Erythromycin in pityriasis rosea: A double-blind, placebo-controlled clinical trial

Pityriasis rosea in pregnancy: A case series and literature review

Background and objective

Pityriasis rosea (PR), a common skin disease in young adults, may adversely affects the course of pregnancy and the unborn child.

Patients and methods

Data from forty‐six pregnant women with PR seen in the dermatological university clinic between 2003 and 2018 were analyzed and compared with patient data (n = 53) from previously published studies to determine the incidence and risk factors for an unfavorable pregnancy outcome after PR infection.

Results

Unfavorable pregnancy outcomes (defined as miscarriage, preterm delivery before week 37 of gestation, or birth weight < 2,500 g) were significantly less frequent in our study population than in a pooled cohort obtained from previously published studies (10.9 % vs. 39.6 %; P = 0.0012). Analysis of pooled data from our study and from previous studies revealed that the week of pregnancy at onset of PR was inversely associated with an unfavorable outcome (odds ratio [OR] = 0.937; 95 % CI 0.883 to 0.993). In addition, duration of PR (OR = 1.432; 95 % CI 1.129 to 1.827), additional extracutaneous symptoms (OR = 4.112; 95 % CI 1.580 to 10.23), and widespread rash distribution (OR 5.203, 95 % CI 1.702 to 14.89) were directly associated with unfavorable outcome.

Conclusion

In most cases, PR does not influence pregnancy or birth outcomes.

Pitiriasis rosada, una reacción exantemática

Las urgencias dermatológicas son eventos poco frecuentes que puedenser causados por alteraciones agudas de la salud, con o sin afectaciónsistémica, o por enfermedades crónicas cuando se presentan cuadros de agudización.

Atypical pityriasis rosea in a young Colombian woman. Case report

Introduction: Pityriasis rosea is an acute and self-limited exanthemfirst described by Gilbert in 1860. Its treatment is symptomatic, and although there is no conclusive evidence, it has been associated with the reactivation of the human herpesviruses 6 and 7 (HHV-6 and HHV-7). Case presentation: A 28-year-old woman, from Bogotá, Colombia, ahealth worker, attended the emergency room due to the onset ofsymptoms that began 20 days earlier with the appearance of punctiformlesions in the left arm that later spread to the thorax, abdomen, opposite arm, and thighs. The patient reported a history of bipolar II disorder and retinal detachment. After ruling out several infectious diseases, and due to the evolution of the symptoms, pityriasis rosea was suspected. Therefore, treatment was started with deflazacort 30mg for 21 days, obtaining a favorable outcome and improvement of symptoms after 2 months. At the time of writing this case report, the patient had not consulted for recurrence. Conclusion: Primary care physicians should have sufficient training indermatology to recognize and treat dermatological diseases since manyof them are diagnosed based on clinical findings. This is an atypicalcase, in which the patient did not present with some of the pathognomonic signs associated with pityriasis rosea.

Pityriasis Rosea: An Updated Review

BACKGROUND

Pityriasis rosea is a common acute, self-limited papulosquamous dermatosis that primarily affects children and young adults. The condition and its clinical variants may pose a diagnostic challenge, especially in the absence of the herald patch.

OBJECTIVE

This article aimed to familiarize pediatricians with clinical manifestations, evaluation, diagnosis, and management of pityriasis rosea.

METHODS

A search was conducted in March 2020 in Pubmed Clinical Queries using the key term " pityriasis rosea". The search strategy included all clinical trials (including open trials, non-randomized controlled trials, and randomized controlled trials), observational studies, and reviews (including narrative reviews and meta-analyses) published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Pityriasis rosea occurs mainly in individuals between 10 and 35 years of age with a peak during adolescence. Human herpesvirus (HHV)-7 and HHV-6 have been implicated as the causative agents in some patients with pityriasis rosea. A mild prodrome consisting of headaches, fever, malaise, fatigue, anorexia, sore throat, enlarged lymph nodes and arthralgia is present in about 5% of patients. The most common presenting sign, found in approximately 80% of patients, is a "herald" or "mother" patch which is larger and more noticeable than the lesions of the later eruption. A generalized, bilateral, symmetrical eruption develops in approximately 4 to 14 days and continues to erupt in crops over the next 12 to 21 days. Typical lesions are 0.5 to 1 cm, oval or elliptical, dull pink or salmon-colored macules with a delicate collarette of scales at the periphery. The long axes tend to be oriented along the skin lines of cleavage (Langer lines). Lesions on the back may have a characteristic "Christmas tree", whereas lesions on the upper chest may have a V-shaped pattern. There are many conditions that may mimic pityriasis rosea. Pityriasis rosea in the absence of the herald patch and its variants may pose a diagnostic challenge. The typical course is 6 to 8 weeks. In the vast majority of cases, reassurance and symptomatic treatment should suffice. Active intervention may be considered for individuals with severe or recurrent pityriasis rosea and pregnant women with the disease. Treatment options include acyclovir, macrolides (in particular, erythromycin), and ultraviolet phototherapy. If active intervention is needed, there is evidence supporting the use of oral acyclovir to shorten the duration of illness.

