[Paraviral exanthems]. / Paravirale Exantheme.

Paraviral exanthems are distinct skin diseases due to infections with different viruses. Although no virus has been identified so far in some exanthems, the main age of manifestation, the clinical course of the exanthem, and the extracutaneous symptoms are suggestive for a viral genesis. While many viral infections are a direct result of the infection, paraviral exanthems reflect the response of the immune system to the infectious pathogens. Viruses cannot be identified in the skin. Typical paraviral exanthems include Gianotti-Crosti syndrome, pityriasis rosea, pityriasis lichenoides, papular-purpuric gloves and sock syndrome, and asymmetrical periflexural exanthema. Unilateral mediothoracic exanthem, eruptive pseudoangiomatosis are rare and eruptive hypomelanosis has been described recently.

A position statement on the management of patients with pityriasis rosea.

Many clinical trials have been conducted on the treatment of pityriasis rosea (PR). Our aim was to establish a position statement for the management of adults with PR based on the best available evidence. We searched PubMed for all reports on randomized controlled trials for the treatment of PR published in the past 30 years. We retrieved 14 articles reporting randomized controlled trials, and found five which met our quality requirements for in-depth analyses. Erythromycin was found in a well-conducted triple-blind study to cast significant impacts on clinical outcomes. However, adverse gastrointestinal effects were fairly common. Another well-conducted study on azithromycin reported no significant benefit. It was reported in three well-conducted studies on oral acyclovir in low dose (400 mg three times daily for 7 days or 400 mg five times daily for 7 days) and high dose (800 mg five times daily for 7 days), that acyclovir is effective in attaining rash regression and lessening the pruritus. When compared against each other, the high-dose regimen demonstrated no benefit over the low-dose regimens. Our statement comprises the follows: (i) The diagnosis of PR should be ascertained; (ii) The patients should be assessed for rash severity and impacts on quality of life; (iii) PR is a self-limiting disease, and most patients do not necessitate any treatment; (iv) For patients necessitating active treatment, oral acyclovir as 400 mg three times daily for 7 days can be considered; (v) Attention should be given to adverse effects and contraindications of acyclovir; (vi) When PR occurs in early pregnancy, oral antiviral therapy could be considered after consulting experienced clinicians; (vii) Inadequate information exists in the use of acyclovir to treatment PR in children and breastfeeding women; and (viii) Treating PR is an off-label use of acyclovir, and this has to be discussed with experienced colleagues and the patients.

Acne prevalence and beyond: acne disability and its predictive factors among Chinese late adolescents in Hong Kong.

BACKGROUND: Data are lacking on the prevalence of acne, its effects on quality of life (QOL) and the treatment usage among Chinese patients in late adolescence. AIM: To derive data about the prevalence and predictive factors of acne, the disability caused by acne and choice of treatment used by Chinese late adolescents in Hong Kong. METHODS: This was a cross-sectional study of a random sample of 389 entrants in a university in Hong Kong, using the Global Acne Grading System (GAGS) to measure the clinical severity of acne and the Cardiff Acne Disability Index (CADI) to measure QOL. RESULTS: The response rate was 99.3%. The prevalence of acne was of 81.5% (95% CI 77.6-85.4%) and coexisted with a high frequency of acne disability at a rate of 81.8% (95% CI 78.1-85.6%). Assessment of the clinical severity of acne did not correlate strongly with the effect on QOL (gamma(s) = 0.445, P < 0.001). Over the previous 6 months, 30.3% of subjects had used topical treatments, 3.9% had taken systemic conventional western drugs and 3.2% of the subjects had used traditional Chinese medicine. Multivariate logistic regression was used to explore the predictive factors for acne disability. Female gender (P = 0.002), higher GAGS score (P < 0.001), higher perceived stress (P = 0.01) and willingness to pay Hong Kong$15,000 (970 pounds) for a hypothetical permanent cure (P = 0.03) were positive predictors. CONCLUSIONS: Acne is prevalent in Hong Kong and has considerable psychological effects. The association between clinical severity and impaired QOL is not strong.

An investigation of the association between diet and occurrence of acne: a rational approach from a traditional Chinese medicine perspective.

