DOI: 10.1111/pde.

13417

Pediatric
CASE REPORT Dermatology

Geographic tonguelike presentation in a child with pityriasis

rosea: Case report and review of oral manifestations of
pityriasis rosea

Nouf A. Alzahrani MBBS | Mohammed I. AlJasser MBBS

Division of Dermatology, College of

Medicine, King Saud bin Abdulaziz
University for Health Sciences, Riyadh,
Saudi Arabia
Correspondence
Mohammed I. AlJasser, MBBS, Division of
Dermatology, King Saud bin Abdulaziz
University for Health Sciences, Riyadh, Saudi
Arabia.
Email: jasserm@ksau-hs.edu.sa
Abstract
Oral lesions are rarely reported in patients with pityriasis rosea. We report a case of
a 3-year-old boy with clinical evidence of generalized pityriasis rosea who devel-
oped asymptomatic oral lesions similar in appearance to geographic tongue. The
generalized eruption and tongue lesions resolved simultaneously within 4 weeks.
We also review the literature on the oral manifestations of Pityriasis rosea.
KEYWORDS
association, geographic, oral, pityriasis, rosea, tongue

1 | INTRODUCTION
Pityriasis rosea (PR) is a common self-limiting dermatosis that usually
1
affects children and young adults. It most commonly presents as
generalized erythematous oval to round papules and small plaques
involving the trunk and extremities. PR lesions characteristically have
collarette scale and follow the lines of skin cleavage. Diagnosis is
generally made based on the typical clinical findings, but some
patients may present with atypical features,2 including oral lesions,
which are uncommon in patients with PR.1,3 We report a case of a
child with PR who was found to have geographic tonguelike lesions
and review the literature on the oral manifestations of PR.
2 | CASE REPORT
A 3-year-old Middle Eastern boy known to have atopic dermatitis
presented in the spring of 2015 with an asymptomatic skin eruption
for 4 days. It started as a solitary lesion on the trunk followed by
development of a generalized rash. Two days after onset of the rash,
the parents noted two asymptomatic lesions on the tongue. The
patient did not have any history of recent upper respiratory tract
infection, fever, or prodromal symptoms before appearance of skin
lesions. He had not had any oral lesions in the past. He was afebrile
and vitally stable. Cutaneous examination revealed a well-defined
1.5- by 0.5-cm erythematous plaque with collarette scale on the
abdomen and numerous, ill-defined, oval, scaly papules and plaques
involving the trunk and extremities along the skin cleavage lines (Fig-
ure 1A). Examination of the tongue showed two sharply demarcated
oval plaques with regular, raised, white borders and atrophic centers
(Figure 1B). The overall appearance of the tongue lesions was similar
to that of a geographic tongue.
Polymerase chain reaction of a swab taken from the tongue was
negative for herpes simplex virus. The diagnosis of PR was made
based on the characteristic clinical presentation, and a skin biopsy
was not clinically indicated. Guttate psoriasis was clinically excluded
because the lesion morphology was typical of PR and was dis-
tributed along the skin cleavage lines, started with a solitary large
lesion, and occurred in the spring. The patient was started on hydro-
cortisone acetate 1% ointment twice daily on skin lesions. The skin
rash and oral lesions completely resolved within 4 weeks, leaving
mild post-inflammatory skin hyperpigmentation (Figure 2), further
confirming the diagnosis of PR.
3 | DISCUSSION
PR is mostly seen in patients aged 10 to 35 and has a male to female
ratio of 1:1.4.1,4 Cases in children younger than 10 are uncommon,
constituting approximately 6% to 10% of all cases.5,6 PR typically
occurs in the spring and fall and usually disappears spontaneously in 6
to 8 weeks.1 Although no etiology has been proven, several triggers
have been implicated, including human herpes viruses 6 (HHV-6) and
7 (HHV-7), autoimmunity, and some medications.1,6

Pediatric Dermatology. 2018;1–4. wileyonlinelibrary.com/journal/pde © 2018 Wiley Periodicals, Inc. | 1

