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Clinical and Experimental Dermatology

CPD A memorable patient

Plantar herald patch in pityriasis rosea


R. M. Robati and P. Toossi
Skin Research Centre, Shahid Beheshti University, M.C. Shohada-e Tajrish Hospital, Tehran, Iran.
doi:10.1111/j.1365-2230.2008.02772.x

A 15-year-old girl presented to us, reporting that she had developed erythematous annular lesions on her sole a week previously. She reported no pruritus or burning sensation with these eruptions. On physical examination, erythematous patches with ne collarette scales were seen on the plantar aspect of the foot (Fig. 1). The patient was in general good health and no other skin eruptions were visible on any part of her body. A specimen of the lesion was histologically examined. No hyphae or mycelium were seen in potassium hydroxide preparation of the lesional direct smears. A few days later, a diffuse papulosquamous eruption developed on the skin in the cleavage lines of the trunk and limbs. Routine laboratory data including complete blood count, urine analysis and tests for sexually transmitted infections (VDRL) were all normal or negative. A clinical diagnosis of pityriasis rosea was made. The patient was treated successfully with topical steroid, and all the lesions disappeared in 6 weeks. PR is a common, acute disease of uncertain aetiology. Viral and bacterial causes have been sought, but the denite cause has not yet been established. The condition usually affects children and young adults.1 Diagnosis of PR can be difcult. At onset, it is difcult to distinguish from other diseases, and there are no noninvasive tests that verify the condition. In at least half of patients, the rst symptoms of PR are nonspecic and consistent with a viral upper respiratory infection.2 PR is characterized by a herald patch and the later appearance of lesions arrayed along cleavage lines. The rst appearance of the disease is often the appearance
Correspondence: Reza Mahmoud Robati, MD, Skin Research Centre, Shahid Beheshti University M.C., Shohadaye-Tajrish Hospital, Shahrdari St, Tehran, Iran. Tel: +98-21-44309454; Fax: +98-21-22744393 E-mail: rmrobati@irimc.org Conict of interest: none declared. Accepted for publication 30 November 2007

Figure 1 Erythematous patches with ne collarette scales on the plantar aspect of the foot (rosea herald patch).

of the herald patch, which is larger and more noticeable than the lesions of the later eruption. It is commonly located on the thigh, upper arm, trunk or neck; rarely it may be on the face, scalp or penis. This large lesion is frequently 20100 mm in diameter, ovoid, erythematous and faintly raised, with a typical collarette of scale at its edge.3 At this stage, however, the diagnosis usually remains unclear. The herald patch is usually followed by the development of a diffuse papulosquamous rash on the trunk and limbs. These generalized eruptions generally develop a few days to a few weeks after the appearance of the herald patch. At this stage, the diagnosis is usually clear, particularly if the doctor can observe or obtain a history of the herald patch. This patch is occasionally misdiagnosed as eczema.1

2009 The Author(s) Journal compilation 2009 Blackwell Publishing Ltd Clinical and Experimental Dermatology, 34, 269270

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A memorable patient

The differential diagnosis of PR includes diffuse nummular eczema, tinea corporis, pityriasis lichenoides, guttate psoriasis, viral exanthema, lichen planus and drug reaction. Biopsy is usually not indicated when evaluating patients with suspected PR. Histology shows nonspecic subacute and chronic inammation. Dyskeratotic degeneration of epidermal cells has also been seen in some cases.4 Herald patch development at the site of diphtheria vaccination has been reported in the literature.5 However, there is no report of palmoplantar herald patch in PR. It seems prudent to consider herald patch in the differential diagnosis of acute annular scaly rash on the palm or sole.

References
1 Stulberg DL, Wolfrey J. Pityriasis rosea. Am Fam Physician 2004; 69: 8791. 2 Cheong WK, Wong KS. An epidemiological study of pityriasis rosea in Middle Road Hospital. Singapore Med J 1989; 30: 602. 3 Sterling JC. Viral infection. In: Rooks Textbook of Dermatology (Burns T, Breathnach S, Cox N, Grifths C, eds). Blackwell, 2004: 20.7920.81. 4 Okamoto H, Imamura S, Aoshima T et al. Dyskeratotic degeneration of epidermal cells in pityriasis rosea: light and electron microscopic studies. Br J Dermatol 1982; 107: 18994. 5 Laude TA. Herald patch in a DPT injection site. J Am Acad Dermatol 1981; 5: 4756.

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2009 The Author(s) Journal compilation 2009 Blackwell Publishing Ltd Clinical and Experimental Dermatology, 34, 269270

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