10.5826/dpc.1303a149
text/xml
2160-9381
2916
en
Nicola  di Meo
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
halo
Dermoscopic Features of Herpes Zoster: Case Series and Review of the Literature
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2023-07-31
2022-10-20
2023-07-31
2023-08-24
e2023149
Dermatol Pract Concept
Nicola  di Meo
2023/07/31
10.5826/dpc.1303a149
e2023149
Dermatology Clinic of Trieste, Maggiore Hospital, University of Trieste, Trieste, Italy
2160-9381
halo
en
e2023149
Lewis DJ, Schlichte MJ, Dao H Jr. Atypical disseminated herpes zoster: management guidelines in immunocompromised patients. Cutis. 2017;100(5):321;324;330. PMID: 29232422.
Dermoscopic Features of Herpes Zoster: Case Series and Review of the Literature
https://dpcj.org/index.php/dpc/article/download/2916/2241
               Dermoscopic Features of Herpes Zoster:
               Case Series and Review of the Literature
                  Giulia Bazzacco1, Claudio Conforti1, Ludovica Toffoli1, Enrico Zelin1,
                                     Iris Zalaudek1, Nicola di Meo1


1 Dermatology Clinic of Trieste, Maggiore Hospital, University of Trieste, Trieste, Italy



Key words: Herpes, zoster, dermoscopy, clue, halo
Citation: Bazzacco G, Conforti C, Toffoli L, Zelin E, Zalaudek I, di Meo N. Dermoscopic Features of Herpes Zoster: Case Series
and Review of the Literature. Dermatol Pract Concept. 2023;13(3):e2023149. DOI: https://doi.org/10.5826/dpc.1303a149
Accepted: January 14, 2023; Published: July 2023
Copyright: ©2023 Bazzacco 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: Giulia Bazzacco, MD, Dermatology Clinic of Trieste, Maggiore Hospital, University of Trieste,
Trieste, Italy Phone: +39 0403992056 E-mail: giuliabazzacco@gmail.com
Ethics Statement: The patients in this manuscript have given written informed consent to publication of their case details.




Introduction                                                               the available data, we observed a new dermoscopic pattern
                                                                           only partially described in literature.
Herpes zoster (HZ) is a major health burden that affects
individuals of any age. The typical skin manifestation is a
                                                                           Case Presentation
painful and unilateral vesicular exanthema, limited to a sin-
gle or contiguous dermatomes [1]. Diagnosis is usually easy                A group of patients with atypical HZ diagnosed within
and occurs with just clinical evaluation, however recogni-                 the last 6 months were retrospectively retrieved from our
tion of atypical HZ can be a challenge for clinicians. When                secondary referral centers. Dermoscopic evaluation was
clinical presentation is ambiguous, laboratory tests such as               performed by a polarized handheld dermoscope with x10
polymerase chain reaction (PCR), Tzanck preparation and                    magnification. The study included 14 patients (8 males,
histopathology are the gold standard for diagnosis. How-                   6 females) aged between 29 and 84 (mean 54 years), skin
ever, laboratory test usually takes at least one day to perform            phototype (Fitzpatrick) ranged from I/II (71%) to V/VI
it and histopathology is an invasive procedure [1]. Thus, der-             (29%). Clinical diagnosis of the atypical eruption was dif-
moscopy, a non-invasive rapid diagnostic tool, can be helpful              ficult for three main reasons: early stage of rash with only
for early diagnosis of HZ, but there are limited descriptions              few and small lesions, in most cases (50%) (Figure 1); in
on dermoscopic patterns in the literature. The aim of this                 28,5% of cases HZ arose on skin of color and the erythema
study was to compare a case series of HZ with the relevant                 was less clear (Figure 2); in 21,5% there was a diffuse
literature, evaluating the role of dermoscopy as a useful tool             non-dermatomal eruption in immunocompromised hosts.
able to provide an early diagnosis. Reviewing and comparing                Dermoscopically, according to the existing literature [2-4],




