Changes

May 2025 — minor update. Revised wording on the potential risks and the management in first trimester of pregnancy.  

Update

Goals

• Make a diagnosis of pityriasis rosea.
• Provide information about the condition.
• Offer appropriate symptomatic treatment.
• Refer the person to secondary care when appropriate.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

What is it?

• Pityriasis rosea is an acute self-limiting skin rash mainly affecting young adults — it is characterized by distinctive, scaly, erythematous lesions, and in up to 90% of people, a herald patch typically appears within a few days to 3 weeks before a more generalized rash.

[Eisman, 2015; Drago, 2016; Villalon-Gomez, 2018; Harwood, 2024]

What causes it?

• The cause of pityriasis rosea remains uncertain — evidence is strongest for a viral aetiology with herpesvirus-like particles found in 71% of pityriasis rosea lesions. 
  • Reactivation of human herpes virus (HHV)-6 and HHV-7 after an asymptomatic primary infection, have been suggested as possible causes. 

[Chuh, 2016; Drago, 2016; Villalon-Gomez, 2018; Harwood, 2024]

How common is it?

• The estimated prevalence of pityriasis rosea in the community is 1.3%; estimated annual incidence is 0.5–2% [Zawar, 2010; Chuh, 2012; Eisman, 2015; Drago, 2016; Contreras‐Ruiz, 2019]. 
  • CKS did not find any data on the prevalence of pityriasis rosea in the UK.
• In temperate climates, pityriasis rosea is seen more commonly during the winter months [Villalon-Gomez, 2018].
• Most cases of pityriasis rosea occur in people aged 10–35 years [Drago, 2016; Harwood, 2024]:
  • It is less common in infancy, early childhood, and older people.
  • It is slightly more common in females — the reported female-to-male ratio is 1.1–1.4:1 [Contreras‐Ruiz, 2019].
  • Infrequently, it may occur in younger children: 8-12% and 4% respectively in white children aged under 10 years and aged under 4 years, and 26% in dark-skinned children. 

What is the prognosis?

• Skin lesions can continue to appear up to 6 weeks after the initial eruption.
• The rash usually resolves within 2 weeks to a few months, but in some people may persist for up to 5 months.
  • The mean duration of the rash is 45 days. 
• After lesions have disappeared, there may be some temporary hyperpigmentation or hypopigmentation of the affected skin, but there is no scarring.
• Recurrence occurs in 3-4% of people after an interval of months to many years, although multiple recurrences are rare.  
  • In recurrence or relapse the herald patch may be absent and the size and number of lesions reduced.

[Eisman, 2015; Chuh, 2016; Drago, 2016; Villalon-Gomez, 2018; Harwood, 2024]

What are the complications?

• In most people pityriasis rosea resolves completely without long-term complications. In some cases residual hyperpigmentation or hypopigmentation of the affected skin may persist. 
  • Post-inflammatory pigmentary changes are more common in black children (62%). 
• In women with pityriasis rosea in the first trimester of pregnancy there is inconclusive evidence that this has been associated with adverse outcomes, including miscarriage, premature delivery, and neonatal hypotonia and hyperactivity. 

[Chuh, 2016; Drago, 2016; Drago, 2018; Villalon-Gomez, 2018; Rebora, 2019; Harwood, 2024]

When should I suspect pityriasis rosea?

