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Pityriasis rosea (PR) is a self-limited disease with exanthematous papulosquamous rashes mostly associated with reactivation of human herpesvirus (HHV)-6 or HHV-7. PR-like eruptions, which occur along with peripheral eosinophilia, interface dermatitis, and eosinophils on histopathology, may result from medications or vaccinations. Previously, PR-like eruptions had been noted following vaccination for influenza or other vaccines. During this pandemic, acute COVID-19 infection has been related to PR or PR-like eruptions in several cases. Various COVID-19 vaccines associated with PR-like eruptions were rarely reported. Herein, we report a case of cutaneous PR-like eruptions following COVID-19 mRNA-1273 vaccination.

A total of 22 patients who had developed an adverse cutaneous reaction to the Moderna or Pfizer vaccine underwent biopsies. Each patient was assessed light microscopically, and, in select biopsies, spike glycoprotein and cytokine assessment were also conducted. The patients developed self-limited cutaneous reactions often described clinically as urticarial or eczematous within 1 day to 4 weeks after receiving the first or second dose of the Pfizer or Moderna vaccine. Classic clinical and morphologic depictions of type IV cutaneous hypersensitivity with features of eczematous dermatitis, interface dermatitis, granulomatous inflammation, and/or lymphocytic vasculitic component were observed. Clinical and/or histologic features of perniosis, pityriasis rosea, pityriasis rubra pilaris, and guttate psoriasis were seen in select cases. In 2 cases the dominant picture was urticarial vasculitis, possibly reflective of an Arthus type III immune complex action. The biopsy specimens of normal skin post vaccine and of skin affected by the post-vaccine eruption showed rare deep microvessels positive for spike glycoprotein with no complement deposition contrasting with greater vascular deposition of spike protein and complement in skin biopsies from patients experiencing severe coronavirus disease 2019 (COVID-19). It is concluded that self-limited hypersensitivity reactions to the vaccine occur possibly owing to a substance found in the vaccine vehicle (eg, polyethylene glycol). An immune response that is directed against human-manufactured spike has to be considered because some of the reactions clinically and or histologically closely resemble mild COVID-19. Finally, vaccine-associated immune enhancement largely attributable to the adjuvant properties of the vaccine may unmask certain inflammatory milieus operational in psoriasis, atopic dermatitis, and subclinical hypersensitivity.

Background Cutaneous reactions after messenger RNA (mRNA)-based COVID-19 vaccines have been reported but are not well characterized. Objective To evaluate the morphology and timing of cutaneous reactions after mRNA COVID-19 vaccines. Methods A provider-facing registry-based study collected cases of cutaneous manifestations after COVID-19 vaccination. Results From December 2020 to February 2021, we recorded 414 cutaneous reactions to mRNA COVID-19 vaccines from Moderna (83%) and Pfizer (17%). Delayed large local reactions were most common, followed by local injection site reactions, urticarial eruptions, and morbilliform eruptions. Forty-three percent of patients with first-dose reactions experienced second-dose recurrence. Additional less common reactions included pernio/chilblains, cosmetic filler reactions, zoster, herpes simplex flares, and pityriasis rosea-like reactions. Limitations Registry analysis does not measure incidence. Morphologic misclassification is possible. Conclusions We report a spectrum of cutaneous reactions after mRNA COVID-19 vaccines. We observed some dermatologic reactions to Moderna and Pfizer vaccines that mimicked SARS-CoV-2 infection itself, such as pernio/chilblains. Most patients with first-dose reactions did not have a second-dose reaction and serious adverse events did not develop in any of the patients in the registry after the first or second dose. Our data support that cutaneous reactions to COVID-19 vaccination are generally minor and self-limited, and should not discourage vaccination.

