10.5826/dpc.1204a180
Introduction: Blister beetle dermatitis (BBD) and herpes zoster (HZ) manifest suddenly with vesicular lesions mimicking each other and progress rapidly. But a lack of definite differentiating criteria yearns the need for better investigating modality. Though histopathology persuades the need, is an invasive procedure, commonly deferred. Thus, dermoscopy a non-invasive rapid diagnostic tool, can help in differentiating.
Objectives: To evaluate different dermoscopic patterns of BBD and HZ to differentiate both and to study dermoscopic features in early and late stages of lesions.
Methods: An observational cross-section study conducted in southern India. Nine patients with clinical features suggestive of BBD and HZ were recruited. Lesions were divided arbitrarily into early and late. Dermoscopic examination was performed with handheld dermoscope. Diagnosis was confirmed by skin biopsy and Tzanck smear wherever necessary. Statistical analysis performed using data in terms of frequencies and percentages.
Results: Dermoscopy of early BBD lesions showed multiple discrete and confluent yellowish-white structures, brown dots, roundish white globules, gray structures,&nbsp; ‘targetoid pattern’, brown areas over intense reddish pink background. Late BBD lesions revealed pinkish-white area, reduced gray structures and, dotted and globular vessels. Early HZ lesions showed polylobular gray and brown globules, bright pink background, gray globules covered by grayish veil-like structure with gray rim. Late HZ lesions revealed ‘solar eclipse’ pattern and ‘crumpled fabric ‘patterns. The dermoscopic findings correlated with histopathology.
Conclusions: Dermoscopic patterns show peculiar features consistently pertaining to BBD and HZ thus help in early diagnosis assisting in accurate treatment both conditions.
text/xml
2160-9381
2209
en
Aimilios  Lallas
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
bullous disorders
Dermoscopic differentiation of blister beetle dermatitis and herpes zoster: An observational study: Dermoscopy of blister beetle dermatitis and herpes zoster
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-11-30
2022-10-31
2022-12-01
e2022180
Dermatol Pract Concept
Introduction: Blister beetle dermatitis (BBD) and herpes zoster (HZ) manifest suddenly with vesicular lesions mimicking each other and progress rapidly. But a lack of definite differentiating criteria yearns the need for better investigating modality. Though histopathology persuades the need, is an invasive procedure, commonly deferred. Thus, dermoscopy a non-invasive rapid diagnostic tool, can help in differentiating.
Objectives: To evaluate different dermoscopic patterns of BBD and HZ to differentiate both and to study dermoscopic features in early and late stages of lesions.
Methods: An observational cross-section study conducted in southern India. Nine patients with clinical features suggestive of BBD and HZ were recruited. Lesions were divided arbitrarily into early and late. Dermoscopic examination was performed with handheld dermoscope. Diagnosis was confirmed by skin biopsy and Tzanck smear wherever necessary. Statistical analysis performed using data in terms of frequencies and percentages.
Results: Dermoscopy of early BBD lesions showed multiple discrete and confluent yellowish-white structures, brown dots, roundish white globules, gray structures,&nbsp; ‘targetoid pattern’, brown areas over intense reddish pink background. Late BBD lesions revealed pinkish-white area, reduced gray structures and, dotted and globular vessels. Early HZ lesions showed polylobular gray and brown globules, bright pink background, gray globules covered by grayish veil-like structure with gray rim. Late HZ lesions revealed ‘solar eclipse’ pattern and ‘crumpled fabric ‘patterns. The dermoscopic findings correlated with histopathology.
Conclusions: Dermoscopic patterns show peculiar features consistently pertaining to BBD and HZ thus help in early diagnosis assisting in accurate treatment both conditions.
Aimilios  Lallas
2022/10/31
10.5826/dpc.1204a180
e2022180
First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
2160-9381
bullous disorders
en
e2022180
Shen MC, Lin HH, Lee SS, Chen YS, Chiang PC, Liu YC. Double-blind, randomized, acyclovir-controlled, parallel-group trial comparing the safety and efficacy of famciclovir and acyclovir in patients with uncomplicated herpes zoster. J Microbiol Immunol Infect 2004; 37:75-81. PMID: 15181487.
Dermoscopic differentiation of blister beetle dermatitis and herpes zoster: An observational study: Dermoscopy of blister beetle dermatitis and herpes zoster
https://dpcj.org/index.php/dpc/article/download/2209/1783
                  Dermoscopic Differentiation of Blister
                  Beetle Dermatitis and Herpes Zoster:
                         an Observational Study
                     Balachandra Suryakant Ankad1, Varsha R. Koti1, Aimilios Lallas2


