In most cases, a single, 2 to 10 cm (1" to 4") oval red "herald" patch appears, classically on the trunk or neck, having an appearance similar to ringworm. Occasionally, the herald patch may occur in a hidden position (in the armpit, for example) and not be noticed immediately. The herald patch may also appear as a cluster of smaller oval spots, and be mistaken for acne. Rarely, it does not become present at all. After the herald patch appears, usually some days or weeks later, a rash of many small (5–10 mm; 1⁄4" to 1⁄2") pink or red, flaky, oval or round spots appear. They are mostly situated on the trunk and upper limbs. They follow the skins cleavage lines, which on the upper chest and back produce a characteristic "christmas-tree" distribution. In 6% of cases an "inverse" distribution may occur, with rash mostly on the extremities. In children, presentation can be atypical or inverse, and the course is typically milder. About one in four people with PR have mild to severe symptomatic itching. (Moderate itching due to skin over-dryness is much more common, especially if soap is used to cleanse the affected areas.) The itching is often non-specific, and worsens if scratched. This tends to fade as the rash develops and does not usually last through the entire course of the disease.About a fifth of cases have an atypical form, with significant variations in symptoms including the size, distribution, morphology, and evolution of the lesions.
A biopsy of the lesions will show extravasated erythrocytes within dermal papillae and dyskeratotic cells within the dermis.A set of validated diagnostic criteria for pityriasis rosea is as follows:
A patient is diagnosed as having pityriasis rosea if:

On at least one occasion or clinical encounter, the patient has all the essential clinical features and at least one of the optional clinical features, and
On all occasions or clinical encounters related to the rash, the patient does not have any of the exclusional clinical features.The essential clinical features are the following:
Discrete circular or oval lesions,
Scaling on most lesions, and
Peripheral collarette scaling with central clearance on at least two lesions.The optional clinical features are the following:
Truncal and proximal limb distribution, with less than 10% of lesions distal to mid-upper-arm and mid-thigh,
Orientation of most lesions along skin cleavage lines, and
A herald patch (not necessarily the largest) appearing at least two days before eruption of other lesions, from history of the patient or from clinical observation.The exclusional clinical features are the following:
Multiple small vesicles at the centre of two or more lesions,
Two or more lesions on palmar or plantar skin surfaces, and
Clinical or serological evidence of secondary syphilis. Treatment
The condition usually resolves on its own, and treatment is not required. Oral antihistamines or topical steroids may be used to decrease itching. Steroids do provide relief from itching, and improve the appearance of the rash, but they also cause the new skin that forms (after the rash subsides) to take longer to match the surrounding skin color.