Pityriasis rosea of Gibert: clinical guidelines

List of Abbreviations

ICD – International Classification of Diseases

UV – ultraviolet

Terms and Definitions

Pityriasis rosea of Gibert (pityriasis rosea, Gibert's disease, pityriasis circinata, pityriasis rosea) is an acute inflammatory self-resolving dermatosis characterized by typical oval or nummular maculopapular and erythematosquamous lesions located primarily on the trunk and proximal extremities.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Pityriasis rosea of Gibert (pityriasis rosea, Gibert's disease, pityriasis circinata, pityriasis rosea) is an acute inflammatory self-resolving dermatosis characterized by typical oval or nummular maculopapular and erythematosquamous lesions located primarily on the trunk and proximal extremities.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The cause of the disease is unknown. The hypothesis of an infectious, primarily viral, origin is generally accepted, but the etiological agent has not yet been identified. Indirect evidence of the infectious nature of the disease includes its seasonal fluctuations, the presence of prodromal symptoms in some patients, as well as the cyclic nature of the course and development of immunity [1,2].

1.3 Epidemiology of the Disease or Condition

Adolescents and young adults are predominantly affected; the elderly and young children rarely fall ill. The disease develops more frequently in spring and autumn. 1–2% of patients consult a dermatologist for this condition. There is usually a single episode of the disease; two or more episodes are rare. Although the disease is not highly contagious, the incidence is higher in close-contact groups (families, military personnel, etc.) [3].

1.4 Features of Coding the Disease or Condition

L42 – Pityriasis rosea

1.5 Classification of the disease or condition

None.

1.6 Clinical presentation of the disease or condition

In 80% of cases, a bright, oval erythematosquamous plaque, slightly elevated above the skin surface with eccentric growth and a diameter of 2–5 cm, first appears, usually on the trunk with slight scaling in the center. This element is called the "herald" plaque. Sometimes the "herald plaque" is absent or there are multiple "herald plaques". After 1–2 weeks, multiple edematous, pinkish spots up to 1–2 cm in diameter with oval outlines appear, located symmetrically with their long axis along Langer's lines. Their center is delicately wrinkled, brownish-yellow, with minor scaling. Scaling is more characteristic at the border of the central and peripheral zones in the form of a characteristic "collarette". Such pathognomonic elements for pityriasis rosea are typically compared to medallions. Rashes do not appear simultaneously, but in crops, causing evolutionary polymorphism. The elements begin to resolve from the central part, which pales, becomes free of horny scales, and becomes pigmented. The erythema rim gradually disappears, leaving slightly pronounced hyperpigmentation.

Atypical forms of pityriasis rosea may also be observed: urticarial, papular, vesicular, arising due to skin irritation from friction, sweating, or inappropriate topical therapy. However, even in these cases, the rashes are located along Langer's lines. The disease, as a rule, does not recur. Spontaneous recovery usually occurs in the 4th–5th week. In some cases, hypo- or hyperpigmentation occurs, which often appears or becomes more pronounced under the influence of sunlight or UVB therapy.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition: the diagnosis of Pityriasis rosea of Gibert is established based on the clinical manifestations of the disease.

2.1 Complaints and Anamnesis

Patients complain of the presence of rashes. The general condition of patients is usually not disturbed. As a rule, there is no pruritus. Mild pruritus is usually caused by excessive skin irritation from physical factors (mechanical, thermal, radiation), treatment with antiseptics and disinfectants, or antifungal drugs used in dermatology.

There is often a connection between the onset of the disease and a recent infection, hypothermia, or prior general malaise.

2.2 Physical Examination

The main diagnostic method is visual inspection of the patient's skin (visual examination in dermatology A01.01.002). See the "Clinical Presentation" section.

2.3 Laboratory Diagnostics

Comments: Morphological changes in pityriasis rosea of Gibert are characterized by diffuse or focal parakeratosis, absence of the granular layer, slight acanthosis, focal spongiosis, vesicle formation, and dyskeratosis. Edema, homogenous collagen fibers, and a perivascular lymphocytic infiltrate may be observed in the dermis.

