Brief Report

Vol. 30, No. 6, 2018 737

Received September 25, 2017, Revised November 13, 2017, Accepted for publication December 31, 2017

Corresponding author: Kyung Eun Jung, Department of Dermatology, Eulji University Hospital, Eulji University School of Medicine, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea. Tel: 82-42-611-3035, Fax: 82-42-259-1111, E-mail: jke0224@eulji.ac.krORCID: https://orcid.org/0000-0003-0968-1079

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology

dish-brown color. Unlike red henna, brown henna contains indigo plant leaves and black henna contains PPDA, a well-known contact allergen. Red henna, without any addi-tives, has low allergenic potential and is considered a safer alternative to conventional PPDA-containing hair dyes1. Both patients developed extensive hyperpigmentation fol-lowing mild erythema after using henna-based hair dyes. Post-inflammatory hyperpigmentation, Addison’s disease, friction melanosis, and drug eruption were excluded from differential diagnoses due to the absence of prior in-flammation or hyperpigmentation in the skin creases, and no history of nylon towel on the face or drug use. Patch testing revealed that pure red henna was the causative allergen. The hyperpigmentation gradually faded after dis-continuation of henna product use and treatment with top-ical tacrolimus and oral tranexamic acid.Although the exact pathophysiology of PCD is unclear, it is proposed that persistent contact with low level chem-icals causes cytolysis in the basement membrane, resulting in pigment incontinence without overt spongiosis2. We speculate that traces of henna remained on the scalp and hair after washing, and acted as a persistent allergen. This is consistent with the observed prominent pigmentation on the neck and face of the second patient who washed

his hair in a standing position. We found a single report of PCD caused by pure red henna (Queens HennaTM; NTH Co. Ltd., Tokyo, Japan)3. These case reports have important clinical implications in that pure henna, popular owing to its low allergenicity, al-so poses a risk of contact dermatitis.

CONFLICTS OF INTEREST

The authors have nothing to disclose.

REFERENCES

1. de Groot AC. Side-effects of henna and semi-permanent

‘black henna’ tattoos: a full review. Contact Dermatitis 2013;

69:1-25.2. Nakayama H, Matsuo S, Hayakawa K, Takhashi K,

Shigematsu T, Ota S. Pigmented cosmetic dermatitis. Int J

Dermatol 1984;23:299-305.3. Lee YB, Park SM, Kim JW, Yu DS. Combination treatment of

low-fluence Q-switched Nd:YAG laser and oral tranexamic

acid for post-inflammatory hyperpigmentation due to allergic contact dermatitis to henna hair dye. J Cosmet and Laser

Ther 2016;18:95-97.

https://doi.org/10.5021/ad.2018.30.6.737

Multiple Milia after Herpes Zoster

Dae Young Oh, Joong Sun Lee, Dae Won Koo, Kyung Eun Jung

Department of Dermatology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea

Dear Editor:The occurrence of a new unrelated disorder at the site of an already healed disease, most commonly identified as

the herpes virus, is known as Wolf’s isotopic response1,2. Here, we describe a unique case of multiple epidermal cysts and milia arising on the healed herpes zoster area of

Brief Report

738 Ann Dermatol

Fig. 1. (A) Linearly and unilaterally distributed grouped skin to erythe-matous papules with variable size on right shoulder. (B) Close-up view,well demarcated grouped tiny papules with central black pore and large erythematous papule (1 cm in diameter).

Fig. 2. (A) Epidermal cyst is lined with stratified squamous epitheliumthat contains a granular layer. Older cysts may exhibit calcifica-tion (H&E, ×40). (B) Dense lym-phocyte-dominant inflammatory re-sponse may be present in the cysts that have ruptured. Laminated keratin contents are noted inside the cyst (H&E, ×200).

a healthy male patient. A 57-year-old male patient presented with pruritic group-ed erythematous papules on his right shoulder, which had persisted for 3 months. He had a history of being diag-nosed with herpes zoster which had presented with a painful vesiculopapular eruption about 4 months pre-viously on the exactly same site. After oral antiviral and analgesic treatment, the pain was reduced, but a slight pruritus arose.The physical examination revealed multiple, unilaterally and linearly distributed erythematous to skin colored tiny papules with a central black pore on the right anterior shoulder (Fig. 1). We received the patient’s consent form about publishing all photographic materials.A histopathological examination of the shoulder demon-strated a ruptured epidermal cyst lined with stratified squ-amous epithelium that contained a granular layer (Fig. 2).Due to severe pruritus and inflammation, the patient re-ceived three injections of an intra-lesional substance with

triamcinolone; after this treatment, the pruritus and clin-ical features improved significantly. The skin primarily damaged by viruses could have a sec-ondary unrelated disease. The