Letters to the Editor
544
disease with absence of systemic involvement, a simple surveillance is required. die,1 A. Fauconneau,1 B. Vergier,2 E. Imbert,1 A.-L. Ve re,1 O. Demay,1 C. Larrouy-Midy,1 G. de la Valussie M.-S. Doutre1,* 1
Service de dermatologie, 2Service d’anatomie et cytologie pathologique, ^pital Haut-Le v e ^que, Chu Bordeaux, Avenue de Magellan, Pessac Ho 33604, France *Correspondence: M.-S. Doutre. E-mail: marie-sylvie.doutre@ chu-bordeaux.fr
References 1 Fein H, Steth AP, Mutasim DF. Cutaneous arteritis presenting with hyperpigmented macules: Macular arteritis. J Am Acad Dermatol 2003; 49: 519–522. 2 Lee JS, Kossard S, McGrath MA. Lymphocytic thrombophilic arteritis, a newly described medium-sized vessel arteritis of the skin. Arch Dermatol 2008; 144: 1175–1182. 3 Sadahira C, Yoshida T, Matsuoka Y, Takai I, Noda M, Kubota Y. Macular arteritis in Japanese patients. J Am Acad Dermatol 2005; 52: 364–366. 4 Saleh Z, Mutasim DF. Macular lymphocytic arteritis: a unique benign cutaneous arteritis, mediated by lymphocytes and appearing as macules. J Cutan Pathol 2009; 36: 1269–1274. 5 Shen S, Williams RA, Kelly RI. Neuropathy in a patient with lymphocytic thrombophilic arteritis. Australas J Dermatol 2013; 54: e28–e32. 6 Llamas-Velasco M, Sanchez-Perez J, Fraga J, Garcia-Diez A. Reply: macular lymphocytic arteritis: letter to the Editor. J Cutan Pathol 2014; 41: 481–481. 7 Al-Daraji W, Gregory AN, Carlson JA. Macular arteritis: a latent form of cutaneous polyarteritis nodosa? Am J Dermatopathol 2008; 30: 145–149. 8 Macarenco RS, Galan A, Simoni PM et al. Cutaneous lymphocytic thrombophilic (Macular) arteritis: a distinct entity or an indolent (reparative) stage of cutaneous polyarteritis nodosa ? Report of 2 cases of cutaneous arteritis and review of the literature. Am J Dermatopathol 2013; 35: 213–219. 9 Kossard S, Lee JS, McGrath MA. Macular lymphocytic arteritis. J Cutan Pathol 2010; 37: 1114–1115. DOI: 10.1111/jdv.12941
Vaccine-induced pityriasis rosea and pityriasis rosea-like eruptions: a review of the literature Editor Pityriasis rosea (PR) is an exanthematous disease due to the endogenous systemic reactivation of human herpesvirus-6 (HHV-6) and/or -7 (HHV-7).1 It usually begins with a single, erythematous scaly patch (herald patch) followed in about 2 weeks by smaller lesions on the cleavage lines of the trunk and limbs (Christmas tree distribution).1,2 PR and PR-like eruptions (PR-LE) have rarely been described after vaccinations.3–10 We reviewed the cases of vaccine-induced
JEADV 2016, 30, 446–556
PR reported in literature differentiating typical PR from PR-LE and trying to explain the pathogenetic mechanisms that underlie these conditions. From 1947 to date, 29 cases of PR/PR-LE have been reported after vaccinations for smallpox, tuberculosis, poliomyelitis, influenza, papillomaviruses, diphtheria, tetanus, hepatitis B, pneumococcus, diphtheria-pertussis-tetanus (DTP) and yellow fever3–10 (Table 1). Among these vaccines, the smallpox one was responsible for most of the eruptions (10 patients), followed by the tuberculosis one (5 patients). Unfortunately, based on the available published data, only in 13 cases it was possible to distinguish between PR (10 cases) and PR-LE (3 cases). In fact, virological investigations for search of HHV-6/7 reactivation that are useful to confirm the diagnosis of PR (such as serum viremia), were performed only in three patients. Among the typical PR, the mean patients age was 