Background Syphilis is often misdiagnosed clinically, and biopsies might be required. Objective To determine histopathologic features that distinguish secondary syphilis from pityriasis lichenoides (PL), pityriasis rosea (PR), and early mycosis fungoides (MF). Methods Histopathologic features of 100 cases of syphilis, 110 cases of PL, 72 cases of PR, and 101 cases of MF were compared. Results Elongated rete ridges and interstitial inflammation favor syphilis over PL (likelihood ratios 3.44 and 2.72, respectively), but no feature reliably distinguishes between them. Secondary syphilis and PR can be distinguished by neutrophils in the stratum corneum, plasma cells, interface dermatitis with lymphocytes and vacuoles, and lymphocytes with ample cytoplasm. Plasma cells and lymphocytes with ample cytoplasm are rare in early MF and can be used as distinguishing features. Conclusions Histopathologic features characteristic of syphilis can be seen in PL, PR, and early MF. Distinguishing syphilis from PL can be difficult histologically, and a high index of suspicion is required. Although elongation of rete and interstitial inflammation favor syphilis, plasma cells (historically considered a significant feature of syphilis) are often encountered in PL. Vacuolar interface dermatitis with a lymphocyte in every vacuole is considered characteristic of PL, but this feature appears to be more common in syphilis.

A rash is a disseminated eruption of cutaneous lesions with great variation in appearance, cause, and severity. When the physician is facing a rash, the history and physical examination of the patient are extremely important for the identification of the disease and its causal agent. There are various causes for a rash, which may be infectious, allergic, or rheumatologic, besides many others. Rashes associated with mucosal ulcers may have causes related to viral and bacterial infections or drug reactions. They may be associated with measles; erythema infectiosum; roseola infantum; rubella; hand, foot, and mouth disease; pityriasis rosea; dengue fever; chikungunya; zika; scarlet fever; meningococcal diseases; syphilis; and exanthematous drug eruptions.

Allergists/immunologists see a variety of skin disorders, some of which have a known immunologic basis whereas others do not. We review the prevalence, etiology, clinical presentation, and effective and low-cost care of common dermatologic conditions seen in outpatient practices. Conditions discussed include pityriasis alba, seborrheic dermatitis, rosacea, acne, tinea infections, intertrigo, lichen planus, tinea versicolor, lichen simplex chronicus, scabies, pityriasis rosea, keratosis pilaris, and seborrheic keratosis. An understanding of frequently encountered cutaneous diseases and their therapies will help provide immediate access to treatment and improve the experience for both the affected patient and the clinician.

On December 31, 2019, the World Health Organization identified a novel coronavirus (SARS-CoV-2) in the city of Wuhan in China that spread very quickly and has to date resulted in the deaths of thousands of people by causing COVID-19 disease. Various Coronavirus disease-19 (COVID-19) associated dermatological manifestations have been reported. Among these, Pityriasis rosea (PR) and PR-like rash have been published previously. During the COVID-19 pandemic, the diagnosis of PR has become more common

This review article focuses on the spongiotic tissue reaction pattern and some of the common entities that practicing pathologists can frequently encounter in their practice. The spongiotic tissue reaction pattern is the single most common one encountered in the routine analysis of inflammatory dermatoses, and the most non-specific one as well. Spongiotic dermatoses include a very large list of disorders which are best grouped under neutrophilic, eosinophilic, miliarial, follicular and pityriasiform forms of spogiosis. The dermatoses that will be discussed under this category include contact dermatitis, eczema, pityriasis rosea, stasis dermatitis, seborrheic dermatitis and others.

A switch from cell-mediated to humoral immunity (helper T 1 [Th1] to helper T 2 [Th2] shift) during gestation plays a key role in placental immune tolerance. As a result, skin diseases that are Th2 mediated often worsen, whereas skin diseases that are Th1 mediated often improve during gestation. Also, due to fluctuations in glandular activity, skin diseases involving sebaceous and eccrine glands may flare, whereas those involving apocrine glands may improve during pregnancy. Despite these trends, inflammatory and glandular skin diseases do not always follow the predicted pattern, and courses are often diverse. We review the gestational course of inflammatory skin diseases, such as atopic dermatitis (atopic eruption of pregnancy), psoriasis, impetigo herpetiformis, urticaria, erythema annulare centrifugum, pityriasis rosea, sarcoidosis, Sweet syndrome, and erythema nodosum, as well as glandular skin diseases, including acne vulgaris, acne rosacea, perioral dermatitis, hidradenitis suppurativa, Fox-Fordyce disease, hyperhidrosis, and miliaria. For each of these diseases, we discuss the pathogenesis, clinical presentation, and management with special consideration for maternal and fetal safety.

