Tools for Practice Outils pour la pratique


#356: (A)dressing the Christmas Tree? Therapies for pityriasis rosea.


CLINICAL QUESTION
QUESTION CLINIQUE
What therapies improve resolution of pityriasis rosea (Christmas tree rash)?


BOTTOM LINE
RÉSULTAT FINAL
Pityriasis rosea is self-limiting. Based on limited evidence, oral corticosteroids reduce itch and rash for ~95% of patients while acyclovir is effective in ~70% of patients versus 30-60% on placebo at 1-2 weeks.  Macrolides likely ineffective.  Little/no evidence for topical corticosteroids or oral antihistamines.



CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session



EVIDENCE
DONNÉES PROBANTES
  • One systematic review1 studying all treatments and 1 acyclovir2 (age 2-60). Outcomes at 2-weeks; statistically significant unless stated.
  • Prednisolone (20mg tapered over 15-days) versus placebo [1 randomized, controlled trial (RCT), 70 patients]:1
    • Resolved itch: 94% versus 32% (placebo).
    • Good/excellent rash improvement: 97% versus 60% (placebo).
  • Acyclovir 400-800mg 5x daily 7-days:1,2
    • Versus placebo/vitamins/no treatment (3 RCTs 141 patients):1
      • Good/excellent rash reduction: 67% versus 28% (control).1
    • Versus no acyclovir with calamine lotion and cetirizine 10mg (both arms) (1 RCT, 24 patients):1
      • Itch resolution: 75% versus 17% (no acyclovir).
      • Lesion score3 (1-5, higher worse, baseline=4.1): 0.9 versus 3 (no acyclovir).
  • Macrolides:
    • Clarithromycin or azithromycin versus placebo (4 RCTs, 207 patients):1
      • Rash/itch improvement: No difference.
    • Erythromycin 1gram daily x7-14 days versus placebo:1
      • Itch score reduction (1-10, more reduction=better) (1 RCT, 34 patients): 5.7 versus 1.8 (placebo).
      • Rash improvement (2 RCTs, 86 patients): No difference.
      • Gastrointestinal upset: 12% versus 6% (placebo).
  • Topical corticosteroids: No RCTs.1
  • Antihistamines:1 Dexchlorpheniramine versus oral betamethasone versus combined (1 RCT, 85 patients).1
    • Dexchlorpheniramine versus Betamethasone: No difference.
    • Either versus combined: No difference in itch, but rash improved more in either alone versus combined (likely spurious).
  • Limitations: Few/small studies, some unblinded.1

CONTEXT
CONTEXTE
  • Distribution of secondary lesions along Langer lines, appearing ≤6 weeks after herald patch. Self-limiting lasting ~45 days with moderate-severe pruritis in 30-50%.1
  • Guidance:4
    • Consider antihistamines or topical/oral corticosteroids if symptoms severe.
    • Consider acyclovir in pregnancy but pityriasis rosea risks inconsistent/unclear. Example, case-series (38 pregnancies) suggesting first-trimester had higher pregnancy loss5 not supported in subsequent case-series (53 and 33 pregnancies).6,7 Treatment effect unknown.
  • Proposed viral etiology (examples HHV-6, HHV-7), with constitutional symptoms ~69%.4
  • Not to be confused with tinea (pityriasis) versicolor, caused by Malassezia yeast genus.8


William Dobson January 8, 2024

practical case

Hama Abdel-Salam January 8, 2024

Very well presented

Hama Abdel-Salam January 8, 2024

I like how concise and to the point

Greg Sherman January 25, 2024

practical-I may use valcyclovir

Dimitra Trambakoulos June 12, 2024

Great review.


Latest Tools for Practice
Derniers outils pour la pratique

#367 Oral Calcitonin Gene-related Peptide Antagonists: A painfully long name for the acute treatment of migraines

What are the risks and benefits of ubrogepant for the acute treatment of episodic migraines?
Read Lire 0.25 credits available Crédits disponibles

#366 Looking for Closure: Managing simple excisions or wounds efficiently

What are some options for efficiency in wound closure?
Read Lire 0.25 credits available Crédits disponibles

#365 Shrooms for Glooms: Evidence for psilocybin for depression

What are the benefits and harms of psilocybin for treatment-resistant/recurrent depression?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session


Author(s)
Auteur(s)
  • Jennifer Young MD CCFP-EM
  • Émélie Braschi MD PhD
  • G. Michael Allan MD CCFP

1. Contreras-Ruiz J, Peternel S, Jiménez-Gutiérrez C, et al. Cochrane Database Syst Rev. 2019; 10:CD005068.

2. Rodriguez-Zuniga M, Torres N, Garcia-Perdomo H. An Bras Dermatol. 2018; 93(5):686-95.

3. Das A, Sil A, Das NK, et al. Indian Dermatol Online J. 2015; 6(3):181-4.

4. Villalon-Gomez J. Am Fam Physician. 2018; 97(1):38-44.

5. Drago F, Broccolo F, Zaccaria E, et al. J Am Acad Derma¬tol. 2008; 58(5 suppl 1): S78-S83.

6. Wenger-Oehn L, Graier T, Ambros-Rudolph C, et al. J Dtsch Dermatol Ges. 2022; 20(7):953-959.

7. Stashower J, Bruch K, Mosby A et al. J Am Acad Derm. 2021; 85(6):1648-9.

8. Leung AK, Barankin B, Lam JM, et al. Drugs Context. 2022; 11:2022-9-2.

Authors do not have any conflicts of interest to declare.