23 years, whereas it was 44 years in PR-LE; the average time lapse between vaccination and eruption onset was 17 days in PR, whereas it was 5 days in PR-LE and the average exanthem duration was 6 weeks in PR, whereas it was 2 weeks in PR-LE. These data are in agreement with the different clinical features between PR and PR-LE, as reported previously.2 PR-LE may occur after administration of drugs (as captopril, barbiturates, isotretinoin) and show clinical, histopathological and virological differences with respect to PR: the lesions are more itchy, diffuse and confluent and the mucose membranes may be more frequently involved; there is not the herald patch and patients never experienced prodromal symptoms that are common in classic PR. Different from PR, in PR-LE blood eosinophilia and dermal eosinophils at histopathology may be found and, notably, there are no signs of HHV-6/7 systemic reactivation.2 The precise pathogenetic mechanism leading to PR after a vaccination is unknown. It could be hypothesized that the vaccine, eliciting a specific immune response against a definite infectious agent, and elevating the amount of plasma cytokines, may distract the T-cell-mediated control on the latent infections, such as HHV-6/7, which may reactivate. Conversely, PR-LE may occur as a hypersensitivity delayed response to a vaccine, as may happen with a drug. Another possible mechanism is the molecular mimicry with a viral epitope that could result in a T-cell-mediated skin reaction. In fact, in our experience on drug-induced PR-LE we did not find any signs of HHV-6/7 reactivation, neither in plasma nor in skin, different from typical PR.2 Moreover, in paediatric patients we should consider a temporal relationship between the vaccines of the vaccination schedule and PR/PR-LE. In conclusion, further studies, including clinical and virological investigations, in both paediatric and adult patients are needed to achieve the exact amount of vaccine-induced PR/PR-LE. To distinguish between PR and PR-LE is of paramount importance, especially in cases of multi-dose vaccines. In fact, when a
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
545
Table 1 Cases of vaccine-induced PR/PR-like eruptions described in literature. Vaccination
Number of patients
Smallpox
10
Tuberculosis
5
Poliomyelitis
4
Influenza
2
Papillomavirus
2
Patient’s age (years)
Time between vaccination and onset of PR
Exanthem duration
Typical/PR-like PR
Reference number
51
10 days
Not reported
ND
7
18
4 weeks
12 weeks
ND
7
27
4 weeks
6 weeks
ND
7
60
11 days
Not reported
ND
7
45
10 days
4 weeks
ND
7
28
4 weeks
10 weeks
ND
7
30
1 week
Not reported
ND
7
24
1 week
2 weeks
PR
3
18
1 week
4 weeks
PR
3
33
11 days
1 week
PR-like
6
Not reported
4 weeks
Not reported
ND
8
Not reported
NR
Not reported
ND
8
Not reported
2 weeks
Not reported
ND
8
12
6 days
6 weeks
PR
5
60
1 day
6 weeks
PR-like
3
Not reported
4 weeks
Not reported
ND
8
Not reported
4 weeks
Not reported
ND
8
Not reported
4 weeks
Not reported
ND
8
Not reported
NR
Not reported
ND
8
25
5 days
2 weeks
PR
3
71
4 weeks
12 weeks
PR
9
17
4 weeks
8 weeks
PR
4
20
8 weeks
8 weeks
PR
4 8
Diphtheria
1
Not reported
2 weeks
Not reported
ND
Tetanus
1
Not reported
6 weeks
Not reported
ND
8
Hepatitis B
1
38
2 days
5 days
PR-like
3
Pneumococcus
1
8
2 weeks
2 weeks
PR
3
Yellow fever
1
30
2 weeks
6 weeks
PR
10
Diphtheria, pertussis, tetanus
1
4
3 days
4 weeks
PR
3
PR, pityriasis rosea; PR-like, pityriasis rosea-like; ND, not distinguishable.