Background Cutaneous graft-versus-host disease (GVHD) is classically described as morbilliform when acute and lichen planus–like or sclerotic when chronic. In addition to these well-known clinical forms, there are many other presentations of GVHD that are important to recognize. As the number of patients undergoing stem cell transplantation increases and the survival after transplantation improves, the prevalence of GVHD is expected to rise, and its various presentations will be increasingly encountered in clinical practice. Objective We sought to report unusual manifestations of skin GVHD and provide a summary of typical and atypical presentations of GVHD reported in the literature. Methods Patients with stem cell transplantation who developed unusual eruptions after transplantation had biopsy specimens taken to evaluate for histopathologic evidence of GVHD. Results Six patients presented with unusual cases of biopsy-proven GVHD, including follicular hyperkeratosis, thick-appearing white tongue, inverse pityriasis rosea–like, and eczema craquele–like GVHD. Limitations This study is limited by case number. Conclusions Because of the high rate of cutaneous involvement with GVHD, the accessibility of the skin for diagnosis, and the morbidity associated with severe or long-standing skin involvement, it is important for dermatologists to recognize and accurately diagnose cutaneous GVHD in all its protean manifestations.

Objective: A 28-year-old male diagnosed with schizophrenia, maintaining well on Olanzapine, developed akathisia soon after addition of Erythromycin for Pityriasis Rosea. This prompted us to evaluate the relationship of Erythromycin and akathisia. Method: We report the case and the literature focusing on akathisia as a possible adverse event of Erythromycin. Results: Akathisia resolved after Erythromycin was stopped following 5days of treatment. Akathisia was possibly induced or precipitated with use of Erythromycin. Possible etiological reasons of this clinically significant association are discussed. Conclusion: Erythromycin, by itself, may induce akathisia or precipitate akathisia in individuals by interfering with metabolism of other culprit drugs.

Exanthems are rashes that in childhood are most commonly caused by viruses. This article describes the common exanthems, including measles, rubella, varicella, erythema infectiosum, papular-purpuric gloves and socks syndrome, roseola infantum, hand, foot and mouth disease, Gianotti–Crosti syndrome, unilateral laterothoracic exanthem and pityriasis rosea. It outlines their transmission, infectivity, prodrome, clinical presentation, complications and treatment. Although it is often difficult to identify the specific virus, polymerase chain reaction analysis has improved diagnostic accuracy, which is particularly important in immunocompromised individuals and pregnant women. Alternative diagnoses include bacterial and non-infectious causes.

During the last three decades, ultraviolet A1 (UVA1) phototherapy has emerged as a specific phototherapeutic modality with distinct modes of action and some well established indications. Atopic dermatitis, localized scleroderma, and systemic lupus erythematosus seem to be the conditions with the best evidence regarding efficacy and safety of UVA1 phototherapy. Further indications for UVA1 include subacute prurigo, lichen sclerosus, dyshidrotic dermatitis, cutaneous T cell lymphoma, urticaria pigmentosa, and pityriasis rosea; nevertheless, there are some unknowns, uncertainties, and controversies concerning short- and long-term side effects, efficacy and dosage regimens of UVA1 phototherapy in some conditions. We describe and discuss treatment regimens, protocols, dosage, and indications for UVA1 phototherapy.