1 Department of Dermatology, S. Nijalingappa Medical College, Near APMC, Navanagar, Bagalkot, Karnataka, India
2 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece



Key words: dermoscopy, blister beetle dermatitis, herpes zoster, bullous disorders
Citation: Ankad BS, Koti VR, Lallas A. Dermoscopic differentiation of blister beetle dermatitis and herpes zoster: An observational study.
Dermatol Pract Concept. 2022;12(4):e2022180. DOI: https://doi.org/10.5826/dpc.1204a180
Accepted: January 3, 2022; Published: October 2022
Copyright: ©2022 Ankad et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Balachandra Suryakant Ankad, Professor, Department of Dermatology, S. Nijalingappa Medical College, Near
APMC, Navanagar, Bagalkot-587102, Karnataka, India. Cell Phone: +91 9980410056. Fax: 08354 235360, E-mail: drbsankad@gmail.com



  ABSTRACT             Introduction: Blister beetle dermatitis (BBD) and herpes zoster (HZ) manifest suddenly with vesicular
                       lesions mimicking each other and progress rapidly. But a lack of definite differentiating criteria yearns
                       the need for better investigating modality. Though histopathology persuades the need, is an invasive
                       procedure, commonly deferred. Thus, dermoscopy, a non-invasive rapid diagnostic tool, can help in
                       differentiating.
                       Objectives: To evaluate different dermoscopic patterns of BBD and HZ to differentiate both and to
                       study dermoscopic features in early and late stages of lesions.
                       Methods: An observational cross-section study conducted in southern India. Nine patients with clin-
                       ical features suggestive of BBD and HZ were recruited. Lesions were divided arbitrarily into early and
                       late. Dermoscopic examination was performed with handheld dermoscope. Diagnosis was confirmed
                       by skin biopsy and Tzanck smear wherever necessary. Statistical analysis performed using data in
                       terms of frequencies and percentages.
                       Results: Dermoscopy of early BBD lesions showed multiple discrete and confluent yellowish-white
                       structures, brown dots, roundish white globules, gray structures, ‘targetoid pattern’, brown areas over
                       intense reddish pink background. Late BBD lesions revealed pinkish-white area, reduced gray struc-
                       tures and, dotted and globular vessels. Early HZ lesions showed poly-lobular gray and brown glob-
                       ules, bright pink background, gray globules covered by grayish veil-like structure with gray rim. Late
                       HZ lesions revealed ‘solar eclipse’ pattern and ‘crumpled fabric’ patterns. The dermoscopic findings
                       correlated with histopathology.
                       Conclusions: Dermoscopic patterns show peculiar features consistently pertaining to BBD and HZ,
                       thus help in early diagnosis assisting in accurate treatment in both conditions.




