Pityriasis rosea in otherwise asymptomatic confirmed COVID-19–positive patients: A report of 2 cases

Abstract

To the editor: We enjoyed reading the case series on pernio-like eruptions in skin of color and appreciate the awareness the authors brought to this COVID-19–associated manifestation, previously largely documented in Fitzpatrick skin types I and II and darker skin types.1Daneshjou R. Rana J. Dickman M. Yost J.M. Chiou A. Ko J. Pernio-like eruption associated with COVID-19 in skin of color.JAAD Case Rep. 2020; 6: 892-897Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Pityriasis rosea-like manifestations have been reported in COVID-19–positive patients,2Freeman E.E. McMahon D.E. Lipoff J.B. et al.The spectrum of COVID-19-associated dermatologic manifestations: an international registry of 716 patients from 31 countries.J Am Acad Dermatol. 2020; 83: 1118-1129Abstract Full Text Full Text PDF PubMed Scopus (269) Google Scholar, 3Ehsani A.H. Nasimi M. Bigdelo Z. Pityriasis rosea as a cutaneous manifestation of COVID-19 infection.J Eur Acad Dermatol Venereol. 2020; 34: e436-e437Crossref PubMed Scopus (85) Google Scholar, 4Enguix D.M. Nievas M.D. Romero D.T. Pityriasis rosea Gibert type rash in an asymptomatic patient that tested positive for COVID-19.Med Clin (Barc). 2020; 155: 273PubMed Google Scholar though similar published images largely show presentations in lighter skin types.5Lester J. Jia J. Zhang L. Okoye G. Linos E. Absence of images of skin of colour in publications of COVID-19 skin manifestations.Br J Dermatol. 2020; 183: 593-595Crossref PubMed Scopus (72) Google Scholar Here, we present 2 cases of pityriasis rosea in Fitzpatrick types III and IV skin in otherwise asymptomatic COVID-19–positive patients. We hope that they contribute to an accurate diagnosis of COVID-19 manifestations in darker skin types. A 39-year-old woman with no significant medical history presented to her primary care provider with a pruritic rash ongoing for 2 weeks. Dermatology was consulted via teledermatology store-and-forward photographs. The rash initially presented on her abdomen and subsequently spread to her axillae and upper extremities. Review of systems was otherwise unremarkable, and she was afebrile (37°C). She denied new medicines or any sick contacts. The photographs revealed Fitzpatrick type III skin with multiple scattered erythematous patches, some with collarettes of scale, located in a Blaschkoid distribution on the trunk, extremities, and groin without mucosal or acral involvement (Figs 1 and 2). Her clinical presentation was consistent with that of pityriasis rosea. Basic laboratory findings were within normal limits, and rapid plasma reagin testing was nonreactive; however, a polymerase chain reaction test performed for SARS-CoV-2 was positive. She was prescribed 0.1% triamcinolone cream as needed for pruritus. At follow-up 18 days later via teledermatology, she was still asymptomatic for COVID-19, and her rash had nearly resolved except for a few persistent areas on the lower extremities.Fig 2Close-up photograph of erythematous patches with a central collarette of scale located on the right portion of the upper chest.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A 23-year-old woman with no significant medical history presented for urgent care with a 1-week history of an asymptomatic diffuse rash of unknown etiology. Dermatology was consulted via teledermatology store-and-forward photographs. The rash began as a few patches and disseminated after a few days. Review of systems was otherwise negative, and she was afebrile (37.2°C). She denied new medications or known COVID-19 exposures; however, she notably worked in health care, with patient contact. Polymerase chain reaction testing result for SARS-CoV-2 performed 3 weeks prior was negative. The photographs revealed Fitzpatrick type IV skin with scattered, thin, erythematous-to-hyperpigmented plaques and patches with scale on the upper and middle portions of the chest, abdomen, back, and flanks in a Blaschkoid distribution (Figs 3 and 4). Larger patches with visible collarettes of scale led to the clinical diagnosis of pityriasis rosea. Rapid plasma reagin testing was nonreactive, and repeat SARs-CoV-2 testing result was positive. She was prescribed 0.1% triamcinolone ointment as needed for pruritus. The patient relocated and, therefore, has not undergone follow-up examination.Fig 4Photograph of scattered, thin, red-to-hyperpigmented plaques and patches with scale on the left flank in a Blaschkoid distribution.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We hope that our cases help to diversify the available images of the skin manifestations of COVID-19. Additionally, only 2 cases of pityriasis rosea in COVID-19 patients have been published.3Ehsani A.H. Nasimi M. Bigdelo Z. Pityriasis rosea as a cutaneous manifestation of COVID-19 infection.J Eur Acad Dermatol Venereol. 2020; 34: e436-e437Crossref PubMed Scopus (85) Google Scholar,4Enguix D.M. Nievas M.D. Romero D.T. Pityriasis rosea Gibert type rash in an asymptomatic patient that tested positive for COVID-19.Med Clin (Barc). 2020; 155: 273PubMed Google Scholar Our cases highlight the need for SARs-CoV-2 testing in patients presenting with pityriasis rosea-like eruptions, even if otherwise asymptomatic, for appropriate diagnosis and contact tracing. Pernio-like eruption associated with COVID-19 in skin of colorJAAD Case ReportsVol. 6Issue 9PreviewRecently, the skin manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have emerged, with reports and series documenting petechial eruptions, transient livedo reticularis, erythematous rashes, urticaria, primary varicella-like like presentations, and pernio-like eruption.1-5 The pernio-like eruption, colloquially termed COVID toes, appears associated with an otherwise asymptomatic or mildly symptomatic disease course.4,6,7 Full-Text PDF Open Access