarara Regional Referral Hospital. PATIENTS AND METHODS: A hospital-based cross-sectional descriptive study conducted for a 6-month period in the skin clinic of MRRH in Southwestern Uganda. Data were collected from consecutively recruited patients using structured questionnaires. Patients with a clinical diagnosis of pityriasis rosea were examined using a dermoscope and subsequently sent for KOH and TPHA tests to rule out fungal skin infection and secondary syphilis, respectively, and then received routine care at the skin clinic. RESULTS: There were 54 patients with pityriasis rosea seen. Dermoscopy was done on a total of 162 lesions of which 19 were herald patches, 51 were truncal lesions, 52 on the extremities while 40 were on the face and neck regions. Common dermoscopic features consisted of a violaceous background noted in 145 (89.51%), white scales in 161 (99.38%), diffuse scale distribution in 57 (35.19%), perifollicular scale type in 61 (37.65%), and brown-dotted pigmentary changes in 66 (40.74%). Other unique findings noted in a few lesions were cloudy structures, petechial spots, erosions, and punched out pits. CONCLUSION: Most prevalent dermoscopic features included: a violaceous background, white scales, diffuse scale distribution, perifollicular scale type, brown-dotted pigmentary changes with no visible blood vessels nor follicular changes. Other unique less frequently seen findings were cloudy structures, petechial spots, erosions, and punched out pits.

Impact of COVID-19 on Clinicopathological Spectrum of Pityriasis Rosea in Korea.

BACKGROUND: Pityriasis rosea (PR) is a papulosquamous eruption with generally unknown origin but suspected to be related to viral etiologies. The clinicopathological spectrum of several disorders with viral etiologies has been altered after the coronavirus disease 2019 (COVID-19) pandemic. The author group could experience coherent histological alterations in PR after the COVID-19 pandemic. This study aimed to investigate how the clinicopathological findings of PR were changed after the COVID-19 pandemic. METHODS: Patients (n = 11) diagnosed with PR based on the clinical manifestations and skin biopsies between February 2018 and October 2019 and 11 patients in February 2020 and October 2021 were retrospectively analyzed by investigating the medical records. RESULTS: The patients with PR during the COVID-19 pandemic demonstrated statistically significant histopathological alterations from classic brisk and dense infiltration pattern to dormant and sparse infiltration and psoriasiform-dominant patterns (P = 0.019). PR was associated with more frequent pruritus during the pandemic period (P = 0.027). CONCLUSION: In conclusion, PR demonstrated a significant histopathological alteration with more frequent pruritus during the COVID-19 pandemic. The comparative results about clinicopathological findings of PR will provide a useful reference for dermatologists in the diagnostic process of PR in the COVID-19 pandemic.

Pityriasis Rosea after COVID-19 Infection.

Dear Editor, Pityriasis rosea (PR) is a common, self-limited erythematous papulosquamous dermatosis that mainly affects young adults. It is believed to represent a delayed reaction to viral infections and is usually associated with endogenous systemic reactivation of human herpesvirus (HHV) 6 and / or 7 (1). A 46-year-old man presented to our Department with a two-week history of skin rash associated with mild pruritus. He described the appearance of an erythematous centrally scaled lesion at the right part of his abdomen, followed by the spreading of red oval mildly scaling lesions on the trunk, neck, and proximal parts of the upper extremities, which showed in the physical examination (Figure 1, a and b). He was otherwise healthy and taking no medications. Six weeks prior to the appearance of the initial skin lesion, the patient had coronavirus disease 2019 (COVID-19) infection with mild clinical presentation (fever up to 38 °C lasting for four days and mild headache) and with symptoms of post COVID-19 syndrome (excessive tiredness). He denied oropharyngeal lesions. Potassium hydroxide, syphilis, and laboratory tests were within normal limits. Within two weeks of topical betamethasone dipropionate treatment, the lesions disappeared completely. In addition to reactivation of HHV-6 or HHV-7, PR can be triggered by some drugs (like angiotensin-converting enzyme inhibitors alone or in combination with hydrochlorothiazide, sartans plus hydrochlorothiazide, allopurinol, nimesulide, and acetyl salicylic acid (2) and vaccines (such as smallpox, poliomyelitis, influenza, human papillomavirus, diphtheria, tuberculosis, hepatitis B, pneumococcus, and yellow fever vaccines) (3). There is a growing number of published cases that link PR to COVID-19 infection, with PR appearing either in the acute phase of COVID-19 or, as in our patient, in the post COVID-19 period (4-9). Unlike in our patient, oropharyngeal lesions were observed in approximately 16% of patients with typical PR (10). It has been suggested that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) induces reactivation of other viruses, such as HHV-6, HHV-7, varicella zoster virus, and Epstein-Barr virus (5). PR has also been reported to follow COVID-19 vaccination (11). As our patient did not receive a COVID-19 vaccine, we cannot evaluate the latter based on the present case. We speculate that PR could be a delayed skin manifestation of COVID-19 infection, triggered either by SARS-CoV-2 immediately or indirectly by the reactivation of other viruses such as HHV-6 or HHV-7. However, the etiopathogenetic mechanisms remain largely unknown and further studies are needed in order to clarify the correlation between SARS-CoV-2 and PR.

