Original Article

Treatment of Pityriasis Rosea With Erythromycin and

Prednisolone: A Comparative Study
Ali S. Salloom1, Mohammed J.E. Ahmed2, Nameer K. Al-Sudany3
MBChB, FICMS. Babil Health Directorate, Mahawil General Hospital. [email protected]
1

2
MBChB, CABMS. Al Yarmouk teaching Hospital. [email protected]
3
FICMS, CABMS, DDV. Ibn Sina University for Medical and Pharmaceutical Sciences. [email protected]
Corresponding Email: [email protected]

Abstract
Background: Pityriasis rosea is a common dermatological eruption which is self-limiting with unknown etiology. Many therapeutic
agents have been suggested for its treatment but none of them has gained a uniform consensus. Objective: To assess the efficacy
of erythromycin and prednisolone in reducing the duration of PR. Methods: This is a systematic open placebo-controlled study
and a comparative therapeutic trial conducted through the period from September 2008 to September 2009 in the Department
of Dermatology and Venereology at the Al-Yarmouk Teaching Hospital. Total 75 patients were included in this study and their
demographic information and history of disease, drug and family was recorded. Skin examination was conducted with focus on the
distribution and morphology of the lesions. The patients presented within two weeks of the appearance of their rash were included
and were divided into three groups (25 patients in each group). In group I, adult patients were given erythromycin capsules 250
mg for 4 times per day and children were given erythromycin syrup 25mg/kg in 4 doses/day. Adult patients in group II were
given prednisolone tablets 20mg in two doses daily whereas its 0.5mg a day (2 doses) were given to children. Group III was a
placebo group which received glucose capsules (100mg) four times daily. The duration of treatment was two weeks and every
patient was seen at presentation and asked to attend for evaluation every two weeks until complete disappearance of rash. Results:
In total, 75 patients completed this study of which 44 (58.67%) were females while 31 (41.33%) were males. The mean age of all
patients was 19.19±13.75 years. After two weeks of treatment, the results showed that in erythromycin group, the symptoms got
cleared in 76% of patients at the end of the two weeks as compared to prednisolone group (36%; P=0.005) and placebo group
(12%; P=0.0000064). Prednisolone was found better than placebo with a significant statistical difference (p-value=0.05). The
rash disappeared in 88% & 100% of erythromycin-treated patients, 60% & 84% of prednisolone-treated patients and 24% &
64% in placebo group patients at the end of four and six weeks of therapy respectively. Average number of days for PR to clear
in erythromycin-treated patients was 16.32±8.74 days and in prednisolone-treated patients, it was 26.8±14.69. While in placebo
group, it was 38.8±14.29 (P=0.001). Timing of initiation of treatment, whether it was started within the first week or the second
week, showed minor impact on the course of PR in all therapeutic groups (P=0.26, 0.87 and 0.47 for erythromycin, prednisolone
and placebo group respectively). Conclusions: Both erythromycin and prednisolone are found effective in reducing the duration
of PR; however, erythromycin was found superior to prednisolone.

Keywords: pityriasis rosea, erythromycin, prednisolone

INTRODUCTION pattern.[1]
The term pityriasis rosea (PR) means pink scales. It is
a common, self-limited, acute dermatological eruption Address for Correspondence: MBChB, CABMS. Al Yarmouk teaching
Hospital. [email protected]
which typically starts as a single oval or rounded scaly Email: [email protected]
plaque on the trunk. Also, smaller daughter lesions along Submitted: 01st August, 2022 Received: 06th August, 2022
the cleavage lines of the trunk appear in Christmas tree Accepted: 23rd August, 2022 Published: 22nd September, 2022

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DOI: How to cite this article: Salloom A S., Ahmed M J.E., Al-Sudany N K.
10.4103/jnsbm.JNSBM_13_2_3 Treatment of Pityriasis Rosea With Erythromycin and Prednisolone: A
Comparative Study. J Nat Sc Biol Med 2022;13:102-109

© 2022 Journal of Natural Science, Biology and Medicine | Published by Wolters Kluwer - Medknow 102
 Treatment of Pityriasis Rosea With Erythromycin and Prednisolone: A Comparative Study

