Dermatology: Practical and Conceptual Review | Dermatol Pract Concept 2016;6(3):8 39 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com Pityriasis rosea in pregnancy: report of a spousal occurrence and craniosynostosis in the healthy newborn Tiffany Y. Loh1, Philip R Cohen2 1 School of Medicine, University of California San Diego, La Jolla, CA, USA 2 Department of Dermatology, University of California San Diego, La Jolla, CA, USA Key words: conjugal, craniosynostosis, newborn, pityriasis, pregnancy, rosea, sagittal, spouse Citation: Loh TY, Cohen PR. Pityriasis rosea in pregnancy: report of a spousal occurrence and craniosynostosis in the healthy newborn. Dermatol Pract Concept 2016;6(3):8. doi: 10.5826/dpc.0603a08 Received: January 11, 2016; Accepted: May 1, 2016; Published: July 31, 2016 Copyright: ©2016 Loh et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. All authors have contributed significantly to this publication. Corresponding author: Philip R. Cohen, MD. Email: mitehead@gmail.com Background: Pityriasis rosea is a papulosquamous disease. It may occur during pregnancy; in this setting, it has occasionally been associated with adverse outcomes. Purpose: A woman who developed pityriasis rosea at the beginning of her eighth week of gestation is described. The outcomes in newborns delivered by pregnant women who developed pityriasis rosea during gestation are summarized. Method: A 28-year-old woman developed pityriasis rosea during her eighth week of pregnancy. Her husband had pityriasis rosea two months earlier. PubMed was searched for the following terms: conju- gal, craniosynostosis, newborn, pityriasis, pregnancy, rosea, sagittal, spouse. The papers were reviewed and the references cited were evaluated. Results: Our patient delivered a healthy male infant after 41 weeks of gestation. He had normal weight, height, and Apgar scores. Isolated sagittal craniosynostosis was diagnosed and was success- fully treated at nine weeks after birth without complications. Conclusion: Several retrospective studies have investigated the possibility of adverse outcomes in infants born to women who developed pityriasis rosea during pregnancy, such as stillbirth, low gesta- tional weight, hypotonia, and premature delivery. However, there are also reports of healthy newborns in women who have had pityriasis rosea during gestation. Our patient carried the fetus one week post- term and delivered a healthy boy via C-section; isolated sagittal craniosynostosis was later diagnosed and successfully repaired. The occurrence of craniosynostosis in a woman who developed pityriasis rosea during her first trimester of pregnancy may be two coincidental events. ABSTRACT 40 Review | Dermatol Pract Concept 2016;6(3):8 Introduction Pityriasis rosea is considered to be a benign cutaneous con- dition [1-4]. However, in the setting of pregnancy, adverse effects on the newborn may be observed [5,6]. Craniosynosto- sis is a congenital abnormality, which can occur as an isolated finding or as part of a syndrome with other associated fea- tures [7,8]. A woman who developed pityriasis rosea during her first trimester of pregnancy and who subsequently deliv- ered a healthy baby with craniosynostosis is described, and A B C D E Figure 1. Distant view of abdomen (a), back (b), and left flank (c) of a 28-year old woman at 10 weeks gestation who developed annu- lar lesions of pityriasis rosea 2 weeks earlier. Closer views show the herald patch on her right abdomen (d) and additional plaques with peripheral scaling on her left flank (e). observations of infants born to women who are diagnosed with pityriasis rosea during their gestation are summarized. Case report A 28-year-old healthy woman presented at 10 weeks ges- tation with a skin rash. Two weeks earlier, at eight weeks gestation, she had noticed an initial skin lesion on her abdo- men (Figure 1). Shortly thereafter, she began to develop new lesions on her abdomen and back. Her husband, a 29-year-old man, had presented two months earlier with similar-appearing annular lesions on his neck (Figure 2). A larger lesion had initially appeared on his left neck. Within the next five days, additional