Chronic Leg Ulcerations and Subcutaneous Panniculitis due to Dermal Herpes Zoster in an Immunosuppressed Woman

Herpes zoster (HZ) is a cutaneous viral disease that typically presents with a dermatomal vesicular eruption. Immunosuppressed patients are more likely to have atypical HZ involving chronic ulceration and disseminated distribution, making diagnosis a challenge. The current report describes a unique case of HZ in a woman with systemic lupus on immunosuppressive therapy manifesting as persistent lower extremity ulceration with diffuse dermal and endothelial infection and secondary panniculitis without epidermal involvement. Other potential etiologies were thoroughly excluded. The ulceration successfully responded to several weeks of valacyclovir. Recognizing atypical clinicopathologic manifestations of HZ in the setting of immune compromise is critical to accurate diagnosis and prompt therapy.