CONCLUSION

Pityriasis rosea is a common, acute, self-limiting exanthematous skin disease that primarily affects children and young adults. The condition is characterized by a "herald patch" after which oval erythematous squamous lesions appear along Langer's lines of cleavage on the trunk and proximal extremities, giving it a "Christmas tree" appearance. The disease presenting in its classical form can easily be diagnosed. Clinical variants of the disease may pose a diagnostic challenge for the general pediatrician. Knowledge of the disease is essential to allow prompt diagnosis and to avoid unnecessary investigations.

An Atypical Presentation of Pityriasis Rosea Localized to the Extremities

Pityriasis rosea (PR) is a benign, self-limiting, papulosquamous disorder characterized by the onset of a herald patch followed by an abrupt eruption of multiple salmon-colored papules and plaques on the trunk and proximal extremities. The individual lesions are often outlined by a collarette of scale and are distributed along the lines of cleavage. While many authors acknowledge an etiologic association with human herpesvirus 6 and human herpesvirus 7, thereby suggesting a viral exanthem, the exact cause remains unclear. While typically demonstrating a truncal predilection, this presentation may be absent in some patients who instead exhibit atypical features and distributions. Various clinical variants include papular, vesicular, purpuric, and eczematoid. The condition rarely manifests without truncal involvement and localized only to the distal extremities. We present a unique case report of a 65-year-old-male with biopsy-proven PR that was localized to his distal extremities with a clinical absence of truncal involvement.

Pityriasis in dermatology: an updated review

Dermatology has a very distinctive lexicon. The term pityriasis refers to several dermatologic conditions which all feature scaling of the skin. According to the Merriam-Webster dictionary, the term pityriasis was first used in print in 1684. Although the diseases beginning with the name pityriasis are of diverse causation, they do represent important dermatologic diseases, with some common and others quite rare. It is important for dermatologists to be aware and updated on all pityriasis conditions in dermatology.

Interventions for pityriasis rosea

BACKGROUND

Pityriasis rosea is a scaly, itchy rash that mainly affects young adults and lasts for 2 to 12 weeks. The effects of many available treatments are uncertain. This is an update of a Cochrane Review first published in 2007.

OBJECTIVES

To assess the effects of interventions for the management of pityriasis rosea in any individual diagnosed by a medical practitioner.

SEARCH METHODS

We updated our searches of the following databases to October 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched five trials registers. We also checked the reference lists of included and excluded studies, contacted trial authors, scanned the abstracts from major dermatology conference proceedings, and searched the CAB Abstracts database. We searched PubMed for adverse effects to November 2018.

SELECTION CRITERIA

Randomised controlled trials of interventions in pityriasis rosea. Treatment could be given in a single therapy or in combination. Eligible comparators were no treatment, placebo, vehicle only, another active compound, or placebo radiation treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane. Our key outcomes were good or excellent rash improvement within two weeks, rated separately by the participant and medical practitioner; serious adverse events; resolution of itch within two weeks (participant-rated); reduction in itch score within two weeks (participant-rated); and minor participant-reported adverse events not requiring withdrawal of the treatment.