Original Article | Dermatol Pract Concept. 2022;12(4):e2022180                                                                               1
Introduction                                                               To evaluate dermoscopic differences at early and late
                                                                       stages of evolution of lesions.
Paederus dermatitis, well known as dermatitis linearis or
blister beetle dermatitis (BBD) is an irritant contact der-
                                                                       Methods
matitis following exposure of an insect belonging to the
genus Paederus [1]. Accidental crushing of the beetle over             This study was conducted in southern India between January
the skin releases hemolymph containing a potent vesicant,              2021 and May 2021. The approval from the institutional re-
­paederine [2]. It is characterized with sudden onset of ery-          view board was taken and an informed written consent was
thematous, edematous lesions in linear whiplash appearance             obtained from patients. It was an observational cross-section
over exposed areas or kissing lesions in opposing areas.               analysis. The patients with clinical features suggestive of
    Herpes zoster (HZ) is a segmental eruption due to re-              BBD and HZ were analyzed for demographic details in terms
activation of latent varicella zoster virus from dorsal root           of age, sex and occupation. Vesicular lesions with classical
ganglion which presents as closely grouped papules, rapidly            features without history of previous treatment were included
becoming vesicular and pustular; develop in one or more                in the inclusion criteria. Exclusion criteria included lesions
contiguous dermatomes with sharp cut off at the midline [3].           with super-added infection. Lesions were divided arbitrarily
    BBD and HZ manifest suddenly with vesicular lesions and            into early and late. Lesions with less and more than 3 days
progress rapidly in the disease process. Lesions of both e­ ntity      were considered as early and late lesions respectively. Physi-
are associated with pain and burning sensation and hence               cal examination and hematological investigations were done
they mimic each other morphologically and symptomatically              to assess the systemic involvement.
[4,5]. Thus, both lesions should be diagnosed with accuracy.               Dermoscopic examination of target lesion was done
There are no defined criteria to differentiate both conditions         with handheld dermoscope with 10x magnification using
clinically. However, histopathology plays an important role to         ultrasound gel as interface medium. Care was taken avoid
distinguish. Many times, patients may not agree for the same.          pressure on the lesions. Dermoscopic analysis was done by
    Dermoscopy is a rapid, non-invasive tool which helps               one of the authors (BSA). Diagnosis was confirmed by skin
to visualize surface and sub surface features that are not             biopsy and Tzanck smear wherever necessary.
visible to naked eyes [6]. Dermoscopy of BBD is explained
in a single case report till date [7] and limited descriptions
                                                                       Results
on dermoscopic patterns in HZ are present in the literature
[8,9,10]. Furthermore, there is a hiatus in the dermoscopic            This study included 9 patients with 6 (66.6%) males and
distinction between the two. In this study, we evaluated the           3 (33.3%) females. Age of patients ranged from 10 years
dermoscopic features of BBD and HZ.                                    to 70 years (mean age 35 years). Five (55.5%) patients had
                                                                       BBD with erythematous and linear lesions with crusting and

Objectives                                                             vesicles with burning sensation over exposed body parts
                                                                       (Figures 1A, 2A, 3A, and 4A). One patient was followed up
To evaluate different dermoscopic patterns in distinction of           (5 days) for the healed lesion (Figure 5A). Biopsy was per-
BBD and HZ.                                                            formed in two patients clinically diagnosed with BBD and in




                Figure 1. (A) Clinical image of early lesion of blister beetle dermatitis involving malar eminence and left
                eyelids unilaterally. (B) Dermoscopy reveals presence of multiple discrete and confluent yellowish-white
                structures (star) and brown globules (arrow) indicating excoriation with white scales.



2                                                                           Original Article | Dermatol Pract Concept. 2022;12(4):e2022180
                 Figure 2. (A) Clinical image of early lesion of blister beetle dermatitis over nape of neck. (B) Dermoscopy
                 shows gray structure (yellow star), multiple brown dots/ globules (red arrows), and brown areas (green star)
                 with roundish white globules (red star) over the pink background. Few white globules show brown dots
                 (blue circle) in the center in a targetoid pattern.




                 Figure 3. (A) Clinical image of early lesion of blister beetle dermatitis over right shoulder. (B) ­Dermoscopy
                 of shows brownish structureless area (green star) in center surrounded by confluent gray structures (yel-
                 low star) with gray (yellow circles) and brown dots (red arrow) on pink background. Note the white
                 scales (black arrow) surrounding the brown dots and globules.




                 Figure 4. (A) Clinical image of late lesion of blister beetle dermatitis over peri-orbital region. (B) Dermos-
                 copy reveals multiple confluent gray structures (yellow star), brown areas (green star) and white globules
                 (red star) with brown globules (red arrow). Pinkish-white structureless area (black star) and gray globules
                 (yellow circle) are well appreciated on a pinkish background.



Original Article | Dermatol Pract Concept. 2022;12(4):e2022180                                                                    3
                Figure 5. (A) Clinical image of healed lesion of blister beetle dermatitis over nape of neck. (B) Dermoscopy
                reveals dotted (red circles) and globular vessels (green circles) and scales (black arrow) on a pinkish-white
                background. White globules (green arrow) and multiple gray and brown dots (white circles) are noted.