Pigmented purpuric dermatosis: Ten years of experience in a tertiary hospital and awareness of mycosis fungoides in differential diagnosis.

BACKGROUND: Pigmented purpuric dermatoses (PPD) can clinically mimic many diseases. Histopathology provides a definitive diagnosis. The aim of the study is to reveal the features of patients with PPD and to determine the disease frequency in the differential diagnosis, especially mycosis fungoides (MF). METHODS: We retrospectively reviewed records of patients with PPD admitted to our hospital from January 2010 to May 2019. We studied the histopathological features of 127 patients, and performed pattern analysis on cases with a confirmed histopathologic diagnosis of PPD. Among the cases presenting with clinical features of PPD, but displaying different histopathological diagnoses, we focused on MF and tried to clarify the features of PPD-like MF. RESULTS: Overall, 389 patients were admitted to our hospital with PPD symptoms. Of them, 262 patients were diagnosed clinically and a histopathological examination was performed in 127 patients. Of 127, 87 were diagnosed with PPD, and in the remaining 40, non-specific features (9.4%), vasculitis (6.2%), pityriasis rosea (4.7%), MF (3.9%), suspected-MF (1.5%), and other dermatoses (%5.5) were detected. The biopsy findings of two patients showed PPD, but during follow-up, the diagnosis of MF was established. CONCLUSIONS: MF should be included in the differential diagnosis of PPD cases presenting with longstanding and widespread involvement.

Skin manifestations of COVID-19 in children: Part 3.

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discuss one of the first and most widespread cutaneous manifestations of COVID-19, chilblain-like lesions, and in Part 2 we expanded to other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome. In this part of the review, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children for both COVID-19 and any other pre-existing conditions.

Pityriasis rosea and other infectious eruptions during pregnancy: Possible life-threatening health conditions for the fetus.

Any infectious illness presenting with an eruption in a pregnant patient may be associated with an increased risk of fetal loss. The viruses that can infect the placenta during maternal infection and can be transmitted to the fetus and cause congenital disease include the rubella virus, the measles virus, the varicella zoster virus, parvovirus B19, human cytomegalovirus, arboviruses, and hepatitis E virus type 1. In addition, some bacteria responsible for exanthematous diseases, like Treponema pallidum, can be transmitted during pregnancy from the mother to the fetus and cause fetal loss. All these infectious agents can cause typical and/or atypical exanthems whose etiologic diagnosis is sometimes difficult but important to determine, especially in pregnant women because of the potential risk to the fetus. In the last 20 years, we have extensively studied pityriasis rosea from the clinical and laboratory perspectives, demonstrating the pathogenic role of human herpesvirus (HHV)-6 and -7. We synthesize the available evidence that PR may be associated with active HHV-6/7 infection and therefore with complications during pregnancy and fetal loss. We have also summarized the emerging infectious illnesses of dermatologic interest that may represent life-threatening health conditions for the fetus: measles, rubella, arbovirus infection, and syphilis.

Histopathologic features distinguishing secondary syphilis from its mimickers.