Probably, Robert Willan was the first one who described The severity of itching is variable i.e. it is severe in 25%
PR in 1798.[2] of patients, slight to moderate in 50% and absent in 25%.
Minority of PR patients have flu-like illness which is
Epidemiology associated with fever and malaise, headache, joint pain
Pityriasis rosea occurs in all races, and is relatively
and decrease of appetite.[1] Around 69% of the patients
common throughout the world.[1] Its bimodal distribution
show constitutional symptoms[32] while nearly 20% are
is reported in Brazil and Singapore.[3,4] However, some
presented with atypical symptoms.[1] These atypical
studies show no variation in different seasons.[5,6] A study
clinical signs include primary plaque[1], generalized PR[11],
reported its incidence as 0.68 per 100 dermatological
unilateral PR[33], localized PR[34], pityriasis rosea inversa[35],
diseased patients.[7] A community-based study reported
vesicular PR[34], pustular PR[11], urticarial PR[34], purpuric
its incidence as 172.2 per 100.000 person per year.[8]
PR[34], erythema multiforme[36], pityriasis rosea irritate
The disease is more frequent in Africa i.e. about 2% of [7]
and pityriasis rosea gigantia of darier.[7]
all patients examined, however, high variations have
been seen ranging from 2.6% in South Africa to 0.5% in Differential diagnosis of this disease include secondary
Kenya.[9] Although the female: male ratio is 1.5:1,[8] yet, syphilis[1], superficial tinea,[1,34] seborrheic dermatitis[11],
some studies did not find statistically significant variation erythema dyschromicum perstans (Ashy dermatosis)
between both sexes.[10] [34]
, guttate psoriasis[1] and pityriasis lichenoides.[1,11]
Moreover, pityriasis alba[34], viral exanthem[37], tinea
Mostly, the disease is prevalent in patients of age between
versicolor[37], gianoti crosti syndrome[34], erythema
10-35 years, however, it may also occur in infants and in
multiforme[34], urticaria[11], lichen Planus[11] and scabies
the ninth decade of life.[11]
Are also included.(38)
Etiology Treatment
Although the etiology of disease is uncertain, yet so
Erythromycin[38,39] is a bacteriostatic macrolide which is
many clinical and epidemiological features may suggest
used in treating the symptoms of PR. It interferes with
an infective cause.[11] The powerful evidence against the
protein synthesis of bacteria by binding reversibly with
infectious cause is absence of an infectious agent which
50s unit of the ribosome.[40] It shows efficacy against
might be involved in the etiopathogenesis of the disease.[12]
intracellular pathogens by accumulating in macrophages
Some studies also suggest that PR is a viral exanthem that
and leukocytes. It also has immunomodulatory and anti-
is associated with reactivation of HHV-7 and/or HHV-6.[13-
inflammatory efficacy which explains its effect in treatment
15]
Eruptions like PR are also seen in many neoplasms[16-18]
of PR[7] Other than this, acyclovir[41-43] and phototherapy
and bone-marrow transplantation.[19] Moreover, there are
may also benefit patients with PR.[37,44]
drugs which cause PR like eruptions.[11,16,20-29]
Similarly, glucocorticoid which is an oral steroid, is also
Pathogenesis used for treatment of PR.[34] However, some studies have
Examination under electron microscope shows that these reported PR to become worse or even erythrodermic
virions are similar to HHV7. The presence of HHV7 close with its use.[45] Glucocorticoid works by passive diffusion
to the blood vessels in epidermis and dermis depicts that of drug through the cell followed by binding to soluble
the virus may invades the extravascular dermal spaces protein receptor in the cytoplasm.[46] Also, steroid reduces
and cause damage to dermal and epidermal tissues either the synthesis of many pro-inflammatory compounds such
directly or by interaction with the immune system.[30] as ILs, cytokines, proteases and adhesion molecules.
Additionally, DNA of HHV6 and HHV7 is found in [47]
It also effects the division and migration of many
sera of PR patients. Also, their antigens are detected by cells like eosinophils, lymphocytes and monocytes.
using immunohistochemistry and in situ hybridization [48]
Likewise, cell apoptosis may also be triggered by
which confirms the replicative cycle of virus. All those glucocorticoid which can cause lymphocytopenia. [49]s
findings suggest presence of viral infection at least in Glucocorticoid therapy can not only cause leukocytosis
the acute stages of disease.[14,15] HHV7 acts as a primer due to demargination of WBCs from bone marrow[50] but
that provides a transactivating action in the reactivation also inhibition of neutrophil apoptosis.[51] In addition,
of latent HHV 6,[14,31] leading to the impaired detection this therapy also modulates inflammatory processes
of HHV7 in PCR test. This is the reason that HHV6 is such as inhibitory effect on IL1, IL2, IL6 and TNF.[52,53]
detected in skin and many of the body tissues while Additionally, phagocytosis and antigen processing cells
HHV7 is not detected.[31] (macrophages) are inhibited by glucocorticoid[54,55] which
directly affects immediate and delayed hypersensitivity.
Clinical Features
The PR eruption shows a constant course and pattern in Side effects of systemic corticosteroid include pseudotumor
about 80% of cases.[11] In classical presentation, patients cerebri and other psychiatric disorders, skeletal
experience a single truncal patch followed by multiple complications such as myopathy, aseptic bone necrosis,
smaller lesions on the trunk after several days or weeks. fracture and osteoporosis. Cataract with glaucoma is also