2 | Pediatric
Dermatology
(A) (B)
(A) (B)
In the classic form, the first and largest lesion to appear is called
the herald patch. This is usually followed by crops of smaller, oval,
scaly, pink papules and plaques with collarette scales distributed
along truncal skin cleavage lines in a “Christmas tree” pattern.1,4
When all these typical features are present, diagnosis is usually made
clinically, but atypical variants can be more challenging to diagnose
and require a high level of suspicion.2 Atypical variants of PR may
display nonclassical features in the morphology, size, distribution,
number, or site of involvement.2
The oral mucosa is considered an atypical site of involvement
that is rarely reported in patients with PR. Features of reported PR
7-14
cases with oral lesions are summarized in Table 1. Oral lesions
appear to be more common in children than adults with PR.5,15,16 In
a study of 31 Caucasian children with PR, 11 (35%) had oropharyn-
5
geal lesions. Oral lesions were less common in patients without a
herald patch. The most common morphology was vesicles, seen in
nine patients (82%). Other types of lesions included papules, pete-
chiae, and strawberry tongue.5
Patients with dark skin are thought to be more likely to have oral
lesions. This was mainly based on two studies of Africans with
PR.11,15 The first study was of 100 Africans with PR in Uganda.11
Fourteen percent had oral manifestations, with punctate
ALZAHRANI AND ALJASSER
F I G U R E 1 A, Pityriasis rosea.
Generalized ill-defined oval erythematous
scaly papules and small plaques following
skin cleavage lines. B, Geographic tongue-
like lesions. Lesions showing regular,
raised, white borders and atrophic
erythematous centers. Note atrophy of
filiform papillae within the erythematous
zone (inset)
F I G U R E 2 Resolution of A, pityriasis
rosea and B, geographic tongue-like lesions
simultaneously within 4 weeks
hemorrhages being the most common. In the second study, 12 (9%)
of 138 Nigerian patients with PR were found to have oral lesions.15
Oral involvement was seen more in children with severe diffuse
cutaneous involvement affecting the face and in those with vesicular
PR.15 Oral lesions affected the buccal mucosa, palate, and lip.
Lesions were of two types: tiny punctate hemorrhages (10 patients)
and superficial erosions (2 patients).15 Vidimos and Camisa found
that 8 (16%) of 50 adults with PR had various asymptomatic oral
lesions, with more than half of the patients being African.16
Persistent PR (lasting >12 weeks) is more commonly associated
with oral involvement.14 Oral findings were noticed in 75% of
patients (9/12 adults) with persistent PR, including petechiae,
papules, erosions, and strawberry tongue.14 All cases of persistent PR
were found to have persistent reactivation of HHV-6 or HHV-7.14
Descriptive statistics were gathered from available data from the
more than 60 reported cases of PR with associated oral lesions.
Approximately 60% of patients were younger than 20, and 42%
were younger than 10; 64% were female and 67% African. The sites
most commonly affected were the buccal mucosa (63%), palate
(46%), tongue (15%), and lips (11%). There appear to be five mor-
phologic categories of oral involvement in PR: petechiae, erosions or
ulcers, vesicles, papules, and strawberry tongue. Petechiae (62%) and
ALZAHRANI AND ALJASSER Pediatric | 3
Dermatology
T A B L E 1 Oral manifestations reported in association with pityriasis rosea
Reference Cases, n Age, years Sex Morphology Site Ethnicity Course
Greenbaum7 1941 4 29; NS Female; All patients had petechiae Buccal Caucasian; Resolved with
for 3 NS for 3 NS for 3 rash within
5 weeks;
NS for 3
Costello8 1946 1 6 Male Small erosions Buccal, palate, tongue, NS NS
floor of mouth
Rosenbaum91951 1 28 Male Pinpoint hemorrhages Palate NS Resolved 5 days
before rash
Kestel10 1968 1 18 Male Plaques with superficial Buccal African Resolved with
erosions rash within
4 weeks
Vollum11 1973 14 NS NS Punctate hemorrhages Buccal African NS
(n 11), small ulcers (n 3)
Jacyk15 1980 12 <10 (n = 8) NS Punctate hemorrhages Buccal, palate, lip African Resolved several
10-20 (n 10), superficial days before
(n = 4) erosions (n 2) rash
Kay3 1985 1 19 Female Aphthous-like ulcers Buccal, palate, lip, tongue African Resolved with
rash within
1 week
Dashore12 1988 1 23 Male Small superficial ulcer Buccal NS Resolved with
rash within
3 weeks
Vidimos16 1992 8 28 Female Erythema Tonsils Caucasian NS
51 Female Erosion Gingiva African
24 Female White annular plaques Palate African
30 Female White papule Gingiva African
33 Male Ulcers Tongue, lip Caucasian
14 Female Ulcers Gingiva Caucasian
30 Female Erosions Palate African
17 Male White papule Palate African
Chuh2 2005 1 26 Female Hemorrhagic ulcers Lip NS Resolved with
rash within
3 weeks
Chuah13 2014 1 24 Male Aphthous ulcers Tongue, lip Asian Recurrent and
persistent but
eventually
resolved with
rash
Drago14 2015 9 31 Male Petechiae Palate, tongue Caucasian NS
34 Female Petechiae, erosions
37 Female Papules, strawberry tongue
25 Male Petechiae, papules
35 Female Petechiae, erosions
21 Male Papules, strawberry tongue
32 Male Petechiae, strawberry tongue
31 Female Petechiae, erosions
30 Female Petechiae, strawberry tongue

