ram sharma, 42 years male from Kathmandu ,chief complain: skin lesion over the trunk since 1 week. Making a provisional diagnosis of Pityriasis rosea along with other diiferntials make a case history

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CASE HISTORY

Ram Sharma | 42 Years | Male | Kathmandu

1. PATIENT IDENTIFICATION

Parameter	Details
Name	Ram Sharma
Age	42 years
Sex	Male
Address	Kathmandu, Nepal
Occupation	(To be elicited)
Date of Admission/Visit	June 20, 2026
Informant	Patient himself
Reliability	Reliable

2. CHIEF COMPLAINT

Skin lesion over the trunk since 1 week

3. HISTORY OF PRESENT ILLNESS

Mr. Ram Sharma, a 42-year-old male from Kathmandu, presented with a history of skin lesions over the trunk of 1 week duration.

Onset: The patient first noticed a single, larger, oval-shaped reddish lesion over the chest/trunk approximately 10 days ago. This was followed 1-2 days later by multiple smaller similar-looking lesions spreading over the trunk.

Character of lesions (to be elicited):

Shape: Oval to round
Color: Pink to salmon-colored
Size: The initial solitary lesion (herald patch) approximately 3-5 cm; secondary lesions 0.5-2 cm
Surface: Fine scales noted over the lesions
Margin: Slightly raised advancing margin with a characteristic "collarette" of scale with free edge pointing inward (trailing scale)
Distribution: Predominantly on the trunk; following skin cleavage lines in a "Christmas tree" / "fir-tree" pattern on the back

Evolution:

First lesion (herald patch) appeared on trunk approximately 10-12 days ago
Within 1-2 weeks, multiple smaller lesions blossomed predominantly over the trunk and proximal extremities
No new lesions appearing outside trunk or extremities (face, palms, soles spared - to confirm)

Associated symptoms:

Pruritus: Mild to moderate itching over lesions (variable; present in some patients)
Prodromal symptoms (1-2 weeks before rash): Mild malaise, low-grade fever, headache, or bodyache (to be specifically asked)
No burning sensation
No vesicles, pustules, or bleeding from lesions (to confirm - atypical variants exist)
No oral lesions (to confirm)

Aggravating factors: Heat, sweating (to elicit)

Relieving factors: Cooling, antihistamines (to elicit)

Treatment taken: Any OTC medications or antifungals tried (to elicit - many patients initially treat with antifungal cream mistaking for tinea)

4. HISTORY OF PAST ILLNESS

Similar episode in the past? (relapse is rare, 1.8-3.7%)
History of skin diseases (psoriasis, eczema, lichen planus)
History of syphilis or STIs
History of recent viral illness (URTI, fever)
History of jaundice or hepatitis
History of diabetes mellitus or immunosuppressive conditions
History of tuberculosis

5. DRUG HISTORY

Critically important - drug-induced PR-like eruption must be excluded:

Specifically ask about recent use of:

ACE inhibitors (captopril, enalapril)
Beta-blockers
Metronidazole
Isotretinoin
Terbinafine
Omeprazole
Hydrochlorothiazide
NSAIDs
Gold, arsenic, bismuth compounds
TNF inhibitors
Recent vaccines

(Drug-induced pityriasis rosea-like eruptions are often slower to resolve than the idiopathic form)

6. PERSONAL HISTORY

Diet: Vegetarian / non-vegetarian
Bowel and bladder habits: Regular
Sleep: Adequate
Alcohol, smoking, tobacco use
Sexual history: Number of sexual partners, history of unprotected intercourse (important to exclude secondary syphilis as a differential)
Recent travel history
Contact with similarly affected individuals (case clustering supports viral etiology)

7. FAMILY HISTORY

Similar skin lesions in family members or close contacts? (case clustering has been reported in pityriasis rosea, supporting an infectious etiology)
Family history of psoriasis, atopy, or autoimmune skin disease

8. SOCIOECONOMIC HISTORY

Middle / lower-middle class
Occupation: to determine occupational exposure to chemicals, metals
Living conditions: crowded housing? (relevant for tinea, secondary syphilis)

9. REVIEW OF SYSTEMS

General: Fever, weight loss, night sweats, lymphadenopathy
Respiratory: Cough, breathlessness
GI: Nausea, vomiting, oral ulcers
Musculoskeletal: Joint pains, arthralgia (relevant for secondary syphilis)
Genitourinary: Genital ulcers or discharge (to exclude syphilis)
Neurological: Headache

10. PHYSICAL EXAMINATION (To be performed)

General Examination

General condition, build, nourishment
Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
Temperature: may be mildly elevated in prodromal phase
Pulse, BP, Respiratory rate

Dermatological Examination

Local Examination of Skin Lesions:

Feature	Expected Finding in PR
Primary lesion (Herald Patch)	Single oval/round plaque, 2-10 cm, pink-salmon colored, on trunk; raised advancing edge; fine central scaling; trailing collarette of scale
Secondary lesions	Multiple smaller (0.5-1.5 cm), oval papules and plaques; similar morphology but smaller; bilateral and symmetric
Distribution	Trunk and proximal extremities; long axis of lesions parallel to Langer's cleavage lines; "Christmas tree" / "fir-tree" pattern on back
Scale	Fine, white pityriasiform scale; collarette scale with free edge pointing inward
Color	Pink to salmon; may be more papular and hyperpigmented in darker skin
Spared areas	Face, palms, soles usually spared
Mucosa	Oral lesions (uncommon, but possible)
Lymph nodes	May have mild lymphadenopathy

Pityriasis rosea - follicular accentuation pattern in darker skin, showing oval scaly plaques distributed over neck

Pityriasis rosea: oval scaly plaques following skin cleavage lines - Symptom to Diagnosis, 4th Ed.

