Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Pityriasis Rosea
An acute, self-limited disease characterized by a superficial scaling eruption. It is seen classically on the trunk in a “Christmas tree” configuration.
I. Etiology
A. Unknown, although presumed to be viral in origin
B. No definite evidence of contagion, although small epidemics reported
II. Incidence
A. Seen frequently in children, adolescents, and young adults; rare in infants
B. Occurs most often in spring and fall
III. Subjective data
A. May be asymptomatic until rash appears
B. Initially a single scaling, erythematous maculopapular patch with central clearing; generally found on the trunk
C. Mild prodromal symptoms occasionally: Headache, malaise, sore throat, swollen glands
D. Rash appears 3 to 10 days after initial lesion.
E. Pruritus of varying degrees
IV. Objective data
A. Herald patch, or “mother spot,” precedes the generalized rash by 2 to 10 days.
1. Initial lesion
2. Scaly with central clearing; salmon-colored
3. Round or oval plaque, 3 to 6 cm in diameter
4. Spreads peripherally
5. Border erythematous
B. Rash
1. Salmon-colored, oval lesions
2. Lesions smaller than herald patch; vary in size
3. Lesions scaly, generally macular and papular. Vesicular lesions may be present.
4. Generally seen on normally clothed areas (e.g., trunk). Occasionally a reverse distribution is seen with prominent involvement of the face and proximal extremities. The face, hands, and feet are generally spared.
5. In typical case, longest axis of lesions is along cleavage lines, parallel to the ribs, and a Christmas tree configuration can be seen on the back.
C. Mild regional lymphadenopathy
V. Assessment
A. Diagnosis: Usually readily diagnosed by appearance and distribution of rash, particularly if herald patch is present
B. Differential diagnosis
1. Tinea corporis: Primary lesion or herald patch is similar in appearance; however, child is not usually seen with primary lesion alone.
2. Seborrheic dermatitis: Lesions may appear similar but do not have characteristic distribution.
3. Secondary syphilis: Generalized rashes of secondary syphilis and pityriasis are strikingly similar except for pruritus; a serologic test is indicated to rule out syphilis in patients who are sexually active.
4. Psoriasis: Lesions have silvery scales and are on elbows, knees, scalp as well; also, it has a more insidious onset.
5. Guttate psoriasis: Acute onset after streptococcal infection. If initial lesions appear on trunk, they are similar to pityriasis without herald patch.
VI. Plan: Symptomatic treatment
A. Aveeno oatmeal baths
B. Calamine lotion, tid
C. Benadryl, 12.5 to 25 mg tid to qid, or Periactin, 2 to 6 years: 2 mg PO, bid or tid; 7 to 14 years: 4 mg PO, bid or tid
D. Judicious exposure to sunlight will relieve itching and enhance resolution of rash.
E. Severely pruritic cases: Prednisone, 1 to 2 mg/kg/d in 3 divided doses for 5 days
VII. Education
A. No need to isolate; low, if any, communicability
B. Typically, the rash develops over a 2-week period, persists for 2 weeks, and then fades over another 2 weeks. The duration of the rash, however, can be as long as 3 to 4 months but commonly disappears within 6 weeks.
C. Rash disappears in the reverse order in which it appears.
D. Recurrences are uncommon.
E. Antihistamine may cause drowsiness.
F. Prognosis is excellent; disease is self-limited.
G. Either hypoor hyperpigmentation may persist after resolution of initial eruption.
VIII. Follow-up
A. None indicated as a rule. However, with a severe inflammatory reaction, it is advisable to keep in contact by telephone.
B. Recheck in 5 days if on prednisone.
IX. Complications: Lesions excoriated from scratching may be secondarily infected.
X. Consultation/referral: Children with extensive rash and severe pruritus