                Figure 6. (A) Clinical image of herpes zoster involving left ophthalmic branch of trigeminal nerve.
                (B) Dermoscopy shows poly-lobular gray (yellow circles) and brown (red arrow) globules. Note the gray
                veil-like structure (yellow star) covering the pigment globules with gray rim (green arrow).


one patient with HZ. Tzanck smear was performed in two                       HZ lesions were distributed in the ophthalmic branch of
patients clinically suspecting with HZ to see for acantholytic          trigeminal nerve (Figures 6A and 7A) and thoracic, cervical
cells and multinucleated giant cells.                                   nerves (Figures 8A and 9A), as closely grouped red papules
                                                                        and vesicles on erythematous background. Four (44.4%) pa-
Dermoscopy of Early BBD Lesions                                         tients with HZ were included in the study.
Multiple discrete and confluent yellowish-white structures,
brown dots (Figure 1B) with roundish white globules, gray               Dermoscopy of Early HZ Lesions
structures and brown areas (Figures 2B and 3B) over in-                 Polylobular gray and brown globules over a bright pink
tense reddish pink background. Few roundish white glob-                 background were noted with gray globules were covered by
ules showed brownish pigmentation at its center (Figure 2B).            grayish veil-like structure with gray rim. Yellowish-orange
White scales around the brown globules were other features              structure surrounding the pigment globules, red areas and
(Figure 3B).                                                            scales were seen (Figures 6B, 7B and 8B).


Dermoscopy of Late BBD Lesions                                          Dermoscopy of Late HZ Lesions
Similar pattern were observed but for the reduced gray                  Polylobular gray and brown structures surrounded by er-
structures in addition to pinkish-white areas (Figure 4B).              ythematous zone resembling a ‘solar eclipse’ pattern were
Few lesions revealed dotted and globular vessels, scales on a           observed with multiple brown and gray dots (Figures 9B
pinkish-white background (Figure 5B).                                   and 9C). ‘Crumpled fabric’ appearance which describes



4                                                                            Original Article | Dermatol Pract Concept. 2022;12(4):e2022180
                 Figure 7. (A) Clinical image of herpes zoster involving right trigeminal nerve. (B) Dermoscopy shows
                 poly-lobular gray (yellow circle) and brown (red arrows) globules. Gray globules are covered by grayish
                 veil-like structure (yellow star) with gray rim (green arrow). Yellowish-orange structure (white star) sur-
                 rounding the pigment globules is well appreciated. Note the bright pink background.




                 Figure 8. (A) Clinical image of herpes zoster involving right trunk in dermatomal involvement without
                 crossing the midline. (B) Dermoscopy shows poly-lobular gray (yellow circle) and brown (red arrows)
                 globules. Gray globules are covered by grayish veil-like structure (yellow star) with gray rim (green ar-
                 row). Yellowish-orange structure (white star) surrounding the pigment globules is well appreciated. Red
                 areas (white arrow) and scales (black arrow) are seen. Note the bright pink background.




folding of roof of flaccid bullae in late lesions was noted             histopathological changes. Furthermore it also reveals
(Figures 9B and 9C) [8]. There was increased intensity of               the changes that take place in the different layers of skin
gray structures observed in late HZ lesions when compared               by which one can study the disease evolution process. This
to late lesions of BBD. Dermoscopic differentiation between             study is aimed at differentiating BBD from HZ in a dermo-
BBD and HZ is depicted in Table 1.                                      scopic perspective. Clinically BBD manifests as fluid filled
                                                                        and necrotic lesions with pain and burning sensation [11].
                                                                        The differentials include herpes simplex, HZ or contact irri-
Conclusions                                                             tant dermatitis [12].
Dermoscopy being a rapid, non-invasive diagnostic tool,                      Dermoscopic analysis of BBD is very sparse in the lit-
that demonstrates features which correlate well with                    erature and limited to a single case report. Authors noted



Original Article | Dermatol Pract Concept. 2022;12(4):e2022180                                                                     5
Figure 9. (A) Clinical image of late lesion of herpes zoster involving right shoulder and arm. (B and C) Dermoscopy shows poly-lobular gray
(yellow stars) and brown (red arrows) structures surrounded by erythematous zone (black stars). Note the brown and gray dots (yellow
arrows) and the ‘crumpled fabric’ appearance (white circle) and ‘solar eclipse’ pattern (yellow box).