vaccine-induced PR is diagnosed, the patient may cautiously receive the other vaccine doses, whereas in cases of vaccineinduced PR-LE it is preferable to avoid administration of other vaccine doses since more dangerous reactions may develop. F. Drago, G. Ciccarese,* S. Javor, A. Parodi Department of Dermatology, IRCCS A.O.U. San Martino-IST, DISSAL, Largo Rosanna Benzi 10, Genoa 16132, Italy *Correspondence: G. Ciccarese. E-mail: [email protected]
References 1 Broccolo F, Drago F, Careddu AM, et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpesvirus-6 and-7. J Invest Dermatol 2005; 124: 1234–1240. 2 Drago F, Ciccarese G, Rebora A, et al. Pityriasis rosea and pityriasis rosealike eruption: can they be distinguished? J Dermatol 2014; 41: 864–865. 3 Chen JF, Chiang CP, Chen YF, et al. Pityriasis rosea following influenza (H1N1) vaccination. J Chin Med Assoc 2011; 74: 280–282.
JEADV 2016, 30, 446–556
4 Drago F, Ciccarese G, Rebora A, et al. PR following HPV vaccination. Braz J Infect Dis 2014; in press. 5 Kaplan B, Grunwald MH, Halevy S. Pityriasis rosea-like eruption associated with BCG vaccination. Isr J Med Sci 1989; 25: 570–572. 6 Gaertner EM, Groo S, Kim J. Papular spongiotic dermatitis of smallpox vaccination. Arch Pathol Lab Med 2004; 128: 1173–1175. 7 Curth HO, Curth W, Garb J. Cutaneous complications of mass vaccination in New York City, 1947. J Invest Dermatol 1948; 11: 167. 8 Bjornberg A, Hellgren L. Pityriasis rosea. A statistical, clinical, and laboratory investigation of 826 patients and matched healthy controls. Acta Derm Venereol Suppl (Stockh) 1962; 42(Suppl. 50): 1–68. 9 Papakostas D, Stavropoulos PG, Papafragkaki D, et al. An atypical case of pityriasis rosea gigantea after influenza vaccination. Case Rep Dermatol 2014; 6: 119–123. 10 Brzezinski P, Chiriac A. Uncommon presentation of pityriasis rosea after yellow fever inoculation. JAMA Dermatol 2014; 150: 1020–1021. DOI: 10.1111/jdv.12942
© 2014 European Academy of Dermatology and Venereology
544
disease with absence of systemic involvement, a simple surveillance is required. die,1 A. Fauconneau,1 B. Vergier,2 E. Imbert,1 A.-L. Ve re,1 O. Demay,1 C. Larrouy-Midy,1 G. de la Valussie M.-S. Doutre1,* 1
Service de dermatologie, 2Service d’anatomie et cytologie pathologique, ^pital Haut-Le v e ^que, Chu Bordeaux, Avenue de Magellan, Pessac Ho 33604, France *Correspondence: M.-S. Doutre. E-mail: marie-sylvie.doutre@ chu-bordeaux.fr
References 1 Fein H, Steth AP, Mutasim DF. Cutaneous arteritis presenting with hyperpigmented macules: Macular arteritis. J Am Acad Dermatol 2003; 49: 519–522. 2 Lee JS, Kossard S, McGrath MA. Lymphocytic thrombophilic arteritis, a newly described medium-sized vessel arteritis of the skin. Arch Dermatol 2008; 144: 1175–1182. 3 Sadahira C, Yoshida T, Matsuoka Y, Takai I, Noda M, Kubota Y. Macular arteritis in Japanese patients. J Am Acad Dermatol 2005; 52: 364–366. 4 Saleh Z, Mutasim DF. Macular lymphocytic arteritis: a unique benign cutaneous arteritis, mediated by lymphocytes and appearing as macules. J Cutan Pathol 2009; 36: 1269–1274. 5 Shen S, Williams RA, Kelly RI. Neuropathy in a patient with lymphocytic thrombophilic arteritis. Australas J Dermatol 2013; 54: e28–e32. 6 Llamas-Velasco M, Sanchez-Perez J, Fraga J, Garcia-Diez A. Reply: macular lymphocytic arteritis: letter to the Editor. J Cutan Pathol 2014; 41: 481–481. 7 Al-Daraji W, Gregory AN, Carlson JA. Macular arteritis: a latent form of cutaneous polyarteritis nodosa? Am J Dermatopathol 2008; 30: 145–149. 8 Macarenco RS, Galan A, Simoni PM et al. Cutaneous lymphocytic thrombophilic (Macular) arteritis: a distinct entity or an indolent (reparative) stage of cutaneous polyarteritis nodosa ? Report of 2 cases of cutaneous arteritis and review of the literature. Am J Dermatopathol 2013; 35: 213–219. 9 Kossard S, Lee JS, McGrath MA. Macular lymphocytic arteritis. J Cutan Pathol 2010; 37: 1114–1115. DOI: 10.1111/jdv.12941