MAIN RESULTS

We included 14 trials (761 participants). In general, risk of selection bias was unclear or low, but risk of performance bias and reporting bias was high for 21% of the studies. Participant age ranged from 2 to 60 years, and sex ratio was similar. Disease severity was measured by various severity indices, which the included studies did not categorise. Six studies were conducted in India, three in Iran, two in the Philippines, and one each in Pakistan, the USA, and China. The included studies were conducted in dermatology departments and a paediatric clinic. Study duration ranged from 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding source. The included studies assessed macrolide antibiotics, an antiviral agent, phototherapy, steroids and antihistamine, and Chinese medicine. None of the studies measured participant-rated good or excellent rash improvement. All reported outcomes were assessed within two weeks of treatment, except for adverse effects, which were measured throughout treatment. There is probably no difference between oral clarithromycin and placebo in itch resolution (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.47 to 1.52; 1 study, 28 participants) or rash improvement (medical practitioner-rated) (RR 1.13, 95% CI 0.89 to 1.44; 1 study, 60 participants). For this comparison, there were no serious adverse events (1 study, 60 participants); minor adverse events and reduction in itch score were not measured; and all evidence was of moderate quality. When compared with placebo, erythromycin may lead to increased rash improvement (medical practitioner-rated) (RR 4.02, 95% CI 0.28 to 56.61; 2 studies, 86 participants, low-quality evidence); however, the 95% CI indicates that the result may also be compatible with a benefit of placebo, and there may be little or no difference between treatments. Itch resolution was not measured, but one study measured reduction in itch score, which is probably larger with erythromycin (MD 3.95, 95% CI 3.37 to 4.53; 34 participants, moderate-quality evidence). In the same single, small trial, none of the participants had a serious adverse event, and there was no clear difference between groups in minor adverse events, which included gastrointestinal upset (RR 2.00, CI 0.20 to 20.04; moderate-quality evidence). Two trials compared oral azithromycin to placebo or vitamins. There is probably no difference between groups in itch resolution (RR 0.83, 95% CI 0.28 to 2.48) or reduction in itch score (MD 0.04, 95% CI -0.35 to 0.43) (both outcomes based on one study; 70 participants, moderate-quality evidence). Low-quality evidence from two studies indicates there may be no difference between groups in rash improvement (medical practitioner-rated) (RR 1.02, 95% CI 0.52 to 2.00; 119 participants). In these same two studies, no serious adverse events were reported, and there was no clear difference between groups in minor adverse events, specifically mild abdominal pain (RR 5.82, 95% CI 0.72 to 47.10; moderate-quality evidence). Acyclovir was compared to placebo, vitamins, or no treatment in three trials (all moderate-quality evidence). Based on one trial (21 participants), itch resolution is probably higher with placebo than with acyclovir (RR 0.34, 95% CI 0.12 to 0.94); reduction in itch score was not measured. However, there is probably a significant difference between groups in rash improvement (medical practitioner-rated) in favour of acyclovir versus all comparators (RR 2.45, 95% CI 1.33 to 4.53; 3 studies, 141 participants). Based on the same three studies, there were no serious adverse events in either group, and there was probably no difference between groups in minor adverse events (only one participant in the placebo group experienced abdominal pain and diarrhoea). One trial compared acyclovir added to standard care (calamine lotion and oral cetirizine) versus standard care alone (24 participants). The addition of acyclovir may lead to increased itch resolution (RR 4.50, 95% CI 1.22 to 16.62) and reduction in itch score (MD 1.26, 95% CI 0.74 to 1.78) compared to standard care alone. Rash improvement (medical practitioner-rated) was not measured. The trial reported no serious adverse events in either group, and there may be no difference between groups in minor adverse events, such as headache (RR 7.00, 95% CI 0.40 to 122.44) (all results based on low-quality evidence).

AUTHORS' CONCLUSIONS

When compared with placebo or no treatment, oral acyclovir probably leads to increased good or excellent, medical practitioner-rated rash improvement. However, evidence for the effect of acyclovir on itch was inconclusive. We found low- to moderate-quality evidence that erythromycin probably reduces itch more than placebo. Small study sizes, heterogeneity, and bias in blinding and selective reporting limited our conclusions. Further research is needed to investigate different dose regimens of acyclovir and the effect of antivirals on pityriasis rosea.

Adverse events in people taking macrolide antibiotics versus placebo for any indication

BACKGROUND

Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment-specific, rather than disease-specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases.

OBJECTIVES

To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides.

SELECTION CRITERIA

We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide-resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta-analysis when three or more included studies reported a specific adverse event.

MAIN RESULTS

We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin.Most studies (89%) reported some adverse events or at least stated that no adverse events were observed.Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low-quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low-quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate-quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate-quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate-quality evidence) were also reported more often in participants taking macrolides compared to placebo.The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000.The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting.There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration.Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low-quality evidence).Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low-quality evidence).We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low-quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low-quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low-quality evidence) compared to placebo.We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo.Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate-quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate-quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate-quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non-significant.There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low-quality evidence).Only 24 studies (13%) provided useful data on macrolide-resistant bacteria. Macrolide-resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent.Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials.

AUTHORS' CONCLUSIONS

The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as "none were observed". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance.

Pityriasis Rosea: Clinical Profile from Central India

Background:

Pityriasis rosea (PR) is a common, self-limiting dermatologic disorder. The information regarding the clinical profile of the disease in India is limited because of inadequate studies.

Materials and Methods:

A retrospective, record-based study on the clinical presentation of PR was conducted in a tertiary care center based in Central India. Data of all the patients presenting to our outpatient department from October 2014 to March 2015 with a clinical diagnosis of PR were analyzed.

Results:

The age of the patients ranged from 9 to 54 (mean-20.32) years. There was a male preponderance with a male-to-female ratio of 1.3:1. History of prodromal symptoms was present in 11 (27.5%) patients. Pruritus was a common symptom in 30 of 40 (75%) patients. Of 40 patients, 15 (35%) had herald patch. The morphology of skin lesions was typical in most of the patients (77.5%). Two (5%) patients had papular skin lesions, four (10%) patients had erythema multiforme-like skin lesions, and one patient each had papulovesicular, psoriasiform, and eczematous skin lesions.

Conclusion:

The clinical features of most of the cases were mostly in accordance with the classical pattern of PR, with few unusual features.

Effectiveness of acyclovir in the treatment of pityriasis rosea. A systematic review and meta-analysis

BACKGROUND

There is a lack of evidence to support acyclovir administration in pityriasis rosea.

OBJECTIVE

To determine the efficacy of acyclovir in patients with typical pityriasis rosea.