           Table 1. Dermoscopic differences between blister beetle dermatitis and herpes zoster.
    Dermoscopic
      features                   Blister beetle dermatitis                                        Herpes zoster
 Early lesions        • Discrete and confluent yellowish-white              • Poly-lobular gray and brown globules.
                        structures.                                         • Gray globules covered by grayish veil-like structure
                      • Brown dots with roundish white globules,              with gray rim.
                        gray structures and brown areas.                    • Yellowish-orange structure surrounding the pigment
                      • White scales.                                         globules and red areas.
                      • Background: intense reddish pink.                   • Scales present.
                                                                            • Background: bright pink.
 Late lesions         • Decreased amount of gray structures.                •   Increased intensity of gray structures.
                      • Vessel morphology: dotted and globular              •   ‘Solar eclipse’ pattern
                        vessel.                                             •   Multiple brown and gray dots.
                      • Scales present.                                     •   ‘Crumpled fabric’ appearance.
                      • Background: pinkish-white




brown/black dots on a gray background surrounded by                        Yellowish-white globules indicate spongiotic vesicles
white halo and erythema in a case of BBD [7].                          with serum within the epidermis and white roundish globules
    In the present report, the dermoscopic patterns varied on          are suggestive of micro-pustules (Figure 10). Gray structure
the basis of duration. Early lesions showed yellowish-white            is due to necrotic pigmented epithelium with non-pigmented
structures with roundish white globules and gray structures            regenerating epithelium. In contrast, brown dots are due to
on intense reddish-pink background. Similar features were              necrotic keratinocytes with retained melanin. Brown areas
noted in late lesions with reduction in the gray structure.            represent dried serum and necrotic keratinocytes with re-
Brown dots/areas and scales were observed in both lesions.             tained melanin. Scales and pink background correspond to
Interestingly, healed lesion showed vascular elements such as          hyperkeratosis and vasodilatation respectively. White glob-
dotted and globular vessels.                                           ules with brown dots in the centre are suggestive of perifol-
    Histopathology of BBD is characterized by destruction              licular micropustule.
of epidermis with necrosis and separation of keratinocytes                 HZ shows ballooning degeneration of necrotic keratino-
with formation of vesicles and infiltration of eosinophils and         cytes within intra-epidermal blister and few multinucleated
polymorphs. Perifollicular and inter-follicular inflammatory           giant cells at the base of blister in histopathology. Dermal
infiltrate is noted [13].                                              small vessel vasculitis is a characteristic feature [14].



6                                                                           Original Article | Dermatol Pract Concept. 2022;12(4):e2022180
                 Figure 10. Schematic histopathological representation of dermoscopy of blister beetle dermatitis. White
                 globules indicate micro-pustules (yellow box), scaling with grayish structures indicates hyperkeratosis
                 and necrosis of pigmented epithelium (green box), brown areas indicate dried serum with necrotic kera-
                 tinocytes with retained melanin (red box). Erythematous background indicates increased vascularity and
                 vasodilation (blue box).




                 Figure 11. Schematic histopathological representation of dermoscopy of herpes zoster. Multiple poly-­
                 lobular gray globules indicates acanthosis and necrotic pigmented keratinocytes within intra-epidermal
                 vesicle (yellow box), brown globules depicting serum, necrotic keratinocytes with retained melanin (red
                 box), yellowish orange structure indicates serum with extra-vasated erythrocytes within the intraepider-
                 mal vesicle (green box). Intense erythematous background with red dots indicate increased vascularity
                 and vasculitis in the superficial dermis (blue box).


