Shingles of the wrist with a bullous evolution
A 27-year-old man with no significant past medical history presented with a pruritic rash resembling contact dermatitis on the volar right wrist. Grouped vesicles had developed on top of an erythematous base over the past several days. One of the vesicles was punctured, and the serous fluid was sent for viral culture after 5 days. Empirical treatment with topical steroid for contact dermatitis was initiated.

The small vesicles gradually coalesced into larger blisters and eventually into a single large bulla after 8 days. Because the lesion did not show any sign of regression or crusting, the patient lanced the lateral side of the bulla with a sterile needle and expressed the serous fluid while leaving the roof of the bulla as a natural dressing. The wound left a shallow ulcer initially and healed with residual flat-topped, dendritic, and violaceous scarring. Two weeks later, the culture result proved positive for varicella-zoster virus.

The rash of herpes zoster (shingles) is commonly diagnosed by clinical examination, but its presentation can be atypical, even in immune-competent hosts. In this case, the initial presentation resembled contact dermatitis. Herpes zoster can sometimes be mistaken for herpes simplex virus (HSV) infection, often prompting laboratory testing.1 Shingles tends to be a band-like lesion following a dermatomal distribution, whereas HSV tends to be more localized. HSV infection that looks like shingles is referred to as “zosteriform herpes simplex.”

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