(Continues)

erosions or ulcers (29%) are the most common. Fourteen percent of tonsillar erythema and white annular plaques, seen in one patient
lesions were vesicular and 15% papular. Strawberry tongue was each.16 Our analysis was similar to the one performed by Kay and
observed in 9% of patients. Less common presentations included colleagues,3 which showed that the two most frequently reported
4 | Pediatric ALZAHRANI AND ALJASSER
Dermatology
TABLE 1 (Continued)
Reference Cases, n Age, years Sex Morphology Site Ethnicity Course
Drago5 2015 11 6 Female Petechiae, vesicles NS Caucasian Disappeared
9 Female Papules, vesicles simultaneously
with rash in all
7 Female Papules, petechiae children
5 Male Papules, vesicles
9 Female Petechiae, vesicles,
strawberry tongue
9 Female Petechiae, vesicles
6 Female Petechiae, vesicles,
strawberry tongue
9 Female Papules, vesicles
6 Male Petechiae
6 Female Petechiae, vesicles
9 Male Papules, vesicles

NS, not specified.

morphologies were punctate hemorrhages and erosions.3 In most
reported cases, oral lesions resolved simultaneously with resolution
of skin lesions within a few weeks.
Our patient had geographic tongue-like lesions on the tongue,
which have not previously been reported to develop during the
course of PR. Vidimos and Camisa 16
mentioned in their report that
three adults had geographic tongue, but it was present before the
development of PR. Geographic tongue has been reported in associ-
ation with several conditions, including psoriasis, lichen planus,
atopy, stress, juvenile diabetes, and Down syndrome.17 Psoriasis
appears to be the most common cutaneous association, with a
prevalence of up to 18%.18
PR is a common dermatologic disorder with a wide spectrum of
clinical presentations. Oral lesions in PR are uncommon but probably
under-reported. They appear to be seen more in children, individuals
with dark skin, patients with severe cutaneous features, and cases of
persistent PR. Oral involvement is most commonly in the form of
petechiae and erosions or ulcers. We report the first case from the
Middle East with a unique geographic tonguelike presentation. Rec-
ognizing such atypical oral involvement might help physicians in
diagnosing atypical PR in children and avoid unnecessary investiga-
tions. Further observations are required to better characterize PR-
associated oral lesions.
ORCID
Mohammed I. AlJasser http://orcid.org/0000-0003-1759-1057
4. Chuh A, Lee A, Zawar V, Sciallis G, Kempf W. Pityriasis rosea—an
update. Indian J Dermatol Venereol Leprol. 2005;71:311-315.
5. Drago F, Ciccarese G, Broccolo F, Cozzani E, Parodi A. Pityriasis
rosea in children: clinical features and laboratory investigations. Der-
matology. 2015;231:9-14.
6. Drago F, Broccolo F, Rebora A. Pityriasis rosea: an update with a
critical appraisal of its possible herpesviral etiology. J Am Acad Der-
matol. 2009;61:303-318.
7. Greenbaum SS. Oral lesions in pityriasis rosea. Arch Derm Syphilol.
1941;44:55-57.
8. Costello MJ. Pityriasis rosea associated with oral lesions in a child.
Arch Derm Syphilol. 1946;53:73.
9. Rosenbaum MG. Oral lesions in pityriasis rosea. AMA Arch Derm
Syphilol. 1951;63:376-377.
10. Kestel Jr JL. Oral lesions in pityriasis rosea. JAMA. 1968;205:597.
11. Vollum DI. Pityriasis rosea in the African. Trans St Johns Hosp Derma-
tol Soc. 1973;59:269-271.
12. Dashore A, Jain VK, Chaudhry SD. Oral lesions in pityriasis rosea.
Indian J Dermatol Venereol Leprol. 1988;54:140-141.
13. Chuah SY, Chia HY, Tan HH. Recurrent and persistent pityriasis rosea:
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14. Drago F, Broccolo F, Ciccarese G, Rebora A, Parodi A. Persistent
pityriasis rosea: an unusual form of pityriasis rosea with persistent
active HHV-6 and HHV-7 infection. Dermatology. 2015;230:23-26.
15. Jacyk WK. Pityriasis rosea in Nigerians. Int J Dermatol. 1980;19:397-399.
16. Vidimos AT, Camisa C. Tongue and cheek: oral lesions in pityriasis
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17. Assimakopoulos D, Patrikakos G, Fotika C, Elisaf M. Benign migra-
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Med. 2002;113:751-755.
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