METHODS

A systematic review and meta-analysis of experimental studies was performed in MEDLINE, SCOPUS, EMBASE and others, from January 1990 to October 2016 on acyclovir for pityriasis rosea. Random effect model was used to find the pooled Risk Ratio. Outcomes, evaluated between weeks 1 to 8, were regression of lesions, cessation of lesions, decrease of symptoms and duration of disease. Comparisons were acyclovir vs. placebo; acyclovir vs. symptomatic treatment; acyclovir vs. antibiotic; acyclovir vs. observation and combined therapy (acyclovir plus symptomatic treatment) vs. symptomatic treatment alone.

RESULTS

Seven papers were analyzed with 324 participants, of which 159 received acyclovir and 165 were controls. Acyclovir was superior to placebo for complete regression of lesions at week 1 (Risk Ratio 5.72, CI95% 2.36-13.88). However, combined therapy was not superior to symptomatic treatment at week 4 (Risk Ratio 1.46, CI95% 0.93-2.29). Individual studies showed the superiority of acyclovir for the control of symptoms and pruritus.

STUDY LIMITATIONS

We faced differences designs of trials and inconsistency between reports.

CONCLUSION

Symptomatic treatment is a reasonable option for pityriasis rosea, and the addition of acyclovir is justified for the control of symptoms and pruritus.

An observational study of the efficacy of azithromycin in erythema annulare centrifugum

Erythema annulare centrifugum (EAC) is a form of figurate erythema consequent to a cutaneous hypersensitivity reaction to an underlying agent. In the present study, we aimed to assess the role of oral azithromycin in cases of idiopathic EAC. We performed an open trial of azithromycin in 10 patients with idiopathic EAC. Histopathological examination of biopsies was performed to exclude any alternative diagnosis and to assess the depth of the infiltrate. Patients were administered oral azithromycin 250 mg once daily until clinical resolution of the disease, and followed up regularly to monitor for possible relapse. Histopathological examination of the 10 biopsies revealed superficial pattern in 3, deep pattern in 2 and mixed pattern in the remaining 5. Of the 10 patients, 8 responded to azithromycin 250 mg, with no relapse during follow-up. Oral azithromycin might be a promising therapy in cases of idiopathic EAC. Cases with a superficial pattern respond earlier than cases with a deep pattern.

Anti-inflammatory and Immunomodulatory Effects of Antibiotics and Their Use in Dermatology

Antibiotics (antibacterial, antiviral, and antiparasitic) are class of drugs which result in either killing or inhibiting growth and multiplication of infectious organisms. Antibiotics are commonly prescribed by all specialties for treatment of infections. However, antibiotics have hitherto immunomodulatory and anti-inflammatory properties and can be exploited for various noninfectious dermatoses. Dermatologists routinely prescribe antibiotics in treatment of various noninfectious disorders. This study will review anti-inflammatory and immunomodulatory effects of antibiotics and their use in dermatology.

A Review of Antibiotics in Dermatology

Background:

Since the early 1930s when antibiotics were first introduced, they have revolutionized the way physicians treat infections. Skin conditions from acne to leprosy, which were once shunned by society, are now easily treated with oral antibiotics.

Objective:

Antibiotics are chemicals derived from bacteria and fungi that uniquely have antibacterial action. The most notable example is penicillin, which is derived from a mold. With hundreds of antibiotics available to the practicing physician, improper use of these drugs has become widespread and expensive and has spawned resistant strains. For the dermatologist, antibiotics are vital weapons in the drug armamentarium for treating various skin conditions.

Conclusion:

This review explores the newest and most common oral, parenteral, and topical antibiotics used in dermatology, their indications, adverse effects, dosage, and spectrum of activity. Furthermore, systemic antibacterial prophylaxis and vaccines pertinent to dermatology are discussed. The penicillins, cephalosporins, tetracyclines, macrolides, fluoroquinolones, sulfonamides, aminoglycosides, lincosamides, folate inhibitors, and a new synthetic class of drugs, the oxazolidinones, are reviewed. These antibiotics are used to treat a variety of organisms.

Pityriasis Rosea: An Update on Etiopathogenesis and Management of Difficult Aspects

Pityriasis rosea (PR) is a benign papulosquamous disorder seen commonly in clinical practice. Despite its prevalence and benign nature, there are still times when this common disorder presents in an uncommon way or course posing diagnostic or management problems for the treating physician. The etiopathogenesis of PR has always been a dilemma, and extensive research is going on to elicit the exact cause. This review focuses mainly on the difficult aspects of this benign common disorder such as etiopathogenesis, atypical manifestations, recurrent cases, differential diagnosis, therapy and pregnancy considerations. Although we could not find a black and white solution to all these problems, we have tried to compile the related literature to draw out some conclusions.

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.

Erythromycin as a Safe and Effective Treatment Option for Erythema Annulare Centrifugum

Background:

Erythema annulare centrifugum (EAC) is an inflammatory dermatosis with unknown etiology. It is usually self-limited, but chronic disease may be difficult to treat. We observed incidentally the therapeutic effect of erythromycin for EAC among patients taking erythromycin for other diseases.

