LETTERS
NOTES & COMMENTS
Pityriasis rosea and pityriasis roseaelike
eruptions
To the Editor: We read with great interest the case of
pityriasis rosea (PR)elike eruption associated with
lamotrigine by Papadavid et al.1 This article may raise
the issue of why a drug eruption presents with
clinical features that strikingly resemble genuine
PR. It may be speculated that the drug could have
triggered human herpesvirus (HHV) 6 and/or HHV 7,
recently implicated in the pathogenesis of PR,2-4 to
abandon their latency and to reactivate. This
phenomenon has been demonstrated in drug
reactions associated with eosinophilia and systemic
symptoms (DRESS).5
Our experience, however, seems to disprove such
a hypothesis. In fact, we studied 12 patients with
PR-like eruptions from a clinical, histopathologic,
and virologic point of view. The eruptions followed,
without a definite interval, a lesion resembling the
herald patch in only 3 cases. Lesions were more
confluent than in typical PR, they involved the limbs
more extensively, in 2 cases the face, in 6 cases the
mucous membranes (mouth and tongue), and
caused excessive itching. No patient experienced
prodromal symptoms. Five patients had a slight blood
eosinophilia. Histopathology was studied in 9 pa-
tients showing eosinophils in the dermis in all cases, a
perivascular infiltrate in 7 cases, necrotic keratino-
cytes within the epidermis in 8 cases, and signs of
junctional vacuolar degeneration in 7 cases. All the
patients recovered 2 weeks after discontinuing the
drug, which is less than it takes for typical PR.
In 10 patients we searched for HHV 6 and HHV 7
DNA in plasma and blood mononuclear cells, by
calibrated quantitative real-time polymerase chain
reaction as previously described.3 HHV 6 DNA, a
marker of active infection, was detected in the
plasma of only 1 patient.
We hypothesize that the clinical and histo-
pathologic features and, above all, the virologic
investigations, may help to distinguish typical PR
from PR-like eruptions, although, considering our
small series of patients, further studies are needed.
Francesco Drago, MD,a Francesco Broccolo, MD,b
Arianna Agnoletti, MD,a Francesca Drago,a
Alfredo Rebora, MD,a and Aurora Parodi, MDa
DISSAL Section of Dermatology IRCCS Azienda
Universitaria Ospedaliera San Martino-IST,
Genoa,a and Department of Clinical Medicine
196 JANUARY 2014
and Prevention, University of Milano-Bicocca,
Monza,b Italy
Funding sources: None.
Conflicts of interest: None declared.
Correspondence to: Arianna Agnoletti, MD, DISSAL
Section of Dermatology IRCCS Azienda Univer-
sitaria Ospedaliera San Martino-IST, Viale
Benedetto XV, 5, Genoa, 16132, Italy
E-mail: a.agnoletti@virgilio.it
REFERENCES
1. Papadavid E, Panayiotides I, Makris M, Giatrakou S, Dalamaga
M, Nikolaos S, et al. Pityriasis roseaelike eruption associated
with lamotrigine. J Am Acad Dermatol 2013;68:e180-1.
2. Drago F, Ranieri E, Malaguti F, Losi E, Rebora A. Human
herpesvirus 7 in pityriasis rosea. Lancet 1997;349:1367-8.
3. Broccolo F, Drago F, Careddu AM, Foglieni C, Turbino L,
Cocuzza CE, et al. Additional evidence that pityriasis rosea is
associated with reactivation of human herpesvirus-6 and -7.
J Invest Dermatol 2005;124:1234-40.
4. Drago F, Broccolo F, Rebora A. Pityriasis rosea: an update with
a critical appraisal of its herpesvirus origin. J Am Acad
Dermatol 2009;61:303-18.
5. Husain Z, Reddy BY, Schwartz RA. DRESS syndrome. J Am Acad
Dermatol 2013;68:693.e1-14.
http://dx.doi.org/10.1016/j.jaad.2013.08.056
Reply to: Pityriasis rosea and pityriasis
roseaelike eruptions
To the Editor: We appreciate the interest of Drago
and colleagues in our article and we are pleased that
they present their cases of pityriasis rosea (PR)
and PR-like eruptions. However, we would like to
respond with 2 short comments as follows:
1. Herpesviruses are highly adapted to lifelong
infection of their human hosts and thus can
be considered a component of the human
microbiome in addition to their role in illness.1
Herpesvirus reactivation (especially human
herpesvirus [HHV] 6 and HHV 7) has been
demonstrated in drug reaction with eosinophilia
and systemic symptoms (DRESS) syndrome.2,3
A viral origin in PR has been suggested, with
HHV being the most likely etiological agent
according to studies,4 including those by
Drago et al.5 Our case does not fulfill the criteria
of DRESS but represents a well-documented
case of PR-like drug-induced exanthema associ-
ated with adenopathy. We do not propose a
J AM ACAD DERMATOL