• Suspect pityriasis rosea in a person presenting with skin lesions with the following features (images are available at www.dermnetnz.org):
  • Appearance of individual lesions:
    • Multiple, discrete, pink-red (described as 'salmon coloured'). Hypopigmented lesions may also occur — these are more common in dark-skinned people.  
    • Slightly raised.
    • Circular or oval, and typically 0.5–1 cm in diameter.
    • Usually slightly scaly — the centre tends to clear leaving the classical appearance of peripheral 'collarette' scaling around the edge of the lesion.
    • The lesions are not vesicular and do not tend to occur on palmar or plantar skin surfaces.
  • Distribution of lesions:
    • The rash is usually symmetrical. 
    • Most lesions occur on the trunk, base of the neck, and proximal limbs, with few (usually less than 10%) distal to the mid-upper arm and mid-thigh.
    • On the trunk, lesions occur along the cleavage lines forming a 'Christmas tree' pattern on the upper chest and back.
    • Involvement of the face and scalp is common, particularly in children.  
    • Black children have more facial (30%) and scalp involvement (8%). 
    • Oral lesions occur in around 25% of cases and are more common in dark-skinned people. Lesions consist of ill-defined red patches with some erosion or with punctate haemorrhages, or bullae. 
• Pityriasis rosea typically starts with a single 'herald patch' that appears before the generalized eruption, although this may not always be present.
  • The interval between the appearance of the herald patch and the more widespread rash can range from a few days to 3 weeks (or longer). 
  • The herald patch is usually larger than subsequent lesions (typically 2–5 cm in diameter, occasionally much larger), sharply defined, round or oval, erythematous, with a slightly elevated 'collarette' of scale at the margin and a lightly depressed centre. It usually occurs on the trunk, thigh, upper arm, or neck but can appear anywhere on the body. 
• Be aware that:
  • Atypical forms of pityriasis rosea can occur (in around 20% of people) and include:
    • Inverse pityriasis rosea — the face, axillae, and groin are predominantly affected.
    • Pityriasis (rosea) circinata et marginata of Vidal — few large patches that are often localized to the axillae or inguinal region, and may persist for several months. 
    • Pityriasis gigantean — lesions are larger.
    • Pustular, purpuric, haemorrhagic, vesicular, papular, or urticarial lesions. 
  • Itch may be present.
  • Prodromal symptoms may be reported, including malaise, nausea, loss of appetite, headache, difficulty in concentration, irritability, gastrointestinal and upper respiratory symptoms, joint pain, swelling of lymph nodes, sore throat, and mild fever. These symptoms may also be present during the course of the eruption.
• Consider whether the rash may be caused by another condition (such as HIV or secondary syphilis), and arrange further investigation/referral as appropriate — see the CKS topics on HIV infection and AIDS and Syphilis for more information.

What else might it be?