lesions appeared on the remainder of his neck and subsequently, a few lesions appeared on his distal upper extremities. A diag- nosis of inverse pityriasis rosea was established based on the clinical history and lesion morphology. His lesions resolved Review | Dermatol Pract Concept 2016;6(3):8 41 consultation confirmed the diagnosis; at 9 weeks postpar- tum, endoscopic repair was performed successfully with no adverse sequelae. Discussion Pityriasis rosea classically presents as annular plaques with peripheral scale, typically located between the neck and the groin, and may be seasonal in occurrence [2,3,9]. Less com- monly, it can present with lesions on the neck and extremi- ties (inverse pityriasis rosea) [10-11] or during pregnancy [5,6,12,13]. The pathogenesis of pityriasis rosea remains to be defini- tively established. However, associations with human herpes virus (HSV)-6 and HSV-7 have been observed [14-18]. Several studies have found that patients with pityriasis rosea have higher levels of HSV-6 and HSV-7 detected in their skin, sug- gesting that infection by these viruses may have a causal effect on the development of pityriasis rosea. Occasionally, pityriasis rosea has been documented in sib- lings or in spouses (Table 1) [19-21]. In these circumstances, over the next two weeks after treatment with triamcinolone 0.1% cream twice daily. Cutaneous examination of the patient’s lesions showed multiple annular plaques with peripheral scaling on the abdo- men and back (Figure 1). Her lesions were similar in mor- phology to those of her husband. She declined skin biopsy. A diagnosis of pityriasis rosea was established based on the appearance of the lesions and history. Cetaphil® cream was applied twice daily to the patient’s lesions; the lesions resolved during the next eight weeks. Her obstetrician was contacted. She was classified as a high-risk pregnancy and was followed closely for the remainder of her gestation. The patient went into labor at 40 weeks and 6 days. After 15 hours of labor, the baby had not descended into the pelvis; there was no fetal distress, and a decision for C-section was made. His Apgar scores at one and five minutes were 9/9, weight 3827.1 g, and height 50.8 cm. Prior to discharge from the hospital, it was noted that the infant had a curved head. X-ray revealed a sagittal craniosynostosis. Neurosurgery A B C D Figure 2. Anterior (a), posterior (b), and lateral (c and d) views of the neck of a 29-year old man, who is the husband of the woman in figure 1, show annular plaques with peripheral scaling of pityriasis rosea that had developed 2 months prior to those of his wife. The right (c) and left (d) neck show pityriasis rosea lesions, including the herald patch on his left neck (d). 42 Review | Dermatol Pract Concept 2016;6(3):8 Several retrospective studies have observed adverse events affecting the newborn in women who develop pityriasis rosea during pregnancy (Table 2) [6,14,22]. In these individuals, the dermatosis lasted 3 to 13 weeks. The adverse events predominantly included stillbirth at 11 to 28 weeks (median 16 weeks), premature delivery (<37 weeks), hypotonia, weak motion, and low birth weight. Less common adverse effects were hydramnios and foramen ovale. Apgar scores ranged from 6 to 9. Some investigators have discovered that pityriasis rosea occurring earlier in pregnancy, such as in the first trimester, have been more often associated with a poorer prognosis, compared to women who developed the dermatosis during the second or third trimesters [6]. However, our review of the literature showed that the majority of women (16/25, 64%) who experienced adverse events had the onset of pityriasis rosea that occurred during the second trimester. The onset of pityriasis rosea occurred during the first trimester in 9 women (36%) and none in the third trimester. Additional studies looking at the association between HSV-6 and HSV-7 DNA and the occurrence of pityriasis rosea in pregnancy have also been performed [13,14,17,18]. Some of the studies found reactivation of HSV-6 during preg- nancy. However, a positive correlation between viral infection and clinical features of pityriasis rosea