Pruritus in pityriasis rosea (PR) is usually absent or mild. Rarely is it severe in the papular form of the disease. Many patients recall a “herald patch” as the first sign of PR. The herald patch is red, scaling, and often on the trunk, measuring up to 6 to 7 cm in diameter (Fig. 21-1). Up to 3 weeks later, smaller ovoid macules, 1 to 3 cm in diameter, appear on the trunk and proximal extremities. These lesions sometimes follow a dermatomal distribution on the back, giving the famous “Christmas tree” pattern of PR. But this pattern is not always present. It is far more useful to find lesions with a central collarette of scale, which is a more reliable finding that can make the diagnosis (Fig. 21-2). A rare inverse form of PR causes lesions on the palms, soles, and face.