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Arch Pediatr Adolesc Med. 2005;159(10):978-979. doi:10.1001/archpedi.159.10.979.
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DENOUEMENT AND DISCUSSION: PITYRIASIS LICHENOIDES ET VARIOLIFORMIS ACUTA

Pityriasis lichenoides is an erythematous, papulosquamous, T-cell–mediated dermatosis.1 Both acute and chronic forms are described and represent the extremes of a continuous spectrum.1 Pityriasis lichenoides et varioliformis acuta (PLEVA) refers to the acute form.

EPIDEMIOLOGY

It is a common disorder. It occurs most often during the second and third decades of life.2 There is a slight male predominance.2

ETIOLOGY AND PATHOGENESIS

An immunologically mediated reaction to an infectious agent is suspected to be the cause because sporadic outbreaks are common, and the disease has been reported to occur simultaneously among family members.2 An infection-mediated cause is also suggested by reports of PLEVA following infection with specific pathogens, by the isolation of specific pathogens coincidental with the disease, and by the presence of elevated serum titers to specific pathogens.2 Epstein-Barr virus, parvovirus, human immunodeficiency virus, group A β-hemolytic streptococci, and Toxoplasma gondii are the organisms most frequently reported in association with PLEVA.35

Monoclonal T-cell receptor gene rearrangements and predominance of CD8+ T cells in the infiltrates have been described in patients with PLEVA.1,5 The dominant T-cell clone might represent a host-immune response to an infectious agent.

CLINICAL MANIFESTATIONS

Pityriasis lichenoides et varioliformis acuta is characterized by the rapid onset of numerous reddish-brown macules and papules that usually evolve into vesicles, pustules, and crusted ulcers. The lesions have a polymorphous appearance, erupt in crops, and are distributed mainly on the trunk and extremities. The face, scalp, mucous membranes, palms, and soles are usually spared. Constitutional symptoms are uncommon. Lesions are usually asymptomatic and resolve in a few weeks to a few months. Rarely, there may be associated fever, malaise, headache, or pruritus.

COMPLICATIONS

Pityriasis lichenoides et varioliformis acuta might be complicated by secondary bacterial superinfection of the lesions, residual scars, or postinflammatory hypopigmentation or hyperpigmentation.

HISTOPATHOLOGY

The epidermal changes include intercellular and intracellular edema, parakeratosis, and exocytosis of lymphocytes and erythrocytes.6 Dermal changes include a diffuse infiltrate, predominantly lymphocytic, which is more pronounced in the perivascular regions.6

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

The diagnosis of PLEVA is based on the distinctive clinical appearance. Histological confirmation is rarely necessary. The differential diagnosis includes pityriasis rosea, guttate psoriasis, Gianotti-Crosti syndrome, leukocytoclastic vasculitis, lymphomatoid papulosis, varicella, secondary syphilis, drug eruption, and insect bites.

TREATMENT

No treatment is necessary for mild and asymptomatic cases. For symptomatic cases, erythromycin in combination with natural sunlight is the recommended treatment. Erythromycin is prescribed for the anti-inflammatory action rather than for the antibiotic effect. Phototherapy with UV-A, UV-B, or psoralen–UV-A should be considered for symptomatic cases that persist notwithstanding treatment with erythromycin.

Correspondence: Alexander K. C. Leung, MD, Suite 200, 233 16th Ave NW, Calgary, Alberta, Canada T2M 0H5 (aleung@ucalgary.ca).

Accepted for Publication: May 31, 2005.

Weinberg  JMKristal  LChooback  L  et al.  The clonal nature of pityriasis lichenoides. Arch Dermatol 2002;1381063- 1067
PubMed
Klein  PAJones  ECNelson  JL  et al.  Infectious causes of pityriasis lichenoides: a case of fulminant infectious mononucleosis. J Am Acad Dermatol 2003;49S151- S153
PubMed
English  JC  IIICollins  MBryant-Bruce  C Pityriasis lichenoides et varioliformis acuta and group-A beta hemolytic streptococcal infection. Int J Dermatol 1995;34642- 644
PubMed
Smith  KJNelson  ASkelton  H  et al.  Pityriasis lichenoides et varioliformis acuta in HIV-1+ patients: a marker of early stage disease. Int J Dermatol 1997;36104- 109
PubMed
Tomasini  DTomasini  CFCerri  A  et al.  Pityriasis lichenoides: a cytotoxic T-cell-mediated skin disorder: evidence of human parvovirus B19 DNA in 9 cases. J Cutan Pathol 2004;31531- 538
PubMed
Patel  DGKihiczak  GSchwartz  RA  et al.  Pityriasis lichenoides. Cutis 2000;6517- 23
PubMed
Pinton  PCCapezzera  RZane  C  et al.  Medium-dose ultraviolet A1 therapy for pityriasis lichenoides et varioliformis acuta and pityriasis lichenoides chronica. J Am Acad Dermatol 2002;47410- 414
PubMed

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References

Weinberg  JMKristal  LChooback  L  et al.  The clonal nature of pityriasis lichenoides. Arch Dermatol 2002;1381063- 1067
PubMed
Klein  PAJones  ECNelson  JL  et al.  Infectious causes of pityriasis lichenoides: a case of fulminant infectious mononucleosis. J Am Acad Dermatol 2003;49S151- S153
PubMed
English  JC  IIICollins  MBryant-Bruce  C Pityriasis lichenoides et varioliformis acuta and group-A beta hemolytic streptococcal infection. Int J Dermatol 1995;34642- 644
PubMed
Smith  KJNelson  ASkelton  H  et al.  Pityriasis lichenoides et varioliformis acuta in HIV-1+ patients: a marker of early stage disease. Int J Dermatol 1997;36104- 109
PubMed
Tomasini  DTomasini  CFCerri  A  et al.  Pityriasis lichenoides: a cytotoxic T-cell-mediated skin disorder: evidence of human parvovirus B19 DNA in 9 cases. J Cutan Pathol 2004;31531- 538
PubMed
Patel  DGKihiczak  GSchwartz  RA  et al.  Pityriasis lichenoides. Cutis 2000;6517- 23
PubMed
Pinton  PCCapezzera  RZane  C  et al.  Medium-dose ultraviolet A1 therapy for pityriasis lichenoides et varioliformis acuta and pityriasis lichenoides chronica. J Am Acad Dermatol 2002;47410- 414
PubMed

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