Journal of Natural Science, Biology and Medicine ¦ Volume 13 ¦ Issue 2 ¦ January-December 2022 103
 Treatment of Pityriasis Rosea With Erythromycin and Prednisolone: A Comparative Study

a complication of cortisol therapy. GIT complications disappearance of the rash. Patients were clearly acquainted
like chronic pancreatitis and perforation and CVS about the disease and its therapy and their consent was
complications like HT, retention of fluid and sodium gained. Also, ethical approval of this study was obtained
andatherosclerosis can also occur. In addition, it can cause from the Ethical Committee of the Scientific Council
dermatological complications like urticaria, anaphylaxis, of Dermatology, Venereology. Iraqi Board for Medical
suppression of hypothalamic-pituitary-adrenal axis, Specialization.
growth failure and secondary amenorrhea.[56]
Statistical Analysis: Statistical analyses were done through
Study aim descriptive and analytic statistics by using Chi-square
To evaluate the effectiveness of erythromycin and and ANOVA considering p-value ≤ 0.05 as significant.[57]
prednisolone in reducing the duration of pityriasis rosea.

Methodology RESULTS
Total 98 patients were recruited in the study, however,
It is a systematic open placebo-controlled and comparative
due to unknown reasons, 75 patients continued with
therapeutic trial study. Total 98 patients were recruited
it. Of these, 44 (58.67%) patients were females and 31
in the study initially, however, 24 of them were dropped
(41.33%) were males and female to male ratio was 1.42:1.
from the study due to unknown reasons and only 75
The mean age of patients was 19.19±13.75 years. Patients
patients continued. The study was conducted in the
in the second decade of their life were the most common
Department of Dermatology, Venereology in Al Yarmouk
age group involved as shown in Figure1 And their age
Teaching Hospital through the period from September
and gender distribution in different therapeutic groups
2008 - September 2009.
is presented in Table 1.
A detailed history of patients was recorded and included
their age, sex, occupation, residence (urban or rural),
season of disease onset, duration at presentation, chief
complaint and other associated symptoms. In addition,
their drug history, previous treatments and personal and/
or family history for such similar conditions was also
obtained. Physical examination was done for every patient
with focus on the type, distribution and number of lesions.
Also all patients were sent to VDRL to exclude syphilis.

