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LETTER TO THE EDITOR
Year : 2017  |  Volume : 8  |  Issue : 3  |  Page : 217-218  

Persistent and generalized purpuric lesions in an adolescent: A rare atypical form of pityriasis rosea


1 Department of Dermatology, Turgut Ozal University Faculty of Medicine, Ankara, Turkey
2 Department of Pathology, Turgut Ozal University Faculty of Medicine, Ankara, Turkey

Date of Web Publication11-May-2017

Correspondence Address:
Funda Tamer
Department of Dermatology, Turgut Ozal University Faculty of Medicine, Alparslan Turkes Cd, No: 57, Emek, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.206112

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How to cite this article:
Tamer F, Sarifakioglu E, Orenay OM, Yildirim U. Persistent and generalized purpuric lesions in an adolescent: A rare atypical form of pityriasis rosea. Indian Dermatol Online J 2017;8:217-8

How to cite this URL:
Tamer F, Sarifakioglu E, Orenay OM, Yildirim U. Persistent and generalized purpuric lesions in an adolescent: A rare atypical form of pityriasis rosea. Indian Dermatol Online J [serial online] 2017 [cited 2019 Oct 18];8:217-8. Available from: http://www.idoj.in/text.asp?2017/8/3/217/206112

Sir,

Pityriasis rosea is an acute inflammatory skin disease characterized by erythematous scaling macules, papules, and plaques predominantly on the trunk and proximal extremities. It has been suggested that viral infections, including human herpes virus 6 (HHV6) and HHV7, upper respiratory tract infections, and drugs such as isotretinoin, D-penicillamine and terbinafine may be associated with pityriasis rosea. In addition to its characteristic clinical features, the disease may rarely present with atypical lesions.[1]

A 14-year-old Caucasian male presented with a progressive, asymptomatic, erythematous rash on the neck, chest, and arms for the last 2 weeks. The lesions first appeared on the chest and then spread to the trunk and arms. Moreover, the patient reported that he had painful sores in the mouth. These ulcers have been occurring every 4 weeks and healed in a few days without any scar formation. Past medical and family history was unremarkable. There was no history of medication for any other illness in the recent past. Dermatological examination revealed erythematous purpuric macules on the chest, neck, arms [Figure 1]a and [Figure 1]b and minor aphthous ulcers on the lower lip mucosa. The lesions did not blanch on diascopy. Pathergy test was negative. Laboratory tests including complete blood count and chemistry panel were all within normal limits. In addition, serum IgG antibodies to Herpes simplex virus type 1 (HSV1) and serum IgM and IgG antibodies to HSV2 were negative. However, serum HSV1 IgM was positive (34.6 U/mL; reference ranges: 0–19.9 U/mL negative and ≥30 U/mL positive). Histopathological evaluation revealed epidermal thinning, decreased granular layer, loss of the rete ridges, marked perivascular and interstitial mononuclear cell infiltrates, edema, and focal extravasation of erythrocytes in the papillary dermis [Figure 2].
Figure 1: (a and b) Erythematous purpuric macules on the trunk and left arm

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Figure 2: Perivascular and interstitial mononuclear cell infiltrates and focal extravasation of erythrocytes in the papillary dermis (H and E, ×40)

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Pigmented purpuric dermatoses, vasculitis, and hematologic disorders were considered in the differential diagnosis. Based on the clinical and histopathological findings, the diagnosis of purpuric pityriasis rosea was made. The patient was started on topical methylprednisolone and oral desloratadine therapy. Despite treatment, the skin lesions extended from the chest to the upper back and thighs. Therefore, twice weekly narrowband ultraviolet B phototherapy (250 mJ/cm 2) was recommended. However, the patient did not keep follow up appointments.

Atypical forms of pityriasis rosea can present with vesicular, purpuric, hemorrhagic, urticarial, and papular lesions. Pityriasis circinata et marginata is an uncommon form characterized by fewer and larger lesions. Moreover, involvement of intertriginous areas is called pityriasis rosea inversus. There have been reports of patients with hemorrhagic, erosive, or bullous oral lesions. It has been suggested to use the term pityriasis rosea irritata when the skin rash is accompanied by pain and pruritus.[2]

Purpuric pityriasis rosea is a rare atypical type of pityriasis rosea, which clinically presents with purpuric macules and papules on the trunk and extremities. The disease has a self-limited benign course.[3] Purpuric pityriasis rosea-like eruption has been described in patients with acute myeloid leukemia. However, there is controversy whether detailed hematological evaluation is necessary in these patients or not.[4],[5]

Many viruses including HHV6 and HHV7 have been proposed as causative agents for pityriasis rosea, although there is no conclusive evidence. Here, we presented a case of pityriasis rosea coexisting with oral HSV1 infection. Our case is unique because purpuric pityriasis rosea has not been associated with HSV1 previously. Consequently, we suggest that HSV1 may play role in the etiopathogenesis of the disease, and antiviral therapy may be the treatment of choice for extensive and resistant lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Bhalla N, Tambe S, Zawar V, Joshi R, Jerajani H. Localized purpuric lesions in a case of classical pityriasis rosea. Indian J Dermatol Venereol Leprol 2014;80:551-3.  Back to cited text no. 1
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2.
Chuh A, Zawar V, Lee A. Atypical presentations of pityriasis rosea: Case presentations. J Eur Acad Dermatol Venereol 2005;19:120-6.  Back to cited text no. 2
[PUBMED]    
3.
Sonthalia S, Singal A, Pandhi D, Singh UR. Annular purpuric eruption in an adult male. Indian J Dermatol Venereol Leprol 2011;77:731.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Singal A, Pandhi D, Rusia U. Purpuric pityriasis rosea-like eruption: A cutaneous marker of acute myeloid leukaemia. J Eur Acad Dermatol Venereol 2007;21:822-3.  Back to cited text no. 4
[PUBMED]    
5.
Gökdemir A, Şentürk N, Aydın F, Yıldız L, Cantürk T, Turanlı AY. Purpuric pityriasis rosea associated with acute myeloid leukemia: Case report. Turkiye Klinikleri J Dermatol 2009;19:59-62.  Back to cited text no. 5
    


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