Aim:

To evaluate the treatment response of erythromycin for EAC.

Materials and Methods:

During the study period, from July 2007 to February 2011, all patients with EAC were assigned to erythromycin stearate tablet 1000 mg per day for two weeks. EAC was diagnosed by a constellation of clinical and pathological findings. The efficacy (before and after the treatment) was assessed clinically by one dermatologist and photographically by two blinded dermatologists. Secondary outcomes included adverse drug effects and recurrence.

Results:

Eight patients were enrolled in this study. Most patients had chronic relapsing disease with poor response to previous treatment. All the patients showed rapid response with profound reduction in the size of lesion and erythema two weeks after initiation of erythromycin treatment. The response was so obvious and complete that a coincidental response was less likely. Three patients had recurrence of disease and they tended to have more extensive lesions. Readministration of erythromycin was effective. All patients tolerated the treatment well.

Conclusion:

Our study documented erythromycin as a safe and cost-effective treatment for EAC.

Acyclovir in pityriasis rosea: An observer-blind, randomized controlled trial of effectiveness, safety and tolerability

BACKGROUND

Pityriasis rosea (PR) is an acute inflammatory dermatosis. The association of human herpes virus 6 and 7 suggests the utility of use of antiviral agents in this disease.

AIMS AND OBJECTIVES

To evaluate the effectiveness and safety of acyclovir in the treatment of PR.

METHODS

An observer-blind, randomized (1:1), parallel group, add-on trial was conducted on 24 adult patients with PR. Subjects of both Group A and B received the standard of care in the form of cetirizine 10 mg OD and calamine. Group A in addition received acyclovir 400 mg tablets thrice daily for 7 days. Both groups were followed up for four consecutive weeks for assessment of effectiveness and adverse events.

RESULTS

Group A complained of significantly fewer new lesions than Group B (P = 0.046). A complete response was obtained in all patients of Group A and 83% patients of Group B at the end of the follow up period. There was significant reduction in both lesional score and pruritus at second week follow-up in Group A and third week follow-up in Group B (P < 0.05). Minor adverse effects were observed in both treatment arms.

CONCLUSION

Acyclovir offered rapid resolution of clinical severity of PR from second week onwards without significantly increased adverse events as compared to supportive therapy alone.

A Randomized, Double-blind, Placebo-Controlled Study of Efficacy of Oral Acyclovir in the Treatment of Pityriasis Rosea

BACKGROUND

Pityriasis rosea is an acute self-limiting skin disorder of unknown aetiology. Recently human herpes virus 6 and 7 has been hypothesized to be the cause of pityriasis rosea.

OBJECTIVE

To determine the efficacy of acyclovir, an anti-viral drug, in the treatment of pityriasis rosea.

MATERIALS AND METHODS

A randomized, double-blind, placebo-controlled study of efficacy of oral acyclovir in the treatment of pityriasis rosea was conducted on 73 patients. Thirty eight randomly selected patients were started on oral acyclovir. Thirty-five patients were prescribed placebo. The patients as well as the chief investigator were unaware of the therapeutic group to which patients belonged (acyclovir or placebo). Patients in both the groups were evaluated clinically after 7 and 14 days following the first visit and the data were analysed.

RESULTS

Follow up data of 60 patients was available and these were included in the statistical analysis. 53.33% and 86.66% of the patients belonging to the acyclovir group showed complete resolution on the 7(th) day and 14(th) day respectively following the first visit compared to 10% and 33.33% of patients from the placebo group. The findings were statistically significant.

CONCLUSION

The study showed that high dose acyclovir is effective in the treatment of pityriasis rosea.

Antibiotics used in nonbacterial dermatologic conditions

The majority of nonbacterial dermatological conditions treated with antibiotics benefit from the anti-inflammatory properties of these medications, usually dapsone or tetracycline. Many other antimicrobials are used to treat noninfectious conditions. The following chapter is an overview of select noninfectious dermatological conditions for which antibiotics are used, with a focus on the most common antibiotics used for their nonantimicrobial properties.

Macrolides in chronic inflammatory skin disorders

Long-term therapy with the macrolide antibiotic erythromycin was shown to alter the clinical course of diffuse panbronchiolitis in the late 1980s. Since that time, macrolides have been found to have a large number of anti-inflammatory properties in addition to being antimicrobials. These observations provided the rationale for many studies performed to assess the usefulness of macrolides in other inflammatory diseases including skin and hair disorders, such as rosacea, psoriasis, pityriasis rosea, alopecia areata, bullous pemphigoid, and pityriasis lichenoides. This paper summarizes a collection of clinical studies and case reports dealing with the potential benefits of macrolides antibiotics in the treatment of selected dermatoses which have primarily been classified as noninfectious and demonstrating their potential for being disease-modifying agents.