Vaccine-induced pityriasis rosea and pityriasis rosea-like eruptions: a review of the literature Editor Pityriasis rosea (PR) is an exanthematous disease due to the endogenous systemic reactivation of human herpesvirus-6 (HHV-6) and/or -7 (HHV-7).1 It usually begins with a single, erythematous scaly patch (herald patch) followed in about 2 weeks by smaller lesions on the cleavage lines of the trunk and limbs (Christmas tree distribution).1,2 PR and PR-like eruptions (PR-LE) have rarely been described after vaccinations.3–10 We reviewed the cases of vaccine-induced
JEADV 2016, 30, 446–556
PR reported in literature differentiating typical PR from PR-LE and trying to explain the pathogenetic mechanisms that underlie these conditions. From 1947 to date, 29 cases of PR/PR-LE have been reported after vaccinations for smallpox, tuberculosis, poliomyelitis, influenza, papillomaviruses, diphtheria, tetanus, hepatitis B, pneumococcus, diphtheria-pertussis-tetanus (DTP) and yellow fever3–10 (Table 1). Among these vaccines, the smallpox one was responsible for most of the eruptions (10 patients), followed by the tuberculosis one (5 patients). Unfortunately, based on the available published data, only in 13 cases it was possible to distinguish between PR (10 cases) and PR-LE (3 cases). In fact, virological investigations for search of HHV-6/7 reactivation that are useful to confirm the diagnosis of PR (such as serum viremia), were performed only in three patients. Among the typical PR, the mean patients age was 23 years, whereas it was 44 years in PR-LE; the average time lapse between vaccination and eruption onset was 17 days in PR, whereas it was 5 days in PR-LE and the average exanthem duration was 6 weeks in PR, whereas it was 2 weeks in PR-LE. These data are in agreement with the different clinical features between PR and PR-LE, as reported previously.2 PR-LE may occur after administration of drugs (as captopril, barbiturates, isotretinoin) and show clinical, histopathological and virological differences with respect to PR: the lesions are more itchy, diffuse and confluent and the mucose membranes may be more frequently involved; there is not the herald patch and patients never experienced prodromal symptoms that are common in classic PR. Different from PR, in PR-LE blood eosinophilia and dermal eosinophils at histopathology may be found and, notably, there are no signs of HHV-6/7 systemic reactivation.2 The precise pathogenetic mechanism leading to PR after a vaccination is unknown. It could be hypothesized that the vaccine, eliciting a specific immune response against a definite infectious agent, and elevating the amount of plasma cytokines, may distract the T-cell-mediated control on the latent infections, such as HHV-6/7, which may reactivate. Conversely, PR-LE may occur as a hypersensitivity delayed response to a vaccine, as may happen with a drug. Another possible mechanism is the molecular mimicry with a viral epitope that could result in a T-cell-mediated skin reaction. In fact, in our experience on drug-induced PR-LE we did not find any signs of HHV-6/7 reactivation, neither in plasma nor in skin, different from typical PR.2 Moreover, in paediatric patients we should consider a temporal relationship between the vaccines of the vaccination schedule and PR/PR-LE. In conclusion, further studies, including clinical and virological investigations, in both paediatric and adult patients are needed to achieve the exact amount of vaccine-induced PR/PR-LE. To distinguish between PR and PR-LE is of paramount importance, especially in cases of multi-dose vaccines. In fact, when a