Background The association of human herpesvirus 6 (HHV-6) and HHV-7 with pityriasis rosea suggests that systemic drugs directed against HHV may hasten recovery of patients with pityriasis rosea. Objective The purpose of this study was to verify the efficacy of oral acyclovir in the treatment of pityriasis rosea. Methods Eighty-seven consecutive patients were treated for 1 week with either oral acyclovir (800 mg 5 times daily) or placebo. In all patients, the time of lesion clearing and the number of new lesions appearing during treatment were recorded. Results On the 14th day of treatment, 79% of treated patients fully regressed compared with 4% of the placebo group. The lesions cleared in 18.5 days in treated patients and in 37.9 days in the placebo group. Clearance was achieved in 17.2 days in patients treated in the first week from onset and in 19.7 days in the patients treated later. On the 7th day, there were significantly fewer new lesions in patients treated in the first week than in those treated later. Limitations This trial was neither randomized nor double blind. Objectivity was achieved by counting the lesions. Conclusion Acyclovir may be effective in the treatment of pityriasis rosea, especially in patients treated in the first week from onset, when replicative viral activity of HHV is probably very high.

Eczema is defined in the third Webster’s unabridged dictionary as an “acute or chronic noncontagious inflammatory condition of the skin characterized by redness, itching, oozing...associated with exposure to chemicals or irritants.” The word derives from Greek, meaning literally to erupt, ferment, or boil. The broadness of this term and its association with just about any inflammatory condition of the skin has prompted some authors to opine that “ it is devoid of meaning” and that it should be “expunged” from the dermatologic lexicon. The consensus among many dermatopathologists and a few dermatologists is that the expression eczema should be replaced with the term “spongiotic dermatitis.” Spongiosis refers to the histopathologic changes that underlie most of the so-called eczemas, ie, edema between the keratinocytes of the stratum malpighii, which gives a spongy appearance to the epidermis. Although most authors have accepted this concept, it is actually a gross oversimplification. Spongiosis occurs in numerous other dermatoses that are not, by conventional wisdom, classified as “eczema.” Examples include, but are not limited to pityriasis rosea, Gianotti Crosti syndrome, the annular erythemas, miliaria, Grover’s disease, polymorphous light eruptions, papular urticaria, lichen striatus, and some pigmented purpuras. Because a full discussion of this issue is beyond the scope of this article, for purposes of discussion, eczema is defined here as “an inflammatory skin disorder that histologically shows spongiosis and is related etiologically to some type of immunologic perturbation.” This review will cover two major points concerning spongiotic dermatitis. First, spongiotic dermatitis will be examined as a histologic continuum. If the antigenic insult is severe and reaction time is short, the resulting dermatitis is designated as acute. If the antigenic stimulus is weaker and takes place over an extended period of time, then it is referred to as chronic. Severe chronic reactions typified by maximal physical changes are termed lichen simplex chronicus and prurigo nodularis. Although this histopathologic schema is a convention in common use by dermatopathologists, it should be understood that pathologic changes don’t always correlate exactly with a defined time course in a clinical dermatitis. The second major consideration of this paper will be the varieties of spongiotic dermatitis that occur at different anatomic sites and that may have varying etiologies. An attempt will be made to differentiate the characteristic histopathologic changes occurring at different anatomic locations and those occurring within different subtypes of spongiotic dermatitis; we will also discuss whether such changes can be readily identified by the dermatopathologist. For some of the dermatitides, a short summary of pathogenesis is included if it is relevant to understanding the pathology. There are five general categories of spongiotic dermatitis: 1) acute spongiotic dermatitis; 2) subacutespongiotic dermatitis; 3) chronic spongiotic dermatitis; 4) lichen simplex chronicus; and 5) prurigo nodularis. The first three categories actually represent a pathologic continuum, whereas the last two are a pathologic response to trauma superimposed by the patient on the underlying dermatitis. In acute spongiotic dermatitis, the spongiosis is typified by massive intercellular edema of the epidermis with widening of the intercellular spaces. The edema produces disruption of desmosomal attachments, and as a consequence, numerous microvesicles form. Although these vesicles are usually intraepidermal, with sufficient vesiculation they can become subepidermal. In general, the degree of epidermal acanthosis is slight. Dermal edema is common, and it is often accompanied by a pronounced inflammatory infiltrate of mononuclear cells and eosinophils. Although there may be some parakeratosis, in general, the changes in the horn are slight given the rapidity at which the process usually develops. A frequent accompaniment is a scale crust composed of neutrophils, plasma, and bacterial colonies ie, so-called impetiginization (Fig. 1). In subacute spongiotic dermatitis, the vesicles are smaller and there is greater acanthosis of the epidermis. From the Departments of Dermatology and Pathology, Mount Sinai School of Medicine, New York, New York. Address correspondence to Dr. Robert G. Phelps, Dermatopathology Division, Box 1194, 1 Gustave L. Levy Place, New York, NY 10029. E-mail address: bobpderm@aol.com.

