Pityriasis rosea with unusual papulovesicular presentation 
Short communication 
PITYRIASIS ROSEA 
WITH UNUSUAL PAPULOVESICULAR 
PRESENTATION 
J. Miljkovic, M. Berčič and M. Belič 
SUMMARY 
Although pityriasis rosea is a common and well known disorder, some cases with atypical lesions and an 
unusual distribution of the latter are sometimes obseived. 
This paper reports on a 30-year-old male patient with papulovesicular exanthema which in the beginning 
of the disease could not be clearly differentiated. 
Later on the clinical features changed and showed the characteristic signs of pityriasis rosea. The 
pathohistologic symptoms were also different. The spongiosis was more expressed, there were larger spongiotic 
vesicles. 
KEY WORDS 
pityriasis rosea, atypical papulovesicular lesions 
INTRODUCTION 
Pityriasis rosea is a relatively frequent benign 
dermatosis of unknown etiology with typical clinical 
features. Therefore in the majority of cases this skin 
disease is not difficult to diagnose. Nevertheless, 
some cases with atypical lesions such as papulae, 
vesiculae, bullae, urticae and even erythema multi-
forme-like lesions have been described (1,2,3). There 
are also reports on cases with unusual distribution 
of the lesions, i.e. on the extremities, the face or 
scalp (4), and cases with manifestations on the oral 
mucosa (5,6,7). 
For the above reasons we decided to report on 
our 30-year-old male patient with disseminated 
papulovesicular exanthema which in the beginning 
we could not differentiate clearly. 
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CASE REPORT 
The patient was admitted to the Department of 
Dermatology because of acute papulovesicular exan-
thema lasting two days. Previously, at the Unit for 
Infectious Diseases, varicella was excluded (the patient 
already had it in childhood). 
Clinical findings: 
On the trunk and shoulders, on the neck and 
scalp soft, bright-red papules were disseminated quite 
symmetrically. Some of these papules showed evidence 
of a tiny vesicle (Fig. 1 ). Except for vigorous 
pruritus, the patient had no other subjective symptoms. 
Otherwise his health was satisfactory. Routine 
laboratory findings were within normal limits. 
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62 
Pityriasis rosea - with unusual papulovesicular presentation 
Fig. l. Bright-red papules on the trunk. 
In some of these papules a tiny vesicle 
is present. 
Fig. 2. Slight acanthosis, focal para-
keratosis, spongiosis with some larger 
spongiotic vesicles. 
In the upper dermis presence of a 
perivascular lymphohistocytic infiltrate. 
(hematoxylin - eosin x 40) 
Fig. 3. Pityriasis rosea. Typical distribution 
of lesions. 
acta dermatovenerologica A.P.A. Vol 5, 96, No 2 
Pityriasis rosea - with unusual papu./ovesicular presentation 
Patho histologic findings: 
Slight acanthosis, focal parakeratosis, spongiosis 
with some larger spongiotic vesicles. In the upper 
dermis presence of perivascular lymphohistiocytic 
infiltrate. Some exocytosis. (Fig. 2) 
Course of the disease: 
In the differential diagnosis t\vo possibilities were 
taken into consideration. First, there was the possibility 
of an infectious exanthema, and second, of drug 
eruption. Since anamnestic data related to drug 
abuse were negative and general state of the patient 
was satisfactory, only symptomatic therapy was applied. 
After severa! days of observation, the clinical 
features changed. The lesions flattened, became oval, 
the "collarette scaling" occurred. (Fig. 3) 
In spite of the missing herald patch, the clinical 
features became then characteristic of pityriasis rosea. 
The pathohistologic findings are also consistent 
with the clinical diagnosis. Only the larger spongiotic 
vesicles were somewhat unusual. 
COMMENT 
In the majority of cases, the diagnosis of pityriasis 
rosea is easy. Differential diagnostic problems occur 
only in the initial stage of the disease, when clinical 
features are not yet fully developed, and indeed in 
atypical cases. In about 5% of patients, the eruption 
of pityriasis rosea is preceded by prodromes of 
fever, headache, malaise, arthralgia and gastrointestinal 
symptoms consisting of vomiting, diarrhea or 
constipation (8). If in such cases signs of respiratory 
irritation are also present, or there are lesions on 
oral mucosa and skin with an atypical distribution 
of the latter, the differentiation bet\veen infectious 
and drug exanthema is practically impossible. Only 
the occurrence of typical lesions during the later 
course of the disease makes a correct diagnosis 
possible. 
Also in our case the disease was initiated with 
atypical papulovesicular lesions in unusual distribution 
(neck and scalp) and with vigorous pruritus, which 
is rarely seen in pityriasis rosea. Later on, in the 
course of the disease, the symptoms of pityriasis 
rosea became evident and the final diagnosis could 
be made. 
ACKNOWLEDGMENT 
The authors wish to thank Marijana Gajšek-Marcetti, 
translator from the Medica! Research Department, 
for reading, correcting and typing the manuscript. 
REFERENCES 
l. Strauss T, Kuhn A, Steigleder GK. Vesicular 
pityriasis rosea. Hautarzt 1988; 39(8): 524-6. 
2. Bari M, Cohen BA. Purpuric eruption in a 7-
year-old girl. Vesicular pityriasis rosea. Arch Dermatol 
1990; 126(11): 1497-1500. 
3. Friedman SJ. Pityriasis rosea with erythema 
multiforme-like lesions. J Am Acad Dermatol 1986; 
15: 159-167. 
4. Parsons JM. Pityriasis rosea update. J Am Acad 
Dermatol 1986; 15: 159-167. 
5. Sciubba JJ. Oral lesions associated with pityriasis 
rosea. Arch Dermatol 1986; 122(5): 503-4. 
6. Vidimos AT, Camisa C. Tongue and cheek: oral 
lesions in pityriasis rosea. Cutis 1992; 50(4): 276-80. 
7. Kay MH, Rapini RP, Fritz KA. Oral lesions in 
pityriasis rosea. Arch Dermatol 1985; 121: 1449-51. 
8. Gibson EL, Perry CH. Papulosquamous eruptions 
and exfoliative dermatitis. In: Moscella SL, Hurley 
HJ. Dermatology. 3rd ed. Philadelphia: W.B. Saunders 
Company, 1992; 622-625 
AUTHORS' ADDRESSES 
Jovan Miljkovic MD, Specialist in Dermatology, Department of Dermatology and Venereal Disease~, 
Maribor Teaching Hospital, Ljubljanska 5, 2000 Maribor, Sl9venia 
Marija Berčič MD, PhD, Specialist in Dermatology, same address 
Mirijam Belič MD, same address 
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