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
545
Table 1 Cases of vaccine-induced PR/PR-like eruptions described in literature. Vaccination
Number of patients
Smallpox
10
Tuberculosis
5
Poliomyelitis
4
Influenza
2
Papillomavirus
2
Patient’s age (years)
Time between vaccination and onset of PR
Exanthem duration
Typical/PR-like PR
Reference number
51
10 days
Not reported
ND
7
18
4 weeks
12 weeks
ND
7
27
4 weeks
6 weeks
ND
7
60
11 days
Not reported
ND
7
45
10 days
4 weeks
ND
7
28
4 weeks
10 weeks
ND
7
30
1 week
Not reported
ND
7
24
1 week
2 weeks
PR
3
18
1 week
4 weeks
PR
3
33
11 days
1 week
PR-like
6
Not reported
4 weeks
Not reported
ND
8
Not reported
NR
Not reported
ND
8
Not reported
2 weeks
Not reported
ND
8
12
6 days
6 weeks
PR
5
60
1 day
6 weeks
PR-like
3
Not reported
4 weeks
Not reported
ND
8
Not reported
4 weeks
Not reported
ND
8
Not reported
4 weeks
Not reported
ND
8
Not reported
NR
Not reported
ND
8
25
5 days
2 weeks
PR
3
71
4 weeks
12 weeks
PR
9
17
4 weeks
8 weeks
PR
4
20
8 weeks
8 weeks
PR
4 8
Diphtheria
1
Not reported
2 weeks
Not reported
ND
Tetanus
1
Not reported
6 weeks
Not reported
ND
8
Hepatitis B
1
38
2 days
5 days
PR-like
3
Pneumococcus
1
8
2 weeks
2 weeks
PR
3
Yellow fever
1
30
2 weeks
6 weeks
PR
10
Diphtheria, pertussis, tetanus
1
4
3 days
4 weeks
PR
3
PR, pityriasis rosea; PR-like, pityriasis rosea-like; ND, not distinguishable.
vaccine-induced PR is diagnosed, the patient may cautiously receive the other vaccine doses, whereas in cases of vaccineinduced PR-LE it is preferable to avoid administration of other vaccine doses since more dangerous reactions may develop. F. Drago, G. Ciccarese,* S. Javor, A. Parodi Department of Dermatology, IRCCS A.O.U. San Martino-IST, DISSAL, Largo Rosanna Benzi 10, Genoa 16132, Italy *Correspondence: G. Ciccarese. E-mail: [email protected]
References 1 Broccolo F, Drago F, Careddu AM, et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpesvirus-6 and-7. J Invest Dermatol 2005; 124: 1234–1240. 2 Drago F, Ciccarese G, Rebora A, et al. Pityriasis rosea and pityriasis rosealike eruption: can they be distinguished? J Dermatol 2014; 41: 864–865. 3 Chen JF, Chiang CP, Chen YF, et al. Pityriasis rosea following influenza (H1N1) vaccination. J Chin Med Assoc 2011; 74: 280–282.
JEADV 2016, 30, 446–556
4 Drago F, Ciccarese G, Rebora A, et al. PR following HPV vaccination. Braz J Infect Dis 2014; in press. 5 Kaplan B, Grunwald MH, Halevy S. Pityriasis rosea-like eruption associated with BCG vaccination. Isr J Med Sci 1989; 25: 570–572. 6 Gaertner EM, Groo S, Kim J. Papular spongiotic dermatitis of smallpox vaccination. Arch Pathol Lab Med 2004; 128: 1173–1175. 7 Curth HO, Curth W, Garb J. Cutaneous complications of mass vaccination in New York City, 1947. J Invest Dermatol 1948; 11: 167. 8 Bjornberg A, Hellgren L. Pityriasis rosea. A statistical, clinical, and laboratory investigation of 826 patients and matched healthy controls. Acta Derm Venereol Suppl (Stockh) 1962; 42(Suppl. 50): 1–68. 9 Papakostas D, Stavropoulos PG, Papafragkaki D, et al. An atypical case of pityriasis rosea gigantea after influenza vaccination. Case Rep Dermatol 2014; 6: 119–123. 10 Brzezinski P, Chiriac A. Uncommon presentation of pityriasis rosea after yellow fever inoculation. JAMA Dermatol 2014; 150: 1020–1021. DOI: 10.1111/jdv.12942
© 2014 European Academy of Dermatology and Venereology