was not established [17,18]. Individual case reports, including the patient in this report, have described 29 women who developed pityriasis the skin eruption may occur sequentially. Our patient’s husband developed and cleared inverse pityriasis rosea two months prior to his wife developing classic pityriasis rosea. Similar to our patient, in the majority of cases of pityriasis rosea occurring in couples, the lesions appeared in the hus- band prior to the wife (Table 1). The interval between onset of pityriasis rosea in the wife after occurrence in the husband ranged from seven days to one year (median: 2 months). One woman had recurrence of pityriasis rosea each sequential year in the spring [21]. Our review of the literature, including the patient in this report, discovered 54 women who developed pityriasis rosea during their pregnancy (Table 2 [6,14,22] and Table 3 [6,12-14,23,24]). The onset of pityriasis rosea ranged from week 8 of gestation (3 patients: cases 7 and 8 in Table 2 and case 14 in Table 3) to week 32 (1 patient: case 7 in Table 3). The median number of weeks of pregnancy at the onset of pityriasis rosea was 19. An equal number of women were either uniparous or multiparous. Twenty-five women—ages 24 to 34 (median age 29)—had no prior pregnancies. However, pityriasis rosea occurred during either the second (20 women) or the third pregnancy (6 women) for the other women. Most of the women (66%, n=35) developed pityriasis rosea during the second trimester of gestation (13-28 weeks). Nineteen percent (10 women) had the onset of their derma- tosis during the first trimester (0-12 weeks). Only 10% (5 women) experienced it in the third trimester (29-40 weeks). TABLE 1. Pityriasis rosea in spouses: summary of patient features. [Copyright: ©2016 Loh et al.] Ca FOI OIS HA HL HDur WA WL WDur Recur Ref 1 H 7 d 40 4x2 cm oval patch on RLQ abdomen 10 d; Tx ND 36 • 30x10 cm patch R flank • bilateral axilla • 2x1 cm oval lesion L arm extensor surface 3 wk; Tx ND No 20 2 ND ND ND Neck, upper limbs 4 wk, no Tx 28 Neck, chest, thighs, upper limbs 4 wk, no Tx No 19 3 H 1 y ND Trunk ND 34 Upper trunk, ribs [a] Maximum 6 wk per episode Yes [b] 21 4 H 2 mo 29 Neck, distal upper limbs 2 wk, TAC BID 28 Abdomen, back 10 wk, cetaphil cream No CR BID=twice daily; C=couples; Ca=case; CR=current report; d=days; FOI=first occurred in; H=husband; HA= husband’s age in years at onset of pityriasis rosea; HDur=duration in husband; HL=husband’s location of lesion(s); mo=months; ND=not descri- bed; OIS=onset in spouse; Recur=recurrence of pityriasis rosea; RLQ=right lower quadrant; TAC=triamcinolone cream 0.1%; Tx=treatment; WA=wife’s age in years at onset of pitryiasis rosea; WL=wife’s location of pityriasis rosea lesion(s); WDur=duration in wife; wk=weeks; y=years [a] Distribution of the lesions was only described for the last recurrence [b] The woman had 4 recurrences, one per year; each recurrence occurred in the spring Review | Dermatol Pract Concept 2016;6(3):8 43 TABLE 2. Adverse outcomes in infants born to women who developed gestational pityriasis rosea during pregnancy [Copyright: ©2016 Loh et al.] Case A #PP O Dur Symptoms* Loc Del* Newborn weight (g)# Apgar score OAE Ref 1 24 1 6 3 ND Thorax, scattered over body 28 Stillbirth, 2325 at autopsy ND 22 2 25 0 18 5 No Lower L, T(<50%) 36 3000 7 Weak motion 14 3 25 0 19 6 No L, T (<50%) 35 2700 7 Hypotonia 14 4 26 0 25 5 Yes T (<50%) 36 2950 8 6 5 27 0 19 8 Yes L, T (>70%) 32 1900 8 Hypotonia 14 6 27 0 19 5 No Lower L, T (<50%) 34 2600 6 Hypotonia, weak motion 14 7 28 0 8 9 Yes L, T 11 Abortion NA 6 8 28 0 8 11 Yes L, T 11 Stillborn NA 14 9 28 0 9 10 Yes L, T 17 Stillborn NA 14 10 28 1 10 6 Yes L, T 12 Stillborn NA 14 11 29 1 12 11 Yes L, T 16 Stillborn NA 14 12 29 1 16 4 No T (<50%) 36 2950 7 Hypotonia 14 13 29 0 15 9 No L, T 34 2100 8 Weak motion 14 14 30 1 11 10 Yes L, T (>70%) 18 Stillborn NA 14 15 30 1 11 13 Yes L, T 12 Stillborn NA 14 16 30 0 16 9 Yes L, T 38 3100 9 Hydramnios 14 17 31 1 15 6 No T (<50%) 38 2800 8 Hypotonia, foramen ovale 14 18 31 2 19 4 No Lower L, T (<50%) 36 3100 8 Foramen ovale 14 19 31 1 20 5 No Lower L, T (<50%) 35 2900 6 Hypotonia 14 20 32 0 10 11 Yes L, T (>70%) 16 Stillborn NA 14 21 32 2 15 8 Yes L, T (>80%) 17 Stillborn NA 14 22 32 2 18 8 Yes L, T 39 2900 9 Hydramnios 14 23 33 1 14 9 No L, T 33 2100 7 Hypotonia 14 24 34 1 14 9 No T 38 3000 8 Hypotonia, hydramnios 14 25 34 1 18 8 No Upper L, T (<50%) 34 2650 8 6 *Constitutional symptoms (i.e., other than cutaneous symptoms) including fatigue, headache, insomnia, gastrointestinal disturbance, inability to concentrate. C=case; A=mother’s age at onset of pityriasis rosea; #PP=number of previous pregnancies; Loc=location; L=limbs; T=trunk; ND=not described; O=onset of pityriasis (weeks in pregnancy); Dur=duration of pityriasis rosea (weeks); L=location of lesions; Del=delivery (weeks in pregnancy); OAE=other adverse events * Premature <37 weeks [a] # Low birth weight <2500g [b] [a] “Preterm birth.” World Health Organization. http://www.who.int/mediacentre/factsheets/fs363/en/ Date of access: 13 Dec. 2015. [b] “Pediatric and Pregnancy Nutrition Surveillance System: PedNSS Health Indicators.” Center of Disease and Control. http://www. cdc.gov/pednss/what_is/pednss_health_indicators.htm. Date of access: 13 Dec. 2015. http://www.who.int/mediacentre/factsheets/fs363/en/ http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htm http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htm 44 Review | Dermatol Pract Concept 2016;6(3):8 TABLE 3. Healthy infants born to mothers who developed pityriasis rosea during pregnancy. [Copyright: ©2016 Loh et al.] Case A #PP O Dur Symptoms* Loc Del Newborn weight (g)# Apgar score Ref 1 24 1 21 6 No T (<50%) 38 3900 10 6 2 25 0 24 6 No Lower L, T (<50%) 38 3250 9 6 3 26 0 24 4 No (<50%) 40 3850 9 6 4 26 0 26 5 Yes Lower L, T (<50%() 39 3700 9 6 5 26 0 30 6 No T (<50%) 41 3800 8 6 6 27 0 24 5 No T (<50%) 39 3400 10 6 7 27 0 32 5 No L, T (<50%) 38 3900 10 6 8 28 1 13 5 Yes T (<50%) 39 3650 9 6 9 28 2 21 5 No T (<50%) 39 3000 9 6 10 28 0 21 10 No T, proximal aspects of four extremities ND, uneventful ND ND 12 11 28 0 23 5 No T (<50%) 38 3100 8 6 12 28 0 26 4 No T (<50%) 38 3800 10 6 13 28 ND ND, last trimester ND ND R hip, bilateral thighs ND, uneventful ND ND 13 14 28 0 8 10 No T 41 3827 9 CR 15 29 0 26 6 Yes T (<50%) 37 3200 8 6 16 29 1 28 5 No T (<50%) 41 3600 9 6 17 30 1 26 4 No L, T 50% 38 3600 9 6 18 30 1 26 4 No T (<50%) 39 3500 10 6 19 30 1 29 5 No T (<50%) 37 3000 8 6 20 30 0 29 6 No Upper L, T (<50%) 37 3100 8 6 21 30 1 30 4 No Lower L, T (<50%) 38 3400 9 6 22 31 2 14 4 No T (<50%) 38 3300 10 6 23 31 1 24 5 Yes Lower L, T (<50%) 38 2750 7 14 24 31 1 26 5 No Lower L, T (<50%) 38 3300 8 6 25 32 0 26 5 No T (<50%) 38 3250 8 6 26 33 0 11 8 No T, proximal aspects of four extremities ND, full-term 2640 ND 12 27 33 2 23 4 No T (<50%) 39 3200 9 6 28 ND ND ND ND ND ND ND ND ND 23 29 ND ND ND ND ND ND ND ND ND 24 *Constitutional symptoms (i.e., other than cutaneous symptoms) including fatigue, headache, insomnia, gastrointestinal disturbance, inability to concentrate. C=case; A=mother’s age at onset of pityriasis rosea; #PP=number of previous pregnancies; Loc=location; L=limbs; T=trunk; ND=not described; O=onset of pityriasis (weeks in pregnancy); Dur=duration of pityriasis rosea (weeks); Loc=location of lesions; Del=delivery (weeks in pregnancy) Premature <37 weeks [a] # Low birth weight <2500g [b] [a] “Preterm birth.” World Health Organization. http://www.who.int/mediacentre/factsheets/fs363/en/ Date of access: 13 Dec. 2015. [b] “Pediatric and Pregnancy Nutrition Surveillance System: PedNSS Health Indicators.” Center of Disease and Control. http://www. cdc.gov/pednss/what_is/pednss_health_indicators.htm. Date of access: 13 Dec. 2015. http://www.who.int/mediacentre/factsheets/fs363/en/ http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htm http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htm Review | Dermatol Pract Concept 2016;6(3):8 45 Pityriasis rosea also occasionally occurs in women during pregnancy. However, the true incidence is not known, since gestational pityriasis rosea is not frequently reported. Some researchers noted that pityriasis rosea occurring earlier in pregnancy had a greater probability of resulting in adverse events for the fetus, including stillbirth, low