BACKGROUND: The association between diet and acne vulgaris has long been suggested but remains unproven in western medicine. In contrast, the diet-acne relationship is considered important in traditional Chinese medicine (TCM). Aim. To investigate the association between diet and acne, using a TCM approach. METHODS: Using a cross-sectional study of 322 entrants to a university in Hong Kong, China, we examined the participants' clinical severity of acne using the Global Acne Grading System and the participants' yin and yang scores using a quantitative method. We then divided them into two groups, a yin-predominant group (yin-PG) and a yang-predominant group (yang-PG) before the diet-acne relationship was investigated. RESULTS: In total, 82 (25.2%) participants were in the clinical acne group and 240 (74.5%) were in the reference group. There were 155 (48.1%) participants in the yin-PG and 167 (51.9%) in the yang-PG group. No association of diet and acne was found when the participants were considered as a homogenous group. In yin-PG, intake of foods from street stalls (P = 0.04) was significantly associated with a lower incidence of acne. In yang-PG, the intake of desserts (P = 0.04) and fresh fruit juices (P = 0.02) was significantly associated with a higher incidence of acne, whereas the intake of dairy and soy products (P = 0.04) was significantly associated with a lower incidence of acne. CONCLUSIONS: The application of a TCM approach led to the detection of significant associations between diet and the incidence of acne.

Does age or gender influence quality of life in children with atopic dermatitis?

BACKGROUND: Quality of life (QoL) is impaired in children with atopic dermatitis (AD) but the various aspects of QoL may not be equally affected. Aim. To evaluate if age and gender affect some aspects of QoL in children with AD. METHOD: The Children's Dermatology Life Quality Index (CDLQI) was used for all children with AD seen at a paediatric dermatology clinic over a 3-year period. Disease severity was assessed using the SCORing Atopic Dermatitis (SCORAD) and Nottingham Eczema Severity Score (NESS) tools. RESULTS: We reviewed CDLQI in 133 children (70 male and 63 female; age range 5-16 years) with AD. Itch, sleep disturbance, treatment and swimming/sports were the four aspects of QoL issues that were most commonly affected, in 50%, 47%, 38% and 29% of patients, respectively. Problems with interpersonal issues (friendship, school/holidays, and teasing/bullying) occurred in only a minority of children (

Does dermatoscopy facilitate the detection and diagnosis of vascular skin lesions? A case-control study.

BACKGROUND: During dermatoscope-guided surgical procedures, we noticed that vasculature was easily identified. This study investigated the use of dermatoscopy in detecting and diagnosing vascular skin lesions. METHODS: We retrieved records of patients with vascular skin lesions who underwent dermatoscopy over a 3 month period, in two outpatient clinics affiliated with a university teaching hospital. Our controls were similar patients where dermatoscopy was not performed. RESULTS: Our new findings are: 1, clinical and dermatoscopic examinations diagnosed significantly more patients with vascular skin lesions than clinical examinations alone (risk ratio: 1.36; 95% confidence interval: 1.10-1.67); 2, the detection rate increase was significant for cherry angiomas (p < 0.001), telangiectasias (p < 0.01) and spider angiomas (p < 0.01); 3, qualitatively, dermatoscopy revealed characteristic configurations, hues and colour saturations of the vascular skin lesions; and 4, the first reported dermatoscopic images of focal essential telangiectasia and petechial angioma. CONCLUSION: In our setting, clinical and dermatoscopic examinations significantly facilitated detecting and diagnosing vascular skin lesions, compared to clinical examination alone.

Interventions for pityriasis rosea.

BACKGROUND: Pityriasis rosea is a scaly rash that mainly affects young adults. It can be very itchy but most people recover within 2 to 12 weeks. OBJECTIVES: To assess the effects of interventions for pityriasis rosea. SEARCH STRATEGY: We searched the Cochrane Skin Group Specialised Register (December 2004), the Cochrane Central Register of Controlled Clinical Trials in The Cochrane Library (Issue 4, 2004), MEDLINE (1966 to January 2005), EMBASE (1976 to January 2005), LILACS (1982 to January 2005), BIOSIS Preview (1980 to June 2002), and ongoing trials databases. We scanned bibliographies of published studies, abstracts from dermatology conference proceedings, corresponded with trialists and contacted the pharmaceutical industry. SELECTION CRITERIA: Randomised controlled trials evaluating interventions for pityriasis rosea. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. We contacted study authors to retrieve missing data. MAIN RESULTS: Three trials involving 148 people were included. One poor quality trial (23 people), compared intravenous glycyrrhizin and intravenous procaine. It found no significant difference between the two interventions for treating symptoms and rash. One fair quality trial (85 people), compared the oral antihistamine dexchlorpheniramine (4 mg), the oral steroid betamethasone (500 mcg), and a combination of betamethasone (250 mcg) and dexchlorpheniramine (2 mg). It found no significant difference in itch resolution at two weeks, as rated by the participants, between dexchlorpheniramine and betamethasone, and the combination of dexchlorpheniramine and betamethasone. However, both dexchlorpheniramine and betamethasone alone seem to be better at clearing rash than the combination of dexchlorpheniramine and betamethasone. These interventions were not compared with placebo. The small good quality trial (40 people) that compared oral erythromycin and placebo found that erythromycin was more effective than placebo in terms of rash improvement, as rated by the trialists, after two weeks (RR 13.00; 95% CI 1.91 to 88.64). It was also more effective in decreasing the itch score (difference of 3.95 points, 95% CI 3.37 to 4.53). No serious adverse effects were reported for the interventions. Two out of 17 people on oral erythromycin and 1 out of 17 on placebo reported minor gastrointestinal upset. AUTHORS' CONCLUSIONS: We found inadequate evidence for efficacy for most treatments for pityriasis rosea. Oral erythromycin may be effective in treating the rash and decreasing the itch. However, this result should be treated with caution since it comes from only one small RCT. More research is necessary to evaluate the efficacy of erythromycin and other treatments.

