Granuloma annulare in herpes zoster scars

Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific

Background

Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region.

Methods

We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines.

Results

From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand.

HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation.

Conclusions

Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.

Wolf's post-herpetic isotopic response: Infections, tumors, and immune disorders arising on the site of healed herpetic infection

Herpes simplex viruses (HSV-1/HSV-2) and varicella-zoster virus (VZV) have several characteristics in common. Both are epidermoneurotropic, cause skin eruptions accompanied by sensory symptoms (itch, pain), damage peripheral sensory nerve fibers and cutaneous nerve endings, and interfere with neuromediator release, which can alter local mechanisms of immune control. For this reason, herpes-infected areas may become a preferential location for the subsequent onset of immunity-related skin disorders (infections, tumors, and dysimmune reactions), an event first reported by a neurologist and focused on by two brothers, a dermatologist and a pediatrician. The phenomenon therefore named Wolf's post-herpetic isotopic response (PHIR) refers to the occurrence of a new skin disorder at the site of a previous and already healed herpetic eruption (herpes zoster in most cases). Until now, we have been able to gather 189 well-documented cases of PHIR (all reported in the reference section), but our list is far from being complete. Some of the most emblematic cases are briefly described here. In some circumstances, the opposite of PHIR occurs, with diffuse skin disorders or eruptions that selectively spare herpes-infected areas (Wolf's post-herpetic isotopic nonresponse). Experimental investigations with patch testing have been performed in seven patients who were sensitized to nickel and had had herpes zoster in the past years. The tests were carried out bilaterally on the affected dermatomes and on the unaffected contralateral ones. The uneven immune responses we obtained have shown that the immune behavior of an herpes zoster-affected dermatome can be different from that of the corresponding contralateral dermatome, thus supporting the existence of immune dysregulation in herpes-infected areas.

Granuloma annulare as an isotopic response to herpes zoster

BACKGROUND

Wolf's isotopic response is the phenomenon of a new skin disease occurring at the site of another unrelated and already healed skin disorder. Most cases in the literature report herpes zoster (HZ) as the original disease; however, the isotopic responses vary greatly. Including this case, our literature search revealed 32 cases of isotopic granuloma annulare (GA) following HZ.

CASE REPORT

An 82-year-old male presented with GA localized to the right T9 dermatome that later appeared at other sites on the trunk and extremities. The patient had an episode of shingles involving the same dermatome 4 years earlier.

DISCUSSION

To our knowledge, this is the first case report of GA occurring initially as an isotopic response in an HZ scar and subsequently becoming generalized. Thirty-eight percent (12 of 32) of patients with isotopic GA following HZ were immunocompromised, which is similar to the published rate of immunodeficiency in patients with HZ.

Etiology, diagnosis, and therapeutic management of granuloma annulare: an update

Granuloma annulare (GA) is a common cutaneous disorder classically presenting as annular groups of skin-colored to erythematous papules without epidermal change localized to the dorsal hands and/or feet. In addition to the localized form, there are variants including generalized (including generalized annular GA, disseminated papular GA, and atypical generalized GA), subcutaneous, and perforating GA, providing for a wide spectrum of clinical lesions. The etiology of GA remains unknown and several systemic associations have been proposed but not proven, including diabetes mellitus, malignancy, thyroid disease, and dyslipidemia. The diagnosis of GA relies on clinicopathological correlation, with a skin biopsy confirming the histological features of the disease, including palisading granulomas, collagen degeneration, mucin, and a lymphohistiocytic infiltrate. Localized GA is often asymptomatic and self-limited within 2 years; however, the patient may desire treatment for cosmetic reasons, with topical and intralesional corticosteroids as the mainstays of therapy. When GA is generalized, disseminated, or atypical, a more thorough medical workup for underlying diseases may be considered depending on the physical examination, a thorough review of systems, comorbidities, and clinical suspicion. Treatment is often challenging for generalized GA, especially because of its recalcitrant nature and a lack of evidence-based therapy. Over 30 different treatments have been described for GA with variable results; however, the majority of these have been single case reports, small case series, or retrospective studies. Reported treatments for GA include topical, intralesional, intramuscular, and oral medications (steroidal vs. non-steroidal); biologic agents; surgical interventions; phototherapy; and laser treatments. When selecting a systemic therapy for a patient with GA, multiple variables must be considered, such as baseline blood evaluations, comorbidities, drug interactions, compliance, adverse effect profiles, prior treatments, and reproductive status. This evidence-based review will focus on the advances made in the twenty-first century regarding the etiology, diagnosis, and therapeutic management of GA.

Generalized granuloma annulare associated with scabies

Granuloma annulare (GA) is a common dermatosis of unknown etiology, which, in 10%-15% of cases, presents as the generalized subtype. GA has been associated with infections, vaccines, and neoplasias. We describe a case of generalized GA arising in a 50-year-old man with a diffuse infestation by Sarcoptes scabiei.

Granuloma annulare on herpes zoster scars in a Hodgkin's disease patient following autologous peripheral stem cell transplantation

Various cutaneous lesions including granulomatous reactions may occur at sites of resolved herpes zoster infection. A 46-year-old man with Hodgkin's disease developed localized granuloma annulare lesions on herpes zoster scars 3 months after allogeneic peripheral stem cell transplantation. This is the first case of granuloma annulare localized on herpes zoster scars that developed following peripheral stem cell transplantation.

Granuloma annulare in the hand

A review of our cases of granuloma annulare in the hand revealed that it presented as either an annular or subcutaneous lesion, most commonly on the dorsum of the metacarpophalangeal joint of the middle or ring fingers. Lesions were approximately 10 mm in diameter and the diagnosis was confirmed by surgical biopsy. The majority of cases resolved spontaneously within 1 year, and recurrence, though common, did not necessitate a further biopsy.

Isotopic response after herpesvirus infection: an update

The term postherpetic isotopic response describes the occurrence of a new, unrelated disease that appears at the same location as a previously healed herpetic infection. When dealing with the pathogenetic mechanism involved in the isotopic response, several possibilities should be considered: a viral origin, an immunologic origin, a vascular origin, and a neural origin. The aim of this article is to review and discuss the different pathogenetic mechanisms with particular attention to new information related to the possible neural origin of this abnormal response of the skin.

Granuloma annulare: another manifestation of Bartonella infection?

Granuloma annulare (GA) is a common cutaneous eruption whose pathogenesis remains unknown. Recent literature has suggested a relation between Borrelia infection and GA, a relation that has not been widely accepted. Earlier works attempted unsuccessfully to implicate various other infectious agents. Some reports have demonstrated the increased frequency of GA in patients with human immunodeficiency virus infection, again raising the possibility of an infectious etiology. Using polymerase chain reaction amplification, we examined 19 biopsy specimens from 19 patients with GA (14 with classic palisading GA and 5 with an interstitial pattern) for the presence of a 153-base pair sequence specific for Bartonella henselae or Bartonella quintana. None of our patients were known to be human immunodeficiency virus-positive. These primers failed to detect B. henselae and B. quintana DNA in any of the specimens examined. Our findings do not support the hypothesis that GA represents a granulomatous reaction pattern to cutaneous Bartonella infection. Nevertheless, we cannot exclude the possibility that there may be a relation in other geographic locations or in immunocompromised patients or that GA represents an autosensitization reaction in response to a distant site of infection. Additional studies are needed to address these hypotheses.