gestational weight, hypotonia, and/or premature delivery. However, there are a similar number of reports of women who developed pityriasis rosea during their gestation and delivered normal newborns. Indeed, the ratio of normal to abnormal newborns was found to be 29:25. Our patient developed pityriasis rosea during her first trimester beginning at 8 weeks gestation and lasting through 18 weeks. Her son was carried to term and delivered at 40 weeks and 6 days with Apgar scores, weight, and height in normal range. Isolated craniosynostosis was discovered and subsequently repaired. Whether the presence of craniosynostosis was associated with our patient’s devel- opment of pityriasis rosea during her pregnancy remains to be determined. References 1. Wollenberg A, Eames T. Skin diseases following a Christmas tree pattern. Clin Dermatol 2011;39:189-94. PMID 21396559. DOI: 10.1016/j.clindermatol.2010.09.011. 2. Neoh CY, Tan AW, Mohamed K, Sun YJ, Tan SH. Characteriza- tion of the inflammatory cell infiltrate in herald patches and fully developed eruptions of pityriasis rosea. Clin Exp Derma- tol 2010;35:300-4. PMID: 19663842. DOI: 10.1111/j.1365- 2230.2009.03469.x. 3. Sharma L, Srivastava K. Clinicoepidemiological study of pityriasis rosea. Indian J Dermatol Venereol Leprol 2008;74:647-9. PMID: 19171994. rosea during pregnancy and have delivered healthy newborns (Table 3) [6,12-14,23,24]. Indeed, the literature shows a ratio of 6:5 with regards to healthy newborns versus newborns with adverse events being delivered to women with gesta- tional pityriasis rosea. However, the number of publications regarding gestational pityriasis rosea on the outcome of the newborn may not accurately reflect the incidence of normal newborns whose mothers had gestational pityriasis rosea, since clinicians may not report these women or journals may elect not to publish the papers. Craniosynostosis is a premature fusion of one or more sutures of the skull. It can occur as an isolated incidental event or as part of syndrome (Table 4) [25,26]. As an isolated incidental finding, sagittal craniosynostosis, as observed in our patient’s newborn, is the most common form. If left unrepaired, craniosynostosis may lead to a deformed skull, elevation of intracranial pressure, and cognitive impairment [27]. Our patient’s infant was evaluated shortly after delivery and had repair of the sagittal craniosynostosis at 9 weeks, with no complications and subsequent normal development. The incidence of sagittal craniosynostosis is about 1 in 5,000 live births [28]. To the best of our knowledge, isolated craniosynostosis has not been observed in newborns of women who developed pityriasis rosea during their gestation. Indeed, the occurrence in our patient’s child may merely be a coincidence and not associated with her episode of pityriasis rosea during her first trimester. Conclusion Pityriasis rosea usually occurs as an isolated skin condition. Less commonly, it may be observed in spouses or in siblings. TABLE 4. Syndromes associated with carniosynostosis [25,26] Syndrome [a] Features/Comment Apert syndrome Brachycephaly, flat nasal bridge, syndactyly of fingers (“mitten fingers”), syndatyly of toes Crouzon syndrome Long face with proptosis, maxillary hypoplasia, mandibular prognathism, conductive hearing loss. Associated with increased paternal age. Synostosis may involve the coronal, sagittal, and lambdoid sutures. Can also present with acanthosis nigricans. Pfeiffer syndrome Hypertelorism, maxillary hypoplasia, mandibular prognathism, turribrachycephaly. Partial syndactyly of fingers and toes. May have choanal atresia or stenosis or radiohumeral synostosis at elbows Saethre-Chotzen syndrome Short stature, brachycephaly, acrocephayly, plagiocephaly, facial asymmetry, hypertelorism, beaked nose, deafness, cardiac defect. Carpenter syndrome Brachycephaly with synostosis of coronal, lambdoid, and sagittal sutures. Midface hypoplasia, low-set ears, high arched palate, coxa valgu, genu valgum, polydactyly/ syndactly/clinodactyly/camptodactyly. [a] These are the syndromes most frequently associated with craniosynostosis. 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