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An Original Study on Blaschkoid Pityriasis Rosea – One of the Rarest Atypical Variants of This Paraviral Exanthema

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An Original Study on Blaschkoid Pityriasis Rosea – One of the Rarest Atypical Variants of This Paraviral Exanthema International Journal of TROPICAL DISEASE & Health 14(2): 1-8, 2016, Article no.IJTDH.24416 ISSN: 2278–1005, NLM ID: 101632866 SCIENCEDOMAIN international www.sciencedomain.org An Original Study on Blaschkoid Pityriasis Rosea – One of the Rarest Atypical Variants of this Paraviral Exanthema Antonio Chuh 1* and Vijay Zawar 2 1JC School of Public Health, The Chinese University of Hong Kong and the Prince of Wales Hospital, Shatin, Hong Kong. 2Skin Diseases Center, Nashik, India. Authors’ contributions This work was carried out in collaboration between both authors. Both authors read and approved the final manuscript. Article Information DOI: 10.9734/IJTDH/2016/24416 Editor(s): (1) Shankar Srinivasan, Department of Health Informatics, University of Medicine & Dentistry of New Jersey, USA. Reviewers: (1) Umit Tursen, Mersin University, Turkey. (2) Hamed Mohamed Abdo, Al-Azhar University, Cairo, Egypt. Complete Peer review History: http://sciencedomain.org/review-history/13322 Received 19 th January 2016 Accepted 29 th January 2016 Case Study th Published 16 February 2016 ABSTRACT Background: Blaschko’s lines are believed to be originated from the migration of mosaic populations of epidermal cells and tissues. Pityriasis rosea (PR) is an exanthem which might be associated with human herpesvirus-7 and -6 infections. Objective: To evaluate the risk factors, clinical manifestations, co-morbid associations, and complications in patients with Blaschkoid PR, and to determine its relative incidence among all patients with PR. Methods: Our setting was a skin clinic served by a consultant dermatologist. We searched for and retrieved records of all patients with Blaschkoid PR presented to us during an eight-year period. Results: Out of 507 patients with PR seen by us, three (0.59%) patients had Blaschkoid PR. All three patients exhibited strictly unilateral distribution of one single group of lesions along Blaschko’s lines, as linear or slightly curved stripes. All three patients had prodromal symptoms, herald patches, secondary eruptions, peripheral collarette scaling for some lesions, and spontaneous _____________________________________________________________________________________________________ *Corresponding author: Email: [email protected]; Chuh and Zawar; IJTDH, 14(2): 1-8, 2016; Article no.IJTDH.24416 clinical remission in two to six weeks. We found no risk factor, co-morbidity, and no complications for patients with Blaschkoid PR. Conclusions: Blaschkoid PR is indeed rare. Apart from the rash distribution, clinical manifestations of this variant are in line with classical PR. Keywords: Atypical; Blaschkitis; Blaschkoid; classification of pityriasis rosea; dermatome; mosaicism; variant. 1. INTRODUCTION over an eight-year period (1 January 2006 - 31 December 2013), and retrieved records of all Pityriasis rosea (PR) is an exanthem suspected patients with Blaschkoid PR seen by us during to be related to primary infection or endogenous this period. We also searched for all patients reactivation of herpesviruses including human with PR seen by us during this period. herpesvirus-7 and -6 [1,2]. Lesions in classical PR are discrete, with the distribution being For each patient with Blaschkoid PR identified, symmetrical involving the trunk and proximal we hand-reviewed the risk factors, clinical aspects of the limbs. Some of the individual manifestations, co-morbid associations, and lesions in PR, particularly the larger oval ones, complications. Risk factors included demography, are oriented along lines of skin creases. family history, congenital abnormalities, neonatal problems, immunisations, hospitalisations, Blaschko’s lines are believed to be due to history of PR, history of other viral exanthems migration of mosaic populations of epidermal and paraviral exanthems, congenital or acquired cells and tissues [3]. Apart from congenital skin immunodeficiencies, drug history, travel history, diseases, acquired skin diseases conforming to contact history with other people with viral or these lines are increasingly being reported. The paraviral exanthems, smoking, alcohol intake, underlying mechanisms for such associations are and sexual history. Co-morbid conditions still largely unknown. included atopy, other skin diseases, and chronic diseases. Complications included hyper- or Blaschkoid PR is a very rare variant of PR. This hypo-pigmentations, systemic complications, and term notes that the individual lesions adverse effects due to treatments. conglomerate into a group (or groups), with the entire group(s) following and stretching along We then assessed whether clinical