Can a Herald patch appear on the neck of an adult with no significant past medical history?

Can a Herald Patch Appear on the Neck?

Yes, a herald patch can appear on the neck in pityriasis rosea, though this location is less common than the trunk, thigh, or upper arm. 1

Typical Herald Patch Locations

The herald patch in pityriasis rosea is most commonly found on:

• Trunk 1
• Thigh 1
• Upper arm 1
• Neck 1

Less commonly, the herald patch may appear on the face, scalp, or penis, and even rarer locations like the palm have been documented. 1

Clinical Characteristics to Confirm Pityriasis Rosea

When evaluating a potential herald patch on the neck, look for these features:

• Size: The herald patch is typically larger (often 2-4 cm) and more noticeable than subsequent lesions 2
• Appearance: Oval or elliptical, dull pink or salmon-colored macule with a delicate collarette of scales at the periphery 2
• Timing: Present in approximately 80% of patients, appearing before the generalized eruption by 4-14 days 2
• Secondary eruption: Bilateral, symmetrical eruption of smaller (0.5-1 cm) oval lesions following Langer's lines in a "Christmas tree" pattern on the back or V-shaped pattern on the chest 2, 3

Critical Differential Diagnosis for Neck Lesions in Adults

A neck mass in an adult requires immediate evaluation to exclude malignancy before assuming a benign dermatologic condition. The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that any neck mass present ≥2 weeks without infectious etiology warrants evaluation for malignancy. 4, 5

Red flags that suggest malignancy rather than pityriasis rosea:

• Mass characteristics: Firm consistency, fixed to adjacent tissues, size >1.5 cm, non-tender 4, 5
• Patient factors: Age >40 years, tobacco/alcohol use, prior head and neck malignancy 4, 5
• Associated symptoms: Ipsilateral otalgia, dysphagia, voice change, unexplained weight loss 4, 5

Common Pitfalls to Avoid

The most dangerous error is assuming a neck lesion is benign (like pityriasis rosea) without proper evaluation, particularly in adults over 40. 5 The American Academy of Otolaryngology-Head and Neck Surgery warns against prescribing multiple courses of antibiotics or delaying workup for persistent neck masses, as this delays cancer diagnosis and worsens outcomes. 6, 5

When to suspect pityriasis rosea vs. malignancy:

Favor pityriasis rosea if:

• Patient is between 10-35 years old 2
• Lesion has characteristic collarette of scale 2
• Secondary eruption develops within 2 weeks following Langer's lines 2
• Lesion is flat (macular), not a palpable mass 2

Favor malignancy workup if:

• Palpable mass (not just a flat skin lesion) 4
• Mass present ≥2 weeks without change 4
• Firm, fixed, or >1.5 cm 4
• Patient >40 years with risk factors 4, 5