BACKGROUND: Syphilis is often misdiagnosed clinically, and biopsies might be required. OBJECTIVE: To determine histopathologic features that distinguish secondary syphilis from pityriasis lichenoides (PL), pityriasis rosea (PR), and early mycosis fungoides (MF). METHODS: Histopathologic features of 100 cases of syphilis, 110 cases of PL, 72 cases of PR, and 101 cases of MF were compared. RESULTS: Elongated rete ridges and interstitial inflammation favor syphilis over PL (likelihood ratios 3.44 and 2.72, respectively), but no feature reliably distinguishes between them. Secondary syphilis and PR can be distinguished by neutrophils in the stratum corneum, plasma cells, interface dermatitis with lymphocytes and vacuoles, and lymphocytes with ample cytoplasm. Plasma cells and lymphocytes with ample cytoplasm are rare in early MF and can be used as distinguishing features. CONCLUSIONS: Histopathologic features characteristic of syphilis can be seen in PL, PR, and early MF. Distinguishing syphilis from PL can be difficult histologically, and a high index of suspicion is required. Although elongation of rete and interstitial inflammation favor syphilis, plasma cells (historically considered a significant feature of syphilis) are often encountered in PL. Vacuolar interface dermatitis with a lymphocyte in every vacuole is considered characteristic of PL, but this feature appears to be more common in syphilis.

Pityriasis Rosea Recurrence is Much Higher than Previously Known: A Prospective Study.

Pityriasis rosea is a common acute exanthema of unknown aetiology, which causes severe anxiety. In this study, the demographic data of pityriasis rosea patients, who presented to our clinic between 2013 and 2017, were prospectively recorded. The patients with a confirmed pityriasis rosea diagnosis were followed up for 4 years in order to investigate the recurrence rate. Of the clinically suspected patients, having a typical history of pityriasis rosea manifestations, a herald patch, and/or secondary coloured squamous lesions, 400 were confirmed by biopsy to have pityriasis rosea. The 4-year follow-up was completed in 212 patients, of whom 136 (64.2%) were female and 76 (35.8%) were male. The recurrence rate was determined as 25.9% at the end of the 4-year follow-up period.

Erythematotelangiectatic rosacea may be associated with a subclinical stage of demodicosis: a case-control study.

BACKGROUND: Facial densities of Demodex mites have been observed to be greater in patients with demodicosis and papulopustular rosacea than in healthy control patients. In patients with erythematotelangiectatic rosacea (ETR), this density has been observed to be similar to or greater than that of healthy controls. Erythema and telangiectasia, characteristics of ETR, are often observed among patients with pityriasis folliculorum, a discreet demodicosis, suggesting a possible link between these conditions. OBJECTIVES: To compare the facial Demodex densities of patients with clinical ETR and patients with healthy skin, demodicosis, rosacea with papulopustules, and other facial dermatoses. METHODS: In this retrospective study, we recorded Demodex densities measured using two consecutive standardized skin surface biopsies (SSSB1 and SSSB2) in 23 patients with ETR, 20 healthy control patients, 590 patients with demodicosis, 254 with rosacea with papulopustules and 180 with other facial dermatoses. RESULTS: Patients with ETR had higher Demodex densities (D cm-2 ) than did the healthy controls (mean ± SEM; SSSB1: 15·7 ± 6·3 vs. 1·8 ± 1·1 D cm-2 , P = 0·042; SSSB2: 38·0 ± 13·7 vs. 5·1 ± 2·1 D cm-2 , P = 0·026) and patients with other dermatoses (SSSB1: 0·4 ± 0·1 D cm-2 , P = 0·004; SSSB2: 1·3 ± 0·3 D cm-2 , P = 0·004), but lower densities than patients with demodicosis (SSSB1: 82·7 ± 4·2 D cm-2 , P = 0·008; SSSB2: 172·2 ± 7·7 D cm-2 , P = 0·001) or rosacea with papulopustules (SSSB1: 86·6 ± 7·3 D cm-2 , P = 0·027; SSSB2: 197·0 ± 12·1 D cm-2 , P = 0·002). CONCLUSIONS: ETR may be associated with nonvisible Demodex proliferation, possibly corresponding to a subclinical stage of demodicosis. Dermatologists should be aware of this potential association and look for subclinical demodicosis in patients with ETR, so that topical acaricidal treatment can be offered if Demodex density is high.

Subsets of T lymphocytes in the lesional skin of pityriasis rosea.