2.4 Instrumental Diagnostics

Not applicable.

2.5 Other Procedures

Not required.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Spontaneous recovery typically occurs 2–12 weeks after disease onset. Uncomplicated pityriasis rosea requires no treatment. Patients are advised to limit water procedures (especially hot water), the use of washcloths, rubbing with a hard towel, and the use of aggressive surfactants. Moisturizers may be used to improve skin condition. It is important to avoid skin irritation caused by excessive sweating and non-breathable wool or synthetic clothing. Therapy is indicated in cases of generalized process, pronounced exudative character of rashes, allergic manifestations, eczematization, or pruritus [13].

3.1 Conservative Treatment

• For extensive skin lesions accompanied by severe pruritus, patients with pityriasis rosea of Gibert are recommended topical corticosteroids used in dermatology for external therapy [3,6–11,18]:

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: It is preferable to use agents such as alclometasone cream or ointment 0.05% topically on affected skin areas 2–3 times daily for 5–7 days [11,15,19] or #methylprednisolone aceponate cream or ointment 0.1% twice daily in a thin layer on affected skin areas for 5–7 days, or mometasone** cream or ointment 0.1% once daily in a thin layer on affected skin areas for 7–28 days [11,15,19].

It is preferable to use low-potency (group I) or moderate-potency (group II) corticosteroids such as hydrocortisone** and alclometasone.

• To relieve pruritus, patients with pityriasis rosea of Gibert are recommended systemic antihistamines [3,5–7,14]:

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: It is preferable to use agents such as cetirizine** 10 mg once daily for 7–10 days, loratadine**, chloropyramine**, and clemastine [10,11,12].

• When topical therapy is ineffective and pronounced clinical manifestations of the disease persist, patients with pityriasis rosea of Gibert are recommended systemic corticosteroids [7,14,18].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: Systemic therapy is prescribed in rare cases; low doses of #prednisolone** orally at 15–20 mg daily are usually used until the main clinical symptoms are relieved [14,19].

3.2 Surgical Treatment

Not applicable.

3.3 Other Treatment

Comments: Post-inflammatory hyperpigmentation may occur with this type of therapy. It is prescribed as a course following a schedule of 5 times a week for 1–2 weeks [19]. This therapy may reduce disease severity, but does not shorten its duration.

Diet therapy is not used

Pain management is not used

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not applicable.

5. Prevention and Dispensary Observation

Not developed

6. Organization of Medical Care

Care is provided on an outpatient basis. Hospitalization is not required.

7. Additional Information

Prevention of viral and bacterial infections in the patient reduces the risk of disease development.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Kubanov, Alexey Alekseevich – Academician of the RAS, President of the LLC "AOCDV", Director of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, Moscow;

2. Monakhov Konstantin Nikolaevich – Doctor of Medical Sciences, Professor of the Department of Dermatovenereology with Clinic, First Saint Petersburg State Medical University named after Academician I.P. Pavlov of the Russian Ministry of Health;

3. Khobeysh Marianna Mikhailovna – Candidate of Medical Sciences, Associate Professor of the Department of Dermatovenereology with Clinic, First Saint Petersburg State Medical University named after Academician I.P. Pavlov of the Russian Ministry of Health;

4. Karamova Arfenya Eduardovna – Candidate of Medical Sciences, Associate Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

5. Plakhova Ksenia Ilyinichna – Doctor of Medical Sciences, Associate Professor, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

Conflict of interest:

The authors declare no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Medical specialists: dermatovenereologists

2. Residents and trainees of continuing professional education programs in the specified specialty.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The clinical guidelines update mechanism provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Medical care for patients with pityriasis rosea of Gibert is provided by dermatovenereologists on an outpatient basis.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

1. Excessive skin irritation by physical factors (mechanical, thermal, radiation), treatment with antiseptics and disinfectants, or antifungal drugs used in dermatology is not recommended, as this may provoke worsening of the disease course and pruritus.

2. The disease generally does not recur. Spontaneous recovery usually occurs by weeks 4–5.

3. Prevention of viral and bacterial infections in patients with this dermatosis is advisable.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.