11. PROVISIONAL DIAGNOSIS

Pityriasis Rosea

Basis:

Oval scaly lesions on trunk since 1 week
Initial solitary herald patch followed by secondary eruption
Lesions along Langer's cleavage lines ("Christmas tree" pattern)
Collarette of scale with inward-pointing free edge
Predominantly truncal distribution
Self-limiting course, consistent with viral exanthem (HHV-6/HHV-7)
Male, 42 years (PR peaks 10-35 but occurs at any age; worldwide distribution)

12. DIFFERENTIAL DIAGNOSES

1. Secondary Syphilis (must always be excluded)

Maculopapular rash on trunk; can involve palms and soles (key distinguishing feature)
Associated lymphadenopathy, condyloma lata, mucous patches
History of primary chancre 3-6 weeks earlier
Lesions do NOT follow cleavage lines; no collarette scale
RPR / VDRL and TPHA/FTA-ABS mandatory to exclude

2. Tinea Corporis (Ringworm)

Round/oval scaly plaques; but scale at the PERIPHERAL margin (vs. collarette scale pointing inward in PR)
Central clearing; centrifugal spread
Positive KOH examination (hyphae)
Usually fewer lesions; does not follow cleavage lines
Responds to antifungals

3. Tinea Versicolor (Pityriasis Versicolor)

Hypopigmented or hyperpigmented fine scaly macules on trunk
Fine branlike ("spaghetti and meatballs") KOH pattern
No herald patch; no collarette scale
Chronic, recurrent
More in tropical/humid climate

4. Guttate Psoriasis

Multiple small drop-like scaly papules on trunk; usually post-streptococcal
Scale is thicker, silvery-white (micaceous); Auspitz sign positive
Lesions smaller, do NOT have collarette scale or follow cleavage lines in fir-tree pattern
Family history of psoriasis; nail changes, joint involvement possible

5. Nummular (Discoid) Eczema

Round coin-shaped plaques; extremely pruritic
Oozing, crusting, vesicles possible
No herald patch; does not follow cleavage lines
Chronic, recurrent course
No collarette of scale

6. Pityriasis Lichenoides Chronica (PLC)

Small scaly red-brown papules; chronic course (months to years)
No herald patch; no Christmas tree pattern
Lesions in various stages simultaneously
Biopsy may be needed to distinguish

7. Drug-Induced Pityriasis Rosea-Like Eruption

Morphologically identical to idiopathic PR
History of causative drug (ACE inhibitor, terbinafine, beta-blocker, etc.)
Slower to resolve than idiopathic form
Excluded by careful drug history

8. Lichen Planus

Violaceous, flat-topped, polygonal papules
Wickham's striae on surface
Pruritic; Koebner's phenomenon positive
Can affect mucosae (oral, genital)
No herald patch; different morphology

13. INVESTIGATIONS PLANNED

Investigation	Purpose
RPR / VDRL (+ TPHA/FTA-ABS if positive)	Exclude secondary syphilis - mandatory
KOH examination of skin scraping	Exclude tinea corporis, tinea versicolor
Wood's lamp examination	Tinea versicolor (yellow-green fluorescence)
Skin biopsy (punch biopsy)	If diagnosis uncertain; shows subacute spongiotic dermatitis in PR
CBC, ESR	General inflammation markers
LFT	If drug reaction suspected
Blood glucose	Screen for immunosuppression
HIV screening	If secondary syphilis suspected or high-risk behavior

14. MANAGEMENT

Non-pharmacological

Reassurance: Condition is self-limiting; resolves spontaneously in 6-8 weeks (occasionally up to 5 months)
Avoid hot water baths and friction (can worsen pruritus)
Loose, cotton clothing
Avoid excessive sun exposure (can cause post-inflammatory hyperpigmentation)

Pharmacological

Indication	Treatment
Mild pruritus	Calamine lotion; low-to-medium potency topical corticosteroids (e.g., hydrocortisone 1%, clobetasone butyrate 0.05%)
Moderate-severe pruritus	Oral antihistamines (cetirizine 10 mg OD or loratadine 10 mg OD)
Severe/widespread eruption	Narrowband UVB phototherapy (NB-UVB) or natural sunlight exposure
Severe systemic symptoms	Oral acyclovir (800 mg 5x/day x 1 week) - may hasten resolution per Cochrane review
Rarely	Brief course of systemic corticosteroids if very severe

Follow-up

Review in 2-4 weeks to confirm resolution and address any dyspigmentation
If no improvement in 3 months, reconsider diagnosis - biopsy and syphilis serology if not already done

15. PROGNOSIS

Excellent - complete spontaneous resolution in 6-8 weeks in most patients
Relapse is rare (1.8-3.7%)
Post-inflammatory hypo- or hyperpigmentation may persist for weeks to months (more common in darker skin - relevant for a patient from South Asia/Nepal)
No long-term sequelae in immunocompetent individuals

Sources: Fitzpatrick's Dermatology, 9th Ed., Chapter 31; Dermatology 2-Volume Set 5e (Bol and Dermatology); Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed.

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