BACKGROUND: Pityriasis rosea is a common papulosquamous disorder. However, its etiology and pathogenesis remain unclear. OBJECTIVE: We investigate the types of inflammatory cells infiltrating the lesional skin of pityriasis rosea and demonstrate whether T-cell-mediated immunity is involved in the pathogenesis of this condition or not. METHODS: The biopsies were taken from the lesional skin of 35 cases of patients diagnosed with pityriasis rosea. The specimens were prepared in paraffin sections, then submitted to routine immunohistochemistry procedures using monoclonal antibodies directed against CD3, CD4, CD8, CD20 and CD45RO and horseradish peroxidase-labeled goat anti-human antibodies. The positive sections were determined by the ratio and staining intensity of positive inflammatory cells. RESULTS: The mean score of positive CD3, CD4, CD8, and CD45RO staining was respectively 3.74±3.88, 5.67±4.40, 2.94±3.42 and 7.68±4.33 in these pityriasis rosea patients (P<0.001). The percentage of positive staining was 54.29% (19/35), 69.7% (23/33), 40% (14/35) and 79.41% (27/34) (P<0.05). However, the staining of CD20 was negative in all samples. The mean score of CD3 staining in patients with time for remission ≤60 days (4.90±4.21) was higher than that in patients with time for remission >60 days (2.00±2.5) (P<0.05), whereas no statistical difference in the mean score of CD4, CD8 and CD45RO staining was observed. study liMitations: The sample size and the selected monoclonal antibody are limited, so the results reflect only part of the cellular immunity in the pathogenesis of pityriasis rosea. CONCLUSION: Our findings support a predominantly T-cell mediated immunity in the development of pityriasis rosea.

Subsets of T lymphocytes in the lesional skin of pityriasis rosea

Abstract: Background: Pityriasis rosea is a common papulosquamous disorder. However, its etiology and pathogenesis remain unclear. Objective: We investigate the types of inflammatory cells infiltrating the lesional skin of pityriasis rosea and demonstrate whether T-cell-mediated immunity is involved in the pathogenesis of this condition or not. Methods: The biopsies were taken from the lesional skin of 35 cases of patients diagnosed with pityriasis rosea. The specimens were prepared in paraffin sections, then submitted to routine immunohistochemistry procedures using monoclonal antibodies directed against CD3, CD4, CD8, CD20 and CD45RO and horseradish peroxidase-labeled goat anti-human antibodies. The positive sections were determined by the ratio and staining intensity of positive inflammatory cells. Results: The mean score of positive CD3, CD4, CD8, and CD45RO staining was respectively 3.74±3.88, 5.67±4.40, 2.94±3.42 and 7.68±4.33 in these pityriasis rosea patients (P<0.001). The percentage of positive staining was 54.29% (19/35), 69.7% (23/33), 40% (14/35) and 79.41% (27/34) (P<0.05). However, the staining of CD20 was negative in all samples. The mean score of CD3 staining in patients with time for remission ≤60 days (4.90±4.21) was higher than that in patients with time for remission >60 days (2.00±2.5) (P<0.05), whereas no statistical difference in the mean score of CD4, CD8 and CD45RO staining was observed. study liMitations: The sample size and the selected monoclonal antibody are limited, so the results reflect only part of the cellular immunity in the pathogenesis of pityriasis rosea. Conclusion: Our findings support a predominantly T-cell mediated immunity in the development of pityriasis rosea.

Relapsing Pityriasis Rosea With HHV-7 Reactivation in an 11-Year-Old Girl.

Pityriasis rosea (PR) usually presents as acute exanthema with oval erythematous-squamous lesions localized on the trunk, arms, and legs with spontaneous remission. We present an unusual case of PR with frequent relapses during a period of 7 years. An 11-year-old white female patient presented with many pruritic erythematous oval lesions on her trunk. A second episode followed 2 years later with several pruritic erythematous lesions on her lower limbs. During the following 5 years, the patient had several relapses per year, with 1 to 3 lesions on changing localizations. PR was diagnosed on the basis of the clinical presentation and detection of human herpesvirus 7 DNA. Spontaneous remission occurred without treatment in each episode. Relapsing PR is a rare form of PR characterized by a lower number of lesions and smaller sized lesions compared with the classic form of PR. Pediatricians should consider the diagnosis of relapsing PR even if only a single or few erythematous lesions are present.