Pityriasis rosea (PR) usually presents as acute exanthema with oval erythematous-squamous lesions localized on the trunk, arms, and legs with spontaneous remission. We present an unusual case of PR with frequent relapses during a period of 7 years. An 11-year-old white female patient presented with many pruritic erythematous oval lesions on her trunk. A second episode followed 2 years later with several pruritic erythematous lesions on her lower limbs. During the following 5 years, the patient had several relapses per year, with 1 to 3 lesions on changing localizations. PR was diagnosed on the basis of the clinical presentation and detection of human herpesvirus 7 DNA. Spontaneous remission occurred without treatment in each episode. Relapsing PR is a rare form of PR characterized by a lower number of lesions and smaller sized lesions compared with the classic form of PR. Pediatricians should consider the diagnosis of relapsing PR even if only a single or few erythematous lesions are present.

Pityriasis rosea (PR) presents as acute exanthema with oval erythematous-squamous lesions localized on the trunk, arms, and legs. Spontaneous remission usually occurs after ∼6 weeks. Relapses are reported with a frequency of 1.8% to 3.7% of patients.1,3 

A viral etiology of PR is strongly suspected because human herpesvirus 7 (HHV-7) DNA is frequently detected in blood and saliva of patients with PR.1,4,5 HHV-7 belongs to the Herpesviridae family and the subfamily of Betaherpesvirinae.6 Primary infection usually occurs in childhood and the virus persists for the entirety of the individual’s life in a latent infection with possible reactivations.6 

An 11-year-old white female patient presented with many pruritic erythematous oval lesions on her trunk in June 2010. The first lesion appeared on the right side of the trunk and, during the following days, additional lesions appeared and spread over the trunk. No other symptoms were reported except for sleeping troubles. No other abnormalities were found on physical examination. The past medical history was unremarkable. There were no prodromal symptoms, and the patient took neither medication nor drugs. The episode occurred shortly before an examination. HHV-7 DNA was detected in blood (Table 1) by using the CMV HHV6,7,8 R-Gene kit (Biomérieux, Marcy l'Etoile, France). PR was diagnosed on the basis of the clinical presentation and the detection of HHV-7 DNA. Remission of the lesions occurred after ∼2 months without any treatment.

TABLE 1

Detection of HHV-7 DNA

DateSpecimen TypeHHV-7 R-gene Assay (Ct)
June 21, 2010 Whole blood Positive (34) 
November 23, 2012 Saliva Positive (32) 
May 13, 2015 Saliva Positive (32) 
July 27, 2015 Saliva Positive (31) 
November 18, 2015 Saliva Positive (31) 
March 3, 2017 Saliva Positive (30) 
March 17, 2017 Saliva Positive (30) 
DateSpecimen TypeHHV-7 R-gene Assay (Ct)
June 21, 2010 Whole blood Positive (34) 
November 23, 2012 Saliva Positive (32) 
May 13, 2015 Saliva Positive (32) 
July 27, 2015 Saliva Positive (31) 
November 18, 2015 Saliva Positive (31) 
March 3, 2017 Saliva Positive (30) 
March 17, 2017 Saliva Positive (30) 

Ct, cycle threshold.

In November 2012, the patient developed several pruritic lesions, this time localized on her lower limbs (Fig 1).

FIGURE 1

Herald patch and erythematous patch on the lower limb during the second episode.

FIGURE 1

Herald patch and erythematous patch on the lower limb during the second episode.

Close modal

During the following years, the patient presented relapsing pruritic erythematous lesions ∼3 times a year, usually during episodes of stress (eg, examinations). Apparition of the lesions was preceded by itching. There were only 1 to 3 lesions during these episodes, localized on different areas of the body during each episode (eg, trunk, limbs, or neck). The episodes lasted for 4 to 8 weeks and remission occurred without treatment. During some of these relapses saliva specimens were analyzed for HHV-7 DNA and they were positive (Table 1).

PR usually presents as acute illness with spontaneous remission. The clinical presentation differs between children <10 years old and adults.7 Although the presence of systemic symptoms is frequent in both children and adults, the duration of the exanthema and the time lapse between the appearance of the herald patch and the generalized exanthema were longer in adults, and oropharyngeal lesions were more frequent in children.7 Unusual forms of PR exist; for example, there are both relapsing and persistent forms of PR, both of which have been described mostly in adults.8,9 During the persistent form of PR, the patient presents clinical and virological features of PR lasting >12 weeks.8 The relapsing form of PR is rarely described. In a cohort of 570 cases, 3.7% of the patients had relapses, and all of them were adults.3 Only 2 patients (0.4%) had 3 relapses, and none more than 3.3 A form of relapsing and persistent PR was reported in a 24-year-old man that lasted for 11 months.10 In another report, the authors described 3 relapses of PR in a 4-year-old girl.11 Usually, relapses are limited in number. More than 3 relapses are rarely reported. In 1 publication, 5 relapses in a 39-year-old patient12 and in another, 2 relapses per year for 4 years in a 25-year-old patient were described.13 Therefore, to our knowledge, this is the first report of a case with frequently relapsing PR for 7 years, with several episodes per year. It is of note that this frequently relapsing PR occurred in a child. From the third relapse on, lesions were reduced in size and number compared with the first 2 episodes as has been described for relapsing PR.9 However, in contrast to the characteristics of relapsing PR described by Drago et al,9 other symptoms were absent in the case reported here. In the case reported here, the duration of the exanthema and the time lapse between the appearance of the herald patch and the generalized exanthema were more similar to the features reported for PR in adults than to those reported for children <10 years old.7 

It is noteworthy that in the case described here, relapses occurred during episodes of stress. This is consistent with the hypothesis of viral reactivation because stress has been described as a stimulus inducing the reactivation of Herpesviridae from latency.14 

The detection of HHV-7 DNA in saliva or blood during the episodes supports HHV-7 infection or reactivation as the underlying cause of the relapsing PR.

The activation of cellular immunity and induction of inflammatory response may also be involved in the pathogenesis of PR.15 

Differential diagnoses of PR include other types of infectious exanthemas and PR-like eruptions associated with medication intake.16,18 Taking into account the history of medication intake and traveling, the clinical picture, as well as the histopathologic features and the results of virologic and/or microbiologic investigations can help in the differential diagnosis.16,18 

Pediatricians should be aware of relapsing PR and consider this diagnosis even if only a single or few erythematous lesions are present.

     
  • HHV-7

    human herpesvirus 7

  •  
  • PR

    pityriasis rosea

Prof. Hober initiated the study, participated in analysis and interpretation of data, and revised the manuscript critically for important intellectual content; Dr Engelmann conceptualized and designed the study, collected, analyzed, and interpreted data, and drafted the initial manuscript; Ms J Ogiez collected data, conducted analyses, and revised the manuscript critically for important intellectual content; Ms L Ogiez collected data and revised the manuscript critically for important intellectual content; Drs Dewilde, Lazrek, and Alidjinou participated in analysis and interpretation of data and revised the manuscript critically for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

We thank the technicians of the virology department for excellent technical assistance.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.