• Other conditions that may present similarly to pityriasis rosea include:
  • Guttate psoriasis (most commonly confused with pityriasis rosea). 
    • Typically presents with small, round or oval (2 mm to 1 cm in diameter) pink or red scaly papules. Multiple lesions may develop all over the body, particularly on the trunk and proximal limbs. 
    • See the section on Guttate psoriasis in the CKS topic on Psoriasis for more information.
  • Discoid (nummular) eczema 
    • Intensely itchy, coin-shaped plaques that may be vesicular or crusted, occurring on the limbs and, to a lesser extent, the trunk.
    • See the CKS topic on Eczema - atopic for more information.
  • Drug reactions 
    • Many drugs can induce a pityriasis-rosea-like eruption, including ACE-inhibitors, beta-blockers, clonidine, gold, interferon, isotretinoin, lamotrigine, metronidazole, nonsteroidal anti-inflammatories, omeprazole, terbinafine, and some vaccines (such as Bacillus Calmette–Guérin [BCG], Hepatitis B and pneumococcal). 
    • There is no herald patch, individual lesions tend to be violet-red in colour, pruritus is more severe, and eosinophilia may be present. 
  • HIV seroconversion
    • Symmetrical, erythematous, maculopapular rash affecting the face, trunk, limbs, palms, and soles. 
    • See the CKS topic on HIV infection and AIDS for more information.
  • Lichen planus 
    • Lesions are 1-10-mm in diameter, sharply defined, flat-topped, purple, polygonal, pruritic, papules, and plaques. They often appear on the ankles and volar surfaces of the wrists, but they can also appear on the lumbar region, shins, scalp, glans penis and oral mucosa. 
    • Lesions may be covered with Whickham's striae (fine white lines). 
  • Pityriasis lichenoides 
    • The acute form, is characterized by red-brown, erythematous, ovoid papules, 5-15 mm in diameter, mainly on the trunk and proximal extremities. They evolve into vesicles, pustules, haemorrhagic crusts and ulcers.  There is a pruritus or burning sensation and there may be hypo- or hyperpigmentation after lesions resolve. 
    • In the chronic form, there are larger numbers of small red-brown papules with mica-like scale on more established lesions. 
  • Pityriasis versicolor 
    • Multiple round or oval macules, with a fine scale that may be seen only at the edge, particularly affecting the back, chest, and upper arms. 
    • The colour of the lesions varies and can be fawn, pink, red, brown, or almost white. 
    • See the CKS topic on Pityriasis versicolor for more information.
  • Polymorphic eruption of pregnancy (also known as pruritic urticarial papules and plaques of pregnancy [PUPPP])
    • Usually occurs in the third trimester of the first pregnancy and presents with discrete itchy papules and plaques, which typically start on the abdomen (usually sparing the umbilical region). 
    • See the section on Causes of itch in the CKS topic on Itch in pregnancy for more information. 
  • Seborrhoeic dermatitis 
    • Erythematous patches associated with white/yellow scale. The most commonly affected areas are the scalp, face, upper chest and back, and flexures and skin folds.
    • See the CKS topic on Seborrhoeic dermatitis for more information.
  • Secondary syphilis 
    • Non-itchy, maculopapular rash that may be generalised or only involve the palms of the hands and soles of the feet.
    • See the CKS topic on Syphilis for more information.
  • Tinea corporis 
    • Single or multiple, red or pink, flat or slightly raised annular patches of varying sizes which gradually enlarge over time — lesions have an active red, scaly advancing edge and a clear central area. 
    • See the CKS topic on Fungal skin infection - body and groin for more information.
  • Other rashes with annular lesions, including:
    • Erythema annulare centrifugum — expanding lesions with central clearing and scaling at the trailing edge, most commonly affecting the thighs, buttocks, and upper arms.
    • Erythema migrans (Lyme disease) — one expanding lesion (reaching 5 cm or more in diameter) that usually appears 1–2 weeks (but can appear from 1-36 days) after a tick bite, and may be followed by multiple smaller lesions. See the CKS topic on Lyme disease for more information. 
    • Erythema multiforme — multiple raised annular target-shaped lesions with central erythema. 
    • Granuloma annular — firm, shiny papules that can be violaceous, erythematous, or brown or flesh-coloured with central involution. Lesions most commonly develop on the dorsal side for the hands and feet. 
    • Leprosy (Hansen's disease) — skin lesions present as erythematous annular plaques with or without scales. The lesions may appear hypopigmented in dark-skinned people. There may be decreased sensation to pain, temperature, and touch over the lesions. 
    • Subacute lupus erythematosus — red, annular lesions on sun-exposed areas (chest, face, arms).

Scenario: Management

From age 1 month onwards.

Emollients

• For further information on the availability and choice of emollients, how to apply them, and quantities to prescribe, see the section on Prescribing information in the CKS topic on Eczema - atopic.
  • Be aware that the Medicines and Healthcare products Regulatory Agency (MRHA) recommends advising people who use paraffin or paraffin-free emollients not to smoke or go near naked flames — clothing, bedding, dressings, and other fabric that has dried residue of an emollient product on them may be easily ignited [MHRA, 2018].

Topical corticosteroids

• For prescribing information on topical corticosteroids, including application advice and minimization of adverse effects, see the CKS topic on Corticosteroids - topical (skin), nose, and eyes.

Oral antihistamines

• For prescribing information on oral antihistamines, see the section on Prescribing in the CKS topic on Itch - widespread.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of pityriasis rosea.

Search dates

February 2020 - January 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 20th February 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases.

S3    S1 OR S2 
S2    AB pityriasis rosea OR TI pityriasis rosea 
S1    (MH "Pityriasis Rosea") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.