Research Letter | Dermatol Pract Concept. 2023;13(3):e2023149 ﻿                                                                      1
white polyglobular structures were the most common fea-              (1) early-stage lesions (2) skin of color (Phototypes V/VI)
tures (100%), followed by meliceric crusts (100%), and ery-          and (3) immunocompromised host [5,6]. Limited data are
thematous background (71%).                                          available but dermoscopy is a useful tool to allow an early
                                                                     diagnosis and antiviral treatment when clinical presentation
                                                                     is uncommon. Due to the lack of literature, these observa-
Conclusions                                                          tions need further confirmation on larger series of patients.
In literature a total of 75 patients, irrespective of age and
gender, with a clinical presentation suggestive of HZ were           References
evaluated for dermoscopic features [2-4]. Erythematous
                                                                         1. Patil A, Goldust M, Wollina U. Herpes zoster: A Review of Clin-
background (increased vascularity) was the most common
                                                                            ical Manifestations and Management. Viruses. 2022;14(2):192.
finding (100%), followed by round cloudy white polyglob-
                                                                            DOI: 10.3390/v14020192. PMID: 35215786. PMCID:
ular structures (grouped vesicles) 53%-80%, and central                     PMC8876683.
brown dots 50%-80% (Table 1).                                            2. Narkhede ND, Nikham B, Jamale V, Hussain A, Kale M.
    Comparing the available data, one interesting finding                   Evaluation of Dermoscopic Patterns of Vesiculobullous Dis-
                                                                            ­
arising from our study: the “Halo sign”. It was an annular                  orders. Indian J Dermatol. 2021;66(4):445. DOI: 10.4103/ijd
                                                                            .IJD_294_20. PMID: 34759418. PMCID: PMC8530039.
white/yellowish structure, that was present in the total of
                                                                         3. Rao KMS, Gaikwad S , Dermoscopy in viral infections: An ob-
the retrospectively cases analyzed. “Halo sign” was due to
                                                                            servational study. IP Indian J Clin Exp Dermatol. 2020;6(3):
the contrast between the yellowish/brownish crusted center                  261-267. DOI: 10.18231/j.ijced.2020.053.
of vesicular lesions and the red color of the erythematous               4. Nayak SS, Mehta HH, Gajjar PC, Nimbark VN. Dermoscopy
background which create an annular pattern around every                     of general dermatological conditions in Indian population:
element of the skin rash. It has been previously only partially             Ad­ escriptive study. Clin Dermatol Rev. 2017;1:41-51.
                                                                         5. Dayan RR, Peleg R. Herpes zoster - typical and atypical pre-
described by Narkhede et al and it could be a significant and
                                                                            sentations. Postgrad Med. 2017;129(6):567-571. DOI: 10.1080
easy method to recognize dermoscopic clue [2].
                                                                            /00325481.2017.1335574. PMID: 28540752.
    The role of dermoscopy for the early diagnosis of HZ has             6. Lewis DJ, Schlichte MJ, Dao H Jr. Atypical disseminated herpes
previously been reported, it facilitated an earlier diagnosis by            zoster: management guidelines in immunocompromised patients.
1.62 days [2]. Form our data analysis there were three clini-               Cutis. 2017;100(5):321;324;330. PMID: 29232422.
cal situations in which dermoscopy demonstrated its utility:


  Table 1. Dermoscopic features of herpes zoster in literature references. The relevant literature was
found by searching different databases: PubMed, Google Scholar. The following keywords alone or in
combination were used: “Herpes”, “Zoster”, “Dermoscopy”, “Viral”, and “Infection”. A wide review
                  of the bibliography of each of the selected article was performed.
                                                  Dermoscopic features, Percentage (%)
                                   Cloudy                                Grey
                                 white poly-          Central             to                     Grayish
           Patients Erythematous  globular            brown        White black                structureless  White          Dermoscope
References   (N)     background  structures            dots        halos dots        Erosions     areas     globules         employed
 Narkhede        50     100%             +++          50%          +++       50%    NR          20%            20–80%      DermLite
 et al [2]                                                                                                                 DL 4
                                                                                                                           dermatoscope
 Rao et al       10     100%             80%          80%          NR        30%    20%         NR             NR          Handheld
 [3]                                                                                                                       contact
                                                                                                                           dermoscope,
                                                                                                                           Derm Lite 4
 Nayak           15     +++              53%          53%          NR        NR     NR          NR             NR          Handheld
 et al [4]                                                                                                                 pocket
                                                                                                                           dermoscope
                                                                                                                           Dermlite II
                                                                                                                           Pro

NR = not reported; +++ = well represented.




2                                                                           Research Letter | Dermatol Pract Concept. 2023;13(3):e2023149﻿
Figure 1. (A) Clinical image of herpes zoster involving left mandibular branch of trigeminal nerve. (B) Dermoscopy shows millimetric brown-
ish crusts on white polyglobular structures and an erythematous background (Halo sign).




Figure 2. (A) Clinical image of herpes zoster involving right axilla. (B,C) Dermoscopy shows brownish crusts that cover white polyglobular
structures on skin of color (Halo sign).



Research Letter | Dermatol Pract Concept. 2023;13(3):e2023149 ﻿                                                                          3