Gianotti-Crosti syndrome, pityriasis rosea, asymmetrical periflexural exanthem, unilateral mediothoracic exanthem, eruptive pseudoangiomatosis, and papular-purpuric gloves and socks syndrome: a brief review and arguments for diagnostic criteria

Several exanthems including Gianotti-Crosti syndrome, pityriasis rosea, asymmetrical periflexural exanthem, eruptive pseudoangiomatosis, and papular-purpuric gloves and socks syndrome are suspected to be caused by viruses. These viruses are potentially dangerous. Gianotti-Crosti syndrome is related to hepatitis B virus infection which is the commonest cause of hepatocellular carcinoma, and Epstein-Barr virus infection which is related to nasopharyngeal carcinoma. Pityriasis rosea has been suspected to be related to human herpesvirus 7 and 8 infections, with the significance of the former still largely unknown, and the latter being a known cause of Kaposi's sarcoma. Papular-purpuric gloves and socks syndrome is significantly associated with human B19 erythrovirus infection which can lead to aplastic anemia in individuals with congenital hemoglobinopathies, and when transmitted to pregnant women, can cause spontaneous abortions and congenital anomalies. With viral DNA sequence detection technologies, false positive results are common. We can no longer apply Koch's postulates to establish cause-effect relationships. Biological properties of some viruses including lifelong latent infection, asymptomatic shedding, and endogenous reactivation render virological results on various body tissues difficult to interpret. We might not be able to confirm or refute viral causes for these rashes in the near future. Owing to the relatively small number of patients, virological and epidemiology studies, and treatment trials usually recruit few study and control subjects. This leads to low statistical powers and thus results have little clinical significance. Moreover, studies with few patients are less likely to be accepted by mainstream dermatology journals, leading to publication bias. Aggregation of data by meta-analyses on many studies each with a small number of patients can theoretically elevate the power of the results. Techniques are also in place to compensate for publication bias. However, these are not currently feasible owing to different inclusion and exclusion criteria in clinical studies and treatment trials. The diagnoses of these rashes are based on clinical assessment. Investigations only serve to exclude important differential diagnoses. A wide spectrum of clinical features is seen, and clinical features can vary across different populations. The terminologies used to define these rashes are confusing, and even more so are the atypical forms and variants. Previously reported virological and epidemiological results for these rashes are conflicting in many aspects. The cause of such incongruence is unknown, but low homogeneity during diagnosis and subject recruitment might be one of the factors leading to these incongruent results. The establishment and proper validation of diagnostic criteria will facilitate clinical diagnosis, hasten recruitment into clinical studies, and allow results of different studies to be directly compared with each another. Meta-analyses and systematic reviews would be more valid. Diagnostic criteria also streamline clinical audits and surveillance of these diseases from community perspectives. However, over-dependence on diagnostic criteria in the face of conflicting clinical features is a potential pitfall. Clinical acumen and the experience of the clinicians cannot be replaced by diagnostic criteria. Diagnostic criteria should be validated and re-validated in response to the ever-changing manifestations of these intriguing rashes. We advocate the establishment and validation of diagnostic criteria of these rashes. We also encourage the ongoing conduction of studies with a small number of patients. However, for a wider purpose, these studies should recruit homogenous patient groups with a view towards future data aggregation.

The comparison between the efficacy of high dose acyclovir and erythromycin on the period and signs of pitiriasis rosea

Background:

Pityriasis Rosea (PR) is an acute inflammatory and self-limiting skin disorder, sometimes with troublesome symptoms. To date, there are few treatments available for this disorder.

Aim:

Compare the traditional treatment with erythromycin to a newly introduced antiviral treatment acyclovir for PR.

Materials and Methods:

Patients with clinically confirmed diagnosis of PR, matching our exclusion criteria, were enrolled. They were randomized in two groups that received high-dose oral acyclovir or erythromycin. The participants were evaluated two, four, and eight weeks after commencement of the study and followed for one year.

Results:

A total of 30 patients including 15 males and 15 females completed the study. After eight weeks, 13 patients in the acyclovir group experienced complete response, while in the erythromycin group only six patients had complete response (P < 0.05). Also, patients in the acyclovir group experienced faster resolution of pruritus in comparison with the erythromycin group (not significant). No adverse drug reaction was detected in both groups.

Conclusion:

It seemed that a high-dose of oral acyclovir was a safe and effective therapy for PR, although this remained to be confirmed in larger studies.

Study of role of streptococcal throat infection in pityriasis rosea

Background:

Pityriasis rosea is a common, acute exanthem of uncertain etiology. The exact cause of pityriasis rosea is not known but various hypotheses have been postulated incriminating infective agents such as viruses, bacteria, spirochete and noninfective etiologies such as atopy and autoimmune causes have also been investigated.

Aim:

We undertook a study to investigate the role of Streptococcus haemolyticus in the causation of pityriasis rosea and study the levels of C-reactive protein (CRP) and ASLO titer in patients with pityriasis rosea.

Materials and Methods:

The study included 20 patients with pityriasis rosea attending the outpatient dermatology department at JIPMER hospital during the period from June to December 2004. Corresponding number of age- and sex-matched controls were chosen from amongst healthy individuals and patients attending skin OPD with dermatological disorders other than pityriasis rosea.