Skin disorders are an extremely common complaint in office visits to primary care practitioners. With today's emphasis on cost containment, referral or direct visits by patients to specialists is more difficult, and primary care physicians are asked to diagnose and treat these disorders more often. In a survey of a pediatric outpatient clinic in a teaching center, 24% of visits involved either a primary or secondary skin complaint. 19 In that same survey, an additional 7.3% of patients had a skin finding on physical examination. Data obtained from the 1990 National Ambulatory Medical Care Survey indicated that a dermatologic condition was diagnosed in 9.7% of visits in children 18 years or less. 6 Other surveys generally support the high frequency of skin disorders seen in the primary care setting and in the emergency room. 3,17 An accurate identification of the key morphologic features of skin lesions is necessary for making the correct diagnosis, communicating with a dermatologist if necessary, and following the evolution of the disorder.

Skin diseases are an essential part of primary care medicine. Most dermatologic care is delivered in an outpatient setting. The initial evaluation is usually performed by the primary care physician. Women account for nearly 60% of all visits for dermatologic complaints.

Bone marrow transplantation is associated with numerous cutaneous complications that may be related to the underlying (preexisting) disease, to pretransplant conditioning, to immunosuppression, to concomitant medication, or to graft-versus-host reaction. We describe four bone marrow transplant recipients with the clinical and histologic features of pityriasis rosea, a hitherto unreported association. (J Am Acad Dermatol 1994;31:348-51.)

Adverse cutaneous drug reactions (ACDRs) are common in clinical practice and occur in about 5% of antipsychotic-treated patients. Most ACDRs are benign, but a small percentage of them are serious and life threatening. Pityriasis rosea (PR)-like eruption is a common cutaneous adverse reaction related to many drugs. Clozapine, a complex neurotransmitter receptor-binding in antipsychotic agent, is usually used for treatment-resistant schizophrenia. Clozapine-related ACDRs have been reported frequently, but clozapine-induced PR-like eruption has been reported once in the literature. We report a 54-year-old male patient with chronic schizophrenia who had received clozapine for 28 days and developed generalized skin rashes, high fever, and elevated values in liver function tests. His clozapine was immediately discontinued. He received acute managements with steroid and antihistamine, and his symptoms were relieved after treatment. This case report can be used to remind clinicians of keeping in mind the potential of clozapine-associated ACDRs.