Patients were divided into 3 categories (25 individuals in Figure (1): Age and sex distribution of patients with
each): group I patients were given 250mg of erythromycin Pityriasis Rosea.
ethyl succinate (erythromycin, SDI, Samarra, Iraq)
capsules 4 times per daily for adults and 25mg/kg Table 1: Age and sex distribution of PR patients with
erythromycin ethyl succinate syrup (erythromycin, SDI, each therapeutic category.
Samarra, Iraq) four times per day for children for 14 days. Parameter Erythromycin Prednisolone Placebo
Group II patients were given prednisolone (prisolone, SDI, Age
Samarra, Iraq) tablets (10mg) twice daily for adults and Range 4-50 3-51 4-59
Mean 19.08±13.25 18.08±12.60 22.8±15.36
0.5mg/kg twice/day for children for two weeks. Group III
Gender
patients were given glucose capsules 100mg (as placebo)
Male 10(40%) 10(40%) 11(44%)
four times daily for two weeks. Female 15(60%) 15(60%) 14(56%)

Exclusion Criteria Total 55 (73.33%) patients resided in urban areas,

The patients with the following conditions were excluded whereas 20 (26.67%) were residents of rural areas
from this study: (Figure 2). Additionally, more than half of the cases had
their onset of disease in autumn and spring (Figure 3).
1. Duration at presentation was more than two weeks.
2. Patients with diabetes mellitus or hypertension.
3. Patients with previous drug intake in the last
two weeks prior to rash appearance especially
corticosteroids, antihistamines and drugs which can
cause PR-like eruption.
4. Pregnant women.
5. Immunocompromised patients.
Every patient was observed at presentation and was asked Figure (2): Distribution of PR cases in Urban and
to attend for evaluation every two weeks until complete Rural areas

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 Treatment of Pityriasis Rosea With Erythromycin and Prednisolone: A Comparative Study

Table 5: PR rash clearance at the end of six weeks.

Group Cleared / Total % Chi-square (x2) P-value
8.67 0.0016*
Erythromycin 25/25 100
2.45 0.1†
Prednisolone 21/25 84 2.55 0.11**
Placebo 16/25 64 11.35 0.0034***
*Erythromycin & Placebo
Figure 3: Distribution of PR cases according to the
**Prednisolone & Placebo
season’s onset. †Erythromycin & Prednisolone
No family history of PR was reported among patients at *** Erythromycin, Prednisolone & Placebo
the time of presentation. With respect to the type of PR,
The mean duration of PR rash from the start of the
most patients had classical rash (84%), whereas about
treatment to the total disappearance of the lesions was
16% of patients were presented with atypical forms of
16.32 ±8.74 days in erythromycin group, 26.8±14.69
PR (Table 2).
days in prednisolone group and 38.8±14.29 days in
Table 2: Distribution of cases according to clinical placebo group (Table 6).
types of PR.
Type of PR No. of Cases Percentage (%) Table 6: Average number of days for PR rash to clear.
Classical 63 84 Therapeutic Mean duration of
Atypical 12 16 ANOVA (F-test), p-value
group rash
Generalized 4 33.33 Erythromycin 16.32±8.74
Inversed 2 16.67 Prednisolone 26.8±14.69 19.12,
Double Herald 2 16.67 Placebo 38.8±14.29 0.0000001
Localized 1 8.33
Vesicular 1 8.33 Regarding the effectiveness of treatment in each group,
EM- Like 1 8.33
the patients who were presented within the 1st week of
Irritative 1 8.33
Total 75 100 rash appearance and who received erythromycin, their
rash was cleared in 14.3±9.4 days. On the other hand,
Total 28% patients (n=21), in the present study had those who were presented within 8-14 days, their rash
history of pruritus. Regarding therapeutic outcomes, got disappeared within 18.34±8.44 days. While in
among the patients who received erythromycin, 76% prednisolone group, the rash required 26.3±15.37 days
of them (n=19) showed the best results with complete to clear if treated in the first week whereas it needed
clearance of the rash by the end of fourteen days. 27.3±14.1 days to disappear if treated in the second
Whereas, prednisolone was found less effective but week. Regarding placebo group, those who presented
better than placebo (Table3). The results of follow up at in the first week of their disease, the rash abolished in
the end of 4th and 6th weeks are shown in Tables 4 and 36.7±14.56 days, while those who were presented in
5 respectively. the second week, their rash took 40.9±14.2 days to get
cleared (Table 7). Moreover, no significant side effects
Table 3: PR rash clearance at the end of two weeks. were reported in any of the therapeutic groups.
Group Cleared/Total % Chi-square (x2) P-value
20.36 0.0000064* Table 7: Average number of days for illness to clear
Erythromycin 19/25 76 according to time of treatment commencement.
7.95 0.005†
Prednisolone 9/25 36 3.87 0.05 ** No. of days No. of days
Therapeutic
Placebo 3/25 12 21.55 0.00002*** (treatment started (treatment started Total
Group
*Erythromycin & Placebo in 1st week) in 2nd week)
**Prednisolone & Placebo Erythromycin 14.3±9.4 18.34±8.44 16.32
†Erythromycin & Prednisolone Prednisolone 26.3±15.37 27.3±14.1 26.8
*** Erythromycin, Prednisolone & Placebo Placebo 36.7±14.56 40.9±14.2 38.8