photographs Blaschko’s lines. The orientation of individual were available to us, and whether consent of the lesions is not embraced in the term. The patient or parents/guardians of children under the distribution is unilateral in Blaschkoid PR. age of 16 had been given for us to publish the Only one patient with Blaschkoid PR has been photographs. reported [4]. We report here the first systematic study for patients with Blaschkoid PR and If any risk factors, clinical manifestations, co- describe the clinical manifestations of the second morbid associations, and complications were to the fourth reported patients with this rare found, we would look for such in all patients with variant. PR, and assess the association with the Fisher Exact Probability Test where applicable. 1.1 Aim Otherwise, we would employ the Chi-squire Test. Risk ratios with 95% confidence intervals would Our aim was to evaluate the clinical features of also be calculated where applicable. patients with Blaschkoid PR and to determine its relative incidence among all patients with PR. 3. RESULTS 2. MATERIALS AND METHODS Five hundred and seven patients with PR were seen by us during these eight years. All patients Our setting was a skin clinic served by a board- fulfilled the diagnostic criteria of PR [5]. Clinical certified dermatologist. Patients attended our records of three (0.59%) patients with Blaschkoid clinics with or without referrals. We searched with PR were retrieved. Their clinical manifestations the entrez Blaschko , Blaschko ’s, Blaschkoid , and are listed in Table 1. We noted no predisposing pityriasis rosea for patients who had consulted us factor, co-morbid condition, and no complication. 2 Chuh and Zawar; IJTDH, 14(2): 1-8, 2016; Article no.IJTDH.24416 Table 1. Clinical data of three patients with Blaschkoid pityriasis rosea Patient Age Prodromal Herald Number Symmetry Skin areas with Linear or Peripheral Treatments Clinical course number and symptoms patch of groups Blaschkoid slightly collarette given sex of lesions pityriasis curved scaling rosea strip 1 18 Present Present, One Strictly Medial aspect of Yes Present Oral Clinical remission years, clearly unilateral, left thigh levocetrizine, 19 days after the male documented left topical appearance of the fluticasone herald patch 2 32 Present Present, One Strictly Posterior and Yes Present None Clinical remission years, clearly unilateral, superior aspect 10 days after male documented right of right thigh appearance of the herald patch 3 12 Present Present, One Strictly Medial aspect of Yes Present None Clinical remission years, clearly unilateral, left groin and left 14 days after male documented left scrotal skin appearance of the herald patch 3 Chuh and Zawar; IJTDH, 14(2): 1-8, 2016; Article no.IJTDH.24416 Clinical photographs were available for one Other body surface areas including the patient, with written informed consent to publish palmoplantar surfaces were unaffected. Mucosal his clinical photographs. We hereby present the surfaces were normal. We noted no inguinal and clinical histories and findings of these patients. other regional lymphadenitis. Abdominal examination revealed no hepatosplenomegaly. 3.1 Patient 1 His complete blood picture, fasting glucose, and An 18-year old male student endured coryzal liver and renal function tests were normal. symptoms with no fever. One week later, a skin Antibodies against human immunodeficiency patch was noted by him on the medial surface of virus 1 and 2 and Venereal Disease Research his left thigh. Moderate pruritus was noted. Six Laboratory test were negative. Antistreptolysin O days later, daughter lesions appeared on either titre was not elevated. Lesional scrapping from sides of the herald patch. The secondary lesions the herald patch and several secondary lesions stopped progressing five days later. for potassium hydroxide smear and for fungal culture later came back to be negative for yeasts The patient enjoyed excellent past health. He and for dermatophytes. had no history of allergic or irritant contact Lesional biopsy revealed parakeratosis, dermatitis. Drug history including traditional epidermal spongiosis, occasional dyskeratotic topical or systemic remedies was unremarkable cells and interface dermatitis with upper dermal over the previous month. His family members lymphocytic infiltrates, involving the perivascular including his girlfriend had no skin rash known to areas. Extravasation of erythrocytes was noted him. at some places. We saw the patient two weeks after appearance We diagnosed PR clinically. As the distribution of the herald patch. Examination revealed no of lesions was entirely unilateral and along pallor and no jaundice. One large oval lesion Blaschko’s lines for this region (Fig. 2), we around 4.5 cm at its longest diameter was noted diagnosed Blaschkoid PR. We prescribed at the junction of the upper one-third and low fluticasone
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