    Multiple poly-lobular gray globules correlated to the             dilated vessels (­ Figure 11). The brown dots and globules are
necrotic keratinocytes within the intra-epidermal vesicle.            due to dried serum, necrotic keratinocytes and melanin re-
The grayish veil-like structure is due to the non-pigmented           tention. Scaling is due to hyperkeratosis [8,9]. The white
epithelium of the basal keratinocytes with overlying ne-              linear folds / ‘crumpled fabric’ appearance were due to fold-
crotic pigmented keratinocytes within the vesicular fluid.            ing of superficial keratinocytes (roof) due to flaccidity was
Gray rim is because of edge of vesicle that is seen verti-            observed in late lesions of HZ. This was previously reported
cally under dermoscopy. Yellowish-orange structure cor-               only in pemphigus vulgaris, pemphigus foliaceous and
responds to serum and extra-vasated erythrocytes within               ­Hailey-Hailey disease (as ‘crumpled fabric appearance’) [8].
the intra-epidermal vesicle. Erythematous background                  This appearance is expected in older bullous lesions with
correlates with the increased vascularity and red dots with           flaccidity of bullae.



Original Article | Dermatol Pract Concept. 2022;12(4):e2022180                                                                    7
    Table 2. Dermoscopic histopathological correlation of blister beetle dermatitis and herpes zoster.
    Conditions               Dermoscopic features                                    Histopathological correlation
 Blister beetle     Discrete and confluent yellowish-white         Spongiotic vesicles with necrosis of the epidermis
 dermatitis         structures.
                    White globules                                 Micro-pustules in epidermis
                    Gray structures                                Necrotic pigmented epithelium with regenerating non-
                                                                   pigmented epithelium
                    Brown areas                                    Dried serum and necrotic keratinocytes with retained
                                                                   melanin
                    White scales                                   Hyperkeratosis
                    Dotted and globular vessels.                   Superficial peri-vascular infiltration with vasodilation of
                    Intense reddish pink background.               dermal vessels.
                    White globules with brown dots in the          Perifollicular micro-pustule.
                    centre
 Herpes zoster      Multiple poly-lobular gray globules            Necrotic keratinocytes within intra-epidermal vesicle
                    Greyish veil-like structure                    Pigmented epithelium overlying the vesicle.
                    Grey rim                                       Edge of the vesicle
                    Yellowish orange structure                     Serum and extra-vasated erythrocytes within the intra-
                                                                   epidermal vesicle
                    Erythematous background                        Increased vascularity
                    Red dots                                       Dilated vessels and vasculitis
                    Brown dots and globules                        Dried serum, necrotic keratinocytes and melanin retention
                    Crumpled fabric appearance                     Roof of flaccid blister
                    Scales                                         Hyperkeratosis




    Thus, the dermoscopic features are fairly distinguishable        References
in BBD and HZ (Table 1). They correlate well with corre-
                                                                      1. Padhi T, Mohanty P, Jena S, Sirka CS, Mishra S. Clinico-epide-
sponding histopathological changes (Table 2). The dermo-
                                                                         miological profile of 590 cases of beetle dermatitis in western
scopic patterns observed in our study correlated well with               Orissa. Indian J Dermatol Venereol Leprol. 2007:333-335. DOI:
the study by Narkhede et al [8], in evaluation of HZ, but the            10.4103/0378-6323.35735. PMID: 17921615.
characterization of lesions into early and late lesions pertain-      2. Zargari O, Asadi AK, Fathalikhani F, Panahi M. Paederus der-
ing to duration of onset was not depicted. This is required as           matitis in northern Iran. a report of 156 cases. Int J Dermatol.
                                                                         2003;42:608-612. DOI: 10.1046/j.1365-4362.2003.01771.x.
any intervention with antiviral therapy within 72 hours of
                                                                      3. Sterling JC. Viral infections. In: Griffiths CEM, Barker J, Bleiker T,
onset of rash, reduces the risk of ophthalmic complications,
                                                                         Chalmers R, Creamer D, editors. Rook’s textbook of dermatology.
has effect on severity of acute pain, faster healing of lesions          9th edn, Vol 1. West Sussex: John Wiley and Sons: 2016.pp. 25.12.
and shortens the duration of post herpetic neuralgia [15,16].         4. Singh A, Singh AK, Singh D, Varghese A. Blister beetle derma-
As the lesions of BBD and HZ closely simulate each other,                  titis: Few observations helping in diagnosis. Int J Prev Med.
the dermoscopic differentiation thus helps in early diagno-                2013;4:241. PMID: 23544177.
                                                                      5.   Awad SS, Abdel-Raof H, Hosam-ElDin W, El-Domyati M. Linear
sis and management, as the line of management differs in
                                                                           neutrophilic dermatitis: A seasonal outbreak of Paederus derma-
the two and minimizes the morbidity and the social stigma
                                                                           titis in Upper Egypt. Cutis. 2013;91:300-304. PMID: 23837153.
associated with HZ. Limitations of this study include small           6.   Errichetti E, Zalaudek I, Kittler H, et al,. Standardization of der-
sample size, histopathology was not done in all the lesions,               moscopic terminology and basic dermoscopic parameters to evalu-
and study was conducted in a single center.                                ate in general dermatology (non-neoplastic dermatoses): an expert
    Thus, the use of dermoscopy has spread its wings from                  consensus on behalf of the International Dermoscopy Society. Br J
                                                                           Dermatol. 2020;182(2):454-467. DOI: 10.1111/bjd.18125.
infectious to inflammatory and to malignant conditions, and
                                                                      7.   Uraga PE, Briones CMC, Silva MML. Paederus dermatitis: der-
from being a diagnostic tool to a therapeutic monitoring
                                                                           moscopic characteristics and review of literature. Med Cutan
tool. Here, we observed significant dermoscopic differences                Iber Lat Am. 2019;47(2):92-102.
between BBD and HZ even at their earliest presentation,               8.   Narkhede ND, Nikam BP, Jamale V, Hussain A, Kale M. Evalua-
thus helping the dermatologists in further management of                   tion of dermoscopic patterns of vesiculobullous disorders. Indian
the conditions. It is thus a dermatologist’s stethoscope.                  J Dermatol. 2021;66:445. DOI: 10.4103/ijd.IJD_294_20.




