More than just a coincidence: Herpes zoster and acne rosacea appearing together as Wolf's isotopic response in an Asian female

Abstract

Introduction: Wolf’s isotopic response is a rare dermatologic phenomenon defined as the occurrence of a new, unrelated disease at the site of healed lesions of some other disease. We report the first case of Wolf’s isotopic response in a female presenting with rosacea localized to the site of healing zoster lesions. Case Report: A 35­year­old previously healthy Filipino­American woman with no prior history of a dermatologic condition presented to our clinic with a 9­month history of a painful and pruritic unilateral erythematous papular eruption on her right upper cutaneous lip and cheek that respected the midline. At initial presentation she was started on 800 mg acyclovir five times daily for one week for presumed zoster. Four days into her seven­day acyclovir course, her primary care physician obtained cultures for VZV and HSV, but these tests were negative. The vesicular eruptions completely resolved following treatment with acyclovir, leaving only hyperpigmented scars in the unilateral maxillary distribution. Two months after the completion of her acyclovir treatment, she noticed pink dots, which had a prickly and itchy sensation located in the same unilateral distribution as her previous eruptions. Her condition was refractory to a myriad of topical treatments and a skin biopsy was performed which suggested acne rosacea. She was started on isotretinoin and continued for five months with almost complete resolution of papules and symptoms. Conclusion: The pathogenesis of Wolf’s isotopic response is unknown. We review the various etiologies that have been postulated including direct action of viral, particles, immune activation, alterations in neurologic system and vascular changes. Early recognition of Wolf’s isotopic response may result in more timely and effective treatment for patients. Further studies are needed to define the pathogenesis of isotopic response.