The skin diseases present in the form of lesions which are limited in number. The diseases with different etiologies manifest into lesions similar in appearance, thus confusing clinicians not trained in recognizing these lesions. Since majority of the doctors are posted in the areas which have limited or no skin centers, the patients are referred to dermatology centers for easily manageable ailments like pityriasis versicolor, pityriasis rosea, scabies, drug reactions etc. This problem is aggravated if the patient is a child. The relevance of this lucidly written colour atlas and text book lies in helping clinicians posted in periphery to diagnose and manage common skin diseases. Professor Weston, one of the pioneers of pediatric dermatology has managed to avoid latin jargon and difficult to pronounce names which is often the bane of non dermatologists. The book has more than 850 illustrations along with relevant information about the disease without going into nitty gritty of speculated theories of etiopathogenesis and drugs in trial phases. This book has been written for primary care physicians who form the first contact between the patient and health services. This atlas and textbook covers almost all the common skin diseases encountred in OPDs and unit MI Room. The problem oriented differential diagnosis index on the front and back cover provides easy access to the information required in an emergency or OPD setting. This accessibility is enhanced by a CD-ROM which accompanies the book, thus it can be viewed on computer as well. Since patient education forms the fountainhead of effective management of any disease, there are “patient education sheets” for various ailments in the CD-ROM. These sheets can be printed and given to the patients along with prescription. The drawbacks of the book are that most of the photographs are of Caucasian skin, therefore one has to use little imagination to use the information in the context of Indian skin. The high cost of the book may prohibit its availability. In nutshell this book will be handy to RMOs, nondermatology specialists in the peripheral hospital, residents and interns.

I dislike the term provider but it does indicate a framework under which medical services may be offered. Let me introduce this commentary by the manner in which I described an incident to Dr. Dobson. A 32-year-old, healthy woman came to my office indicating that during the previous few weeks a "scaly patch" developed around the right side of her neck, which enlarged to the size of a quarter. During the next few weeks, additional, scaly, oval patches developed on her back and chest with slight itching. At the time she had the dermatitis only on the neck, she went to her health maintenance organization (HMO) in the belief that she was seeing a physician but instead saw a physician's assistant who prescribed clotrimazole (Lotrimin) for her "fungus infection" and recommended that the patient not return to work because of her contagious disease. With spread of the skin eruption, this patient returned to the HMO and was seen by a registered nurse who made a diagnosis of chickenpox and advised diphenhydramine hydrochloride (Benadryl) and temporary job disability. Luckily, this patient's pityriasis rosea was self-limited. Unfortunately, this woman lost 4 days from work. My outrage was similar to that which many dermatologists have experienced and Dr. Dobson lamented that this was one among many "horror stories." As I considered this commentary, however, my direction changed considerably. Although a dermatologist would not confuse a herald patch with "ringworm," how many dermatologists make the diagnosis of pityriasis rosea with a herald patch? The nurse's confusion, however, was inexcusable because classifications of skin diseases, blistering versus papulosquamous, were confused and a classical presentation of one type of the latter was present. The crux of the problem, however, was in the training of the provider rather than the delivery system for medical care. What level of education and training is necessary to treat 95% of patients with acne, who comprise 30% of the total practice of clinical dermatology? If

An ll-year-old girl noticed several asymptomatic spots on her abdomen. The eruption spread to the remainder of her trunk and proximal extremities during the next 3 weeks. Physical examination revealed multiple, nonscaling petechiae and ecchymoses oriented along Langer's lines on the neck, trunk, and proximal extremities. Complete blood cell count, prothrombin time, partial thromboplastin! time, 16-variable automated chemistry panel and urinalysis were all normal. Antinuclear antibody, rapid plasma reagin, rickettsial profile, and streptococcal antibody titers were unremarkable. A skin biopsy specimen demonstrated a superficial and mid-dermal perivascular mononuclear cell infiltrate with erythrocyte extravasation, No foci of parakeratosis or spongiosis were seen, and there was no evidence ofvascu

Papulosquamous diseases are a heterogeneous group of disorders whose etiology primarily is unknown. The nosology of these disorders is based on a descriptive morphology of clinical lesions characterized by scaly papules and plaques. The major entities in this group include psoriasis, parapsoriasis (including pityriasis lichenoides et varioliformis acuta), lichen planus, lichen nitidus, lichen striatus, pityriasis rosea, pityriasis rubra pilaris, seborrheic dermatitis, and the Gianotti-Crosti syndrome. Many other conditions may become papulosquamous and should be considered in the differential diagnosis.

This article gives a brief synopsis of the most common dermatologic disorders likely to be encountered by a plastic surgeon. Clinical features and aids to diagnosis are emphasized, along with treatment suggestions and characteristic photographs.