Results:

On analyzing the data collected from 20 cases of pityriasis rosea, the average age was found to be 15.3 years and ranged from 5 years to 30 years. The male to female ratio was found to be 1.5:1. The average duration of illness was 14.5 days (median) and 29.3 days (mean). CRP was negative in all the cases as well as the controls. ASLO titer was found to be raised in 2 (10%) cases, while it remained below the critical value in all the controls. On comparing the cases and controls, the raised ASLO titer in the cases was found to be not statistically significant (p = 0.147). From the throat swab culture, Streptococcus haemolyticus was isolated from only one case and none of the controls. This finding was not statistically significant (p = 0.310).

Conclusion:

As per the findings of the present study, we arrived at conclusion that there is no association between streptococcus pharyngitis and pityriasis rosea.

Dermatology for the allergist

Abstract:

Allergists/immunologists see patients with a variety of skin disorders. Some, such as atopic and allergic contact dermatitis, are caused by abnormal immunologic reactions, whereas others, such as seborrheic dermatitis or rosacea, lack an immunologic basis. This review summarizes a select group of dermatologic problems commonly encountered by an allergist/immunologist.

Pityriasis rosea: an update with a critical appraisal of its possible herpesviral etiology

Pityriasis rosea is an acute, self-healing exanthem characterized by oval erythematous-squamous lesions of the trunk and limbs, that usually spares face, scalp, palms, and soles. Constitutional symptoms, which have the character of true prodromes; clinical features, which resemble those of the known exanthems; and many epidemiologic data all suggest an infectious origin. A host of infectious agents have been incriminated, but, recently, human herpesvirus 6 and 7 have been extensively studied. The goal of this review is to outline the epidemiologic, clinical, histologic, and ultrastructural features of pityriasis rosea, but mainly to stress its possible human herpesvirus nature. In addition, clues have been added to help the reader to go through the complex subtleties of the virologic investigation.

An update on pityriasis rosea and other similar childhood exanthems

PURPOSE OF REVIEW

Pityriasis rosea is a common skin condition seen in children and adults. Whereas pityriasis rosea is a benign condition, it is important to distinguish it from other childhood exanthems.

RECENT FINDINGS

Pityriasis rosea can present in a variety of manners. Most often a herald patch precedes the generalized eruption, although this is not always the case. Pityriasis rosea may lead to undesirable outcomes when affecting pregnant women. Guttate psoriasis, secondary syphilis, cutaneous lupus erythematosus, capillaritis, pityriasis versicolor, nummular eczema, and cutaneous T-cell lymphoma are important to consider in the differential diagnosis of pityriasis rosea.

SUMMARY

Pityriasis rosea is self-limiting, usually lasting 1-3 months. Treatment may be considered in certain cases, although there is a paucity of medical studies supporting any definitive treatment. However, treatment may be warranted for other conditions that mimic pityriasis rosea.

Use of antibiotics for noninfectious dermatologic disorders

One fascinating element of medical dermatology is the diversity of available therapeutic agents, and dermatologists are well versed in applying the mechanism of action of a drug to modify a disease process. Oral antibiotics are the ideal example of pharmacologic agents that are effective against inflammatory processes and have obvious roles in infectious diseases.

Pitiríase rósea

Pitiríase rósea é doença inflamatória aguda da pele, que regride espontaneamente, normalmente sem deixar seqüelas, em período que varia de quatro a oito semanas. Clinicamente é caracterizada pelo aparecimento de típicas lesões eritêmato-pápulo-escamosas. Atinge todas as idades, embora seja mais comumente observada entre 10 e 35 anos. Apesar de exaustivas pesquisas, sua etiologia ainda permanece desconhecida. São discutidos alguns aspectos epidemiológicos, anatomoclínicos, diagnósticos diferenciais, doenças associadas, com ênfase no tratamento e etiologia da doença.

Pregnancy outcome in patients with pityriasis rosea

BACKGROUND

The effect of pityriasis rosea (PR) on the outcome of pregnancy has not been previously reported.

OBJECTIVE

We sought to investigate the possible impact of PR in pregnant women.

METHODS

In all, 38 women who developed PR during pregnancy were observed. In one of them, who developed PR at 10 weeks' gestation and aborted 2 weeks later, plasma, peripheral blood mononuclear cells, maternal skin, and placental and embryonic tissues were studied by quantitative calibrated real-time polymerase chain reaction for human herpesviruses (HHV)-6 and -7. Controls included plasma from 36 healthy blood donors, plasma and paraffin-embedded tissue sections from 12 patients with other dermatitides, and from placental and embryonic tissues from one woman who presented with a 19-week intrauterine fetal death.