The diagnostic criteria of pityriasis rosea and Gianotti-Crosti syndrome - a protocol to establish diagnostic criteria of skin diseases.

We established and validated diagnostic criteria for pityriasis rosea and Gianotti-Crosti syndrome. In this paper, we compare and contrast both diagnostic criteria to formulate a protocol in establishing diagnostic criteria for other dermatological diseases. The diagnostic criteria are similar in employing clear dividing lines and conjunctions ('and/or') to assure high reliability. Both sets of criteria should be applicable for all ethnic groups. Spontaneous remission is not included, so diagnosis is not delayed while waiting for disease remission. Laboratory investigations are not enlisted, so that the criteria can be used in medical care systems in different parts of the world. The diagnostic criteria are different in that pathognomonic clinical manifestations exist for pityriasis rosea, such as the herald patch and the orientation of lesions along the lines of skin cleavages. These features, however, score low for sensitivity. These specific manifestations are not seen in Gianotti-Crosti syndrome. Such differences led to different categorisation of clinical features. Atypical variants are more common for pityriasis rosea. The diagnostic criteria for pityriasis rosea therefore do not include a list of differential diagnoses, while diagnostic criteria for Gianotti-Crosti syndrome do. Using this comparison, we constructed a protocol to establish diagnostic criteria for other skin diseases. We advocate the need to justify the establishment of diagnostic criteria, that multiple diagnostic criteria for the same disease should be avoided, that diagnostic criteria should be compatible with the disease classification if applicable, and that the scope should be well-delineated with regard to clinical variants. We outline the need for validation studies to assess the criteria-related validity, test-retest intra-clinician reliability, and inter-clinician reliability. We emphasise that the establishment of diagnostic criteria should not be a generic process. We also highlight limitations of diagnostic criteria, and emphasise that no diagnostic criteria can replace the bedside experience of clinicians.

Diagnostic criteria for Gianotti-Crosti syndrome: a prospective case-control study for validity assessment.

No criteria exist for the modern diagnosis of Gianotti-Crosti syndrome (GCS). Our study objectives were to determine diagnostic criteria for GCS and to assess their validity using a prospective case-control design. We reviewed the clinical features of children with GCS who were reported in the literature from 1996 to 2000 and proposed a set of diagnostic criteria. We documented clinical features of children younger than 18 years who were diagnosed over a period of 18 months as having GCS and of control subjects given (over the same period) differential diagnoses of GCS. Forty-two children were recruited (11 with GCS and 31 controls with differential diagnoses of GCS). All children with GCS, and none of the controls, fulfilled the set of diagnostic criteria as a whole. We conclude that the proposed criteria are practical valid criteria for diagnosing GCS.

The detection of human herpesvirus-8 DNA in plasma and peripheral blood mononuclear cells in adult patients with pityriasis rosea by polymerase chain reaction.

BACKGROUND: Herpesvirus-like particles have been reported to be detectable by electron microscopy in lesional biopsy of patients with pityriasis rosea (PR). We report a study investigating the association of PR with human herpesvirus-8 (HHV-8) infection. METHODS: Our setting is a teaching clinic affiliated to a university. We recruited eight patients aged 28-47 years (mean: 34.5 years) diagnosed with PR during a one-year period. We collected acute blood specimens at presentation and convalescent blood specimens three to four weeks later. We also collected skin scrapings from the herald patch where present and from truncal secondary lesions. RESULTS: We detected HHV-8 DNA by a nested PCR (polymerase chain reaction) targeting, respectively, a 233-bp and a 160-bp fragment of ORF 26. PCR for HHV-8 DNA was negative in the peripheral blood mononuclear cells and plasma of acute and convalescent specimens of all patients, and negative in all skin scrapings. We detected anti-HHV-8 IgG and IgM antibodies by the indirect immunofluorescence. Four patients had IgG antibodies against HHV-8, but with no significant rise of titre. None were positive for anti-HHV-8 IgM antibody. CONCLUSION: We conclude that PR is not associated with HHV-8 infection.

Atypical presentations of pityriasis rosea: case presentations.