8                                                                          Original Article | Dermatol Pract Concept. 2022;12(4):e2022180
 9. Ankad BS, Khare S, Reshme AS. Infective diseases. In: Ankad BS,          rove beetles (Paederus alfierii). Beni-Suef Uni J Basic and App
    Mukherjee SS, Nikam BP, editors. Dermoscopy- Histopathol-                Sci. 2013;2:108-113. DOI: 10.1016/j.bjbas.2013.03.002.
    ogy Correlation. Singapore: Springer Nature Singapore Pte Ltd:       14. Xu X, Yun SJ, Erickson L, Chen L. Disease caused by viruses. In:
    2021.pp. 307-310.                                                        Elder DE, Elenitsas R, Rosenbach M, Murphy GF, Rubin AI, Xu
10. Lacarrubba F, Verzì AE, Musumeci ML, Micali G. Early diagno-             X, editors. Lever’s Histopathology of the skin. 11th edn. Philadel-
    sis of herpes zoster by handheld reflectance confocal microscopy.        phia: Wolters Kluwer; 2015.pp.781-815.
    J Am Acad Dermatol. 2015;73(6):e201–e203. DOI: 10.1016/j.            15. Jeon YH. Herpes zoster and postherpetic neuralgia: practi-
    jaad.2015.08.050. PMID: 26568349.                                        cal consideration for prevention and treatment. Korean J Pain.
11. Hegde SS, Bhat MR. An outbreak of blister beetle dermatitis              2015;28(3):177-184. DOI: 10.3344/kjp.2015.28.3.177.
    in a residential school: A clinical profile. Muller J Med Sci Res.   16. Shen MC, Lin HH, Lee SS, Chen YS, Chiang PC, Liu YC.
    2017;8:47-51. DOI: 10.4103/0975-9727.199376.                             Double-blind, randomized, acyclovir-controlled, parallel-group
12. Singh A, Singh AK, Singh D, Varghese A. Blister beetle derma-            trial comparing the safety and efficacy of famciclovir and acy-
    titis: Few observations helping in diagnosis. Int J Prev Med.            clovir in patients with uncomplicated herpes zoster. J Microbiol
    2013;4:241. PMID: 23544177.                                              Immunol Infect. 2004;37:75-81. PMID: 15181487.
13. Ahmed MS, Boraei HA, Rakha OM. Histopathological charac-
    terization of induced Paederus dermatitis caused by Egyptian




Original Article | Dermatol Pract Concept. 2022;12(4):e2022180                                                                                9