DISCUSSION
Table 4: PR rash clearance at the end of four weeks. This study was designed to assess two therapeutic agents
Group Cleared/Total % Chi-square (x2) P-value (erythromycin and prednisolone) in cutting short the
20.36 0.0000064* duration of PR. The ages of study participants ranged
Erythromycin 22/25 88
4.99 0.025†
Prednisolone 15/25 60 6.52 0.01**
from 3-59 years with second decade as the most common
Placebo 6/25 24 21.04 0.000027*** age group. This age group is in accordance with a study
*Erythromycin & Placebo which showed that top incidence of this disease occurs in
**Prednisolone & Placebo between 10-35 years old patients.[11] Female:male proportion
†Erythromycin & Prednisolone in current study is 1.42:1 which coincides with other
*** Erythromycin, Prednisolone & Placebo studies,[7,8] whereas there are studies which found equal

Journal of Natural Science, Biology and Medicine ¦ Volume 13 ¦ Issue 2 ¦ January-December 2022 105
 Treatment of Pityriasis Rosea With Erythromycin and Prednisolone: A Comparative Study

sex ratio.[10] Another study reported female to male ratio and even cause erythroderma.[56] Whereas in present
in this disease as 1:2.2-3.[58] Clinically, PR was found in study, prednisolone was found effective in PR and no
only 28% of cases under study, whereas in another study, exacerbation of PR was encountered in any of the patients.
the disease was found in 75% of patients.[1] With respect
to the clinical types of PR, the classical variety was the Timing of initiation of treatment, whether it has been
most common (84%) which is somewhat similar to a started within the first week or the second week,
study which reported about 80% of cases as classical.[11] showed minor impact on the course of PR in all study
groups (p-value=0.26, 0.87 and 0.47 for erythromycin,
Despite the cause of PR is not completely known, many prednisolone and placebo group respectively). These
studies have reported the use of antibiotics in the treatment results may be attributed to the limited number of cases
of PR for e.g., erythromycin,[39,58] clarithromycin,[42] recruited in this study. Regarding the side effects, no
azithromycin,[38] and doxycycline.[43] These antibiotics patient encountered any significant unwanted effects
have anti-inflammatory and immunomodulatory effects during the period of treatment, and this goes in parallel
which modify the course of the disease.[7] In present with a study which used erythromycin,[58] however
study, erythromycin was given to patients for two weeks contrasting results were observed with prednisolone in
and it was found that 19 out of 25 (76%) patients were a study.[56]
cleared at the end of two weeks as compared to those
in placebo group P=0.0000064). Similarly, significant
results were obtained at the end of fourth (P=0.0000064)
CONCLUSIONS AND RECOMMENDATIONS
1. Although both oral erythromycin and prednisolone
and sixth week (P=0.0016). The average number of days are effective drugs in shortening the course of PR;
for PR to be cleared in erythromycin treated patients yet, erythromycin is superior to prednisolone.
was 16.32±8.74 days which is highly significant in 2. The use of both oral erythromycin and prednisolone
comparison with prednisolone-treated and placebo-given in recommended doses and duration in this study
patients (P=0.0000001). These findings regarding the showed no significant side effects.
effectiveness of erythromycin in clearing the rash of PR 3. A larger scale study is recommended to assess the
are in accordance with a study in which 73.3% patients effectiveness of erythromycin and prednisolone in
showed complete response with erythromycin[58] higher doses in treatment of PR.
Clarithromycin, a macrolide with a similar action as of
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