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A 15-year-old boy is brought in by his parents on December 23rd because of a rash he has had for 2 weeks; they are going out of town for the holidays and hope to clear the rash up before they leave. It started out with a round lesion that was diagnosed as ringworm, but the 1% clotrimazole prescribed did not resolve it. Within days, he then developed multiple smaller oval lesions as shown. The parents note that he helped to carry in the family Christmas tree on his back around this time, and they wonder if that is the cause of the rash. The rash is only mildly itchy.
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December 15, 2024 at 8:50 pm
A) Reassurance and breaking the news that the rash will likely last several weeks before resolving spontaneously
The history and rash are typical of pityriasis rosea. The etiology of PR is unknown, but is thought to be viral; sometimes the patient will have a prodrome of headache, malaise, and sore throat. It is most common in older children / teens and young adults. 50-90% have a “herald patch” – a larger lesion that can be mistaken for ringworm. Subsequent PR lesions are smaller, ovoid, have a fine “collarette” of scale, and are oriented along the skin cleavage lines, making a Christmas tree pattern. The torso is commonly affected, but children may have atypical distributions, such as on the face, extremities, and pubic, inguinal, and axillary regions. PR is a clinical diagnosis. It will self-resolve, but over 2-3 months. Topical steroids and anti-itch remedies can be used if itchiness is bothersome, but clobetasol is too potent for this use.