Atypical cases of pityriasis rosea (PR) are fairly common and less readily recognized than typical eruptions. We present four patients for whom we believe atypical PR is the most likely diagnosis. A 33-year-old man had purpuric lesions bilaterally on the legs with classical rash on the trunk. A 28-year-old woman had intensely pruritic and urticarial lesions. A 10-year-old girl had hundreds of small papular lesions 1-3 mm in size. A pregnant woman aged 26 had oral haemorrhagic ulcers with classical PR eruption on her trunk. The oral ulcers erupted and remitted at the same time as the generalized eruption. We reviewed the literature and proposed a classification based on rash morphology, rash size, rash distribution, number of lesions, site of lesions, severity of symptoms and course of the eruption. We believe that it is difficult to make a clear division to define typical and atypical PR, and that it is important not to ascribe any unusual or atypical skin eruption with PR unless other dermatoses have been excluded.

Collarette scaling in pityriasis rosea demonstrated by digital epiluminescence dermatoscopy.

Collarette scaling is a characteristic sign in pityriasis rosea. The use of digital epiluminescence dermatoscopy is proposed to assist in the recognition of this sign as this technique can magnify the lesions, eliminate other epidermal changes, and demonstrate the morphology and direction of scaling.

Pityriasis rosea--evidence for and against an infectious aetiology.

Pityriasis rosea, first named as such in 1860, probably holds the longest record for an exanthem suspected to be associated with an infection but for which an exact cause has not been found. The distinctly programmed clinical course, the lack of recurrence for most patients, and the presence of temporal case clustering provide the strongest evidence to support an infectious aetiology. Further support comes from seasonal variation and the association with respiratory tract infections, the unfavourable social and economic background of cases, and a history in some cases of contact with patients with pityriasis rosea. The apparent therapeutic efficacy of several treatment modalities does not provide strong evidence for or against an infectious aetiology. The roles of human herpesvirus 7 and to a lesser extent human herpesvirus 6 remain controversial. There exists reasonable evidence that pityriasis rosea is not associated with cytomegalovirus, Epstein-Barr virus, parvovirus B19, picornavirus, influenza and parainfluenza viruses, Legionella spp., Mycoplasma spp. and Chlamydia spp. infections. Evidence is also unsubstantiated as yet for alternative aetiological hypotheses such as autoimmunity, atopy, and genetic predisposition.

Lack of evidence of active human herpesvirus 7 (HHV-7) infection in three cases of pityriasis rosea in children.

Three cases of pityriasis rosea in Chinese children are presented. Using polymerase chain reaction for detection of human herpesvirus 7 (HHV-7) DNA in plasma and peripheral blood lymphocytes, we find no evidence of active HHV-7 infection.

Human herpesvirus 6 and 7 DNA in peripheral blood leucocytes and plasma in patients with pityriasis rosea by polymerase chain reaction: a prospective case control study.

An association between pityriasis rosea and human herpesvirus 7 (HHV-7) has been reported but remains controversial. The purpose of the present study was to investigate the association between HHV-6 and HHV-7 with pityriasis rosea. Fifteen patients aged 6-54 years with a diagnosis of pityriasis rosea and 15 age-matched controls were recruited. None of the patients had HHV-6 or HHV-7 DNA detected by polymerase chain reaction in the acute or convalescent plasma specimen. In the acute peripheral blood leucocytes specimen, 3 patients and one control had RHV-6 DNA detected (p=0.299; NS), while 7 patients and 5 controls had HHV-7 DNA (p=0.355; NS). Antibody to HHV-6 was detected in the acute specimen of 13 patients and 13 controls, while antibody to HHV-7 was found in all 15 of patients and controls. We thus found no evidence of recent HHV-6 or HHV-7 infection in patients with a diagnosis of pityriasis rosea.

The association of smoking and acne in men in Hong Kong and in India: a retrospective case-control study in primary care settings.

Previous studies on the association of smoking with acne vulgaris have reported conflicting results. The objective of this study was to investigate such an association. Our setting was three primary care practices in Hong Kong and one primary care practice in India. Patient characteristics in all four practices are similar. All medical records in these practices incorporate a section in which the smoking habits of each patient is routinely documented. We searched our database and retrieved 632 records of patients with acne seen in the previous 5 years. We also retrieved 632 records of age- and sex-matched controls. Fifty-three out of 379 male patients with acne and 25 out of 379 male controls were smokers (P = 0.001; OR, 2.3; 95% CI, 1.4-3.8). Six out of 253 female patients with acne and three out of 253 female controls were smokers (OR, 2.0; 95% CI, 0.5-9.4). We conclude that smoking is likely to bear a positive correlation with acne for men. Our numbers are too small for a definite conclusion to be drawn for females.