RESULTS

Of the 38 women, 9 had a premature delivery and 5 miscarried. In particular, 62% of the women who developed PR within 15 weeks' gestation aborted. Neonatal hypotonia, weak motility, and hyporeactivity were noted in 6 cases. In the patient studied in detail, HHV-6 DNA was detected in plasma, peripheral blood mononuclear cells, skin, and placenta and embryonic tissues, whereas HHV-7 DNA was absent. HHV-6 p41 antigen was detected by immunohistochemistry in skin lesions, placenta, and embryonic tissues. No herpesvirus DNA was detected in plasma and tissues from control subjects.

LIMITATIONS

This is a case series study with a small number of patients.

CONCLUSION

PR may be associated with an active HHV-6 infection. In pregnancy, PR may foreshadow premature delivery with neonatal hypotonia and even fetal demise especially if it develops within 15 weeks' gestation.

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.

Childhood viral exanthems

Many viral infections exhibit cutaneous lesions. Recognition of the exanthems associated with these infections and the broader clinical scenarios in which they occur can lead to more rapid diagnosis and appropriate treatment for affected patients.

Use of high-dose acyclovir in pityriasis rosea

BACKGROUND

The association of human herpesvirus 6 (HHV-6) and HHV-7 with pityriasis rosea suggests that systemic drugs directed against HHV may hasten recovery of patients with pityriasis rosea.

OBJECTIVE

The purpose of this study was to verify the efficacy of oral acyclovir in the treatment of pityriasis rosea.

METHODS

Eighty-seven consecutive patients were treated for 1 week with either oral acyclovir (800 mg 5 times daily) or placebo. In all patients, the time of lesion clearing and the number of new lesions appearing during treatment were recorded.

RESULTS

On the 14th day of treatment, 79% of treated patients fully regressed compared with 4% of the placebo group. The lesions cleared in 18.5 days in treated patients and in 37.9 days in the placebo group. Clearance was achieved in 17.2 days in patients treated in the first week from onset and in 19.7 days in the patients treated later. On the 7th day, there were significantly fewer new lesions in patients treated in the first week than in those treated later.

LIMITATIONS

This trial was neither randomized nor double blind. Objectivity was achieved by counting the lesions.

CONCLUSION

Acyclovir may be effective in the treatment of pityriasis rosea, especially in patients treated in the first week from onset, when replicative viral activity of HHV is probably very high.

Azithromycin does not cure pityriasis rosea

OBJECTIVES

Pityriasis rosea (PR) is a common skin disorder in children. Its cause is unknown. A recent publication reported a 73% cure rate in patients with PR after treatment with erythromycin. To duplicate this result using a drug with fewer adverse effects and greater biological half-life, we set out to study the effect of azithromycin on PR. Azithromycin is an azalide antibiotic with a spectrum of antimicrobial activity very similar to that of erythromycin.

DESIGN

We randomly assigned 49 children with PR to receive either azithromycin (12 mg/kg per day, up to a maximum of 500 mg/day) for 5 days or a similar-appearing placebo. Study physicians were blinded to patients' treatment type. Two pediatricians had to agree on the diagnosis of PR before patients could be enrolled. Subjects were seen at follow-up visits 1, 2, and 4 weeks after starting treatment.

OUTCOME MEASURES

We measured the appearance of new lesions and resolution of lesions.

RESULTS

Rates of cure and of partial resolution were similar in the azithromycin and placebo groups.

CONCLUSION

Azithromycin does not cure PR.

Effect on quality of life in patients with pityriasis rosea: Is it associated with rash severity?

BACKGROUND

It is unknown how the quality of life (QOL) is affected in patients with pityriasis rosea (PR), and whether it is related to rash severity.

METHODS

We constructed a valid and reliable Cantonese version of the Dermatology Life Quality Index (DLQI). We recruited patients with PR, with atopic dermatitis and with acne vulgaris, and controls of the same sex and comparable age. We applied the DLQI and the Pityriasis Rosea Severity Score (PRSS) to the patients with PR, the DLQI and the SCORing Atopic Dermatitis Index (SCORAD) to the controls with atopic dermatitis, and the DLQI and the Leeds Acne Grading System (LAGS) to the controls with acne vulgaris.

RESULTS

Total DLQI scores of the 22 patients with PR (mean: 6.36, SD: 5.79) were significantly lower than those of the 22 controls with atopic dermatitis (mean: 12.00, SD: 5.38) (P = 0.021), but were insignificantly different from those of the 22 controls with acne vulgaris (mean: 6.86, SD: 4.53) (P = 0.57). Correlation between the total DLQI and PRSS scores was weak (gamma(s) = +0.19) and insignificant (P = 0.40). All six DLQI parameters were insignificantly correlated with the PRSS scores. In contrast, the total DLQI scores and most of the DLQI parameters were strongly correlated with the rash severity scores for the control subjects. Significantly more patients with PR have concerns regarding disease etiology and infectivity.

CONCLUSIONS

The QOL of the patients with PR was significantly less affected than that for the patients with atopic dermatitis, but was insignificantly different from the patients with acne vulgaris. Unlike atopic dermatitis and acne vulgaris, the effects on the QOL in PR are insignificantly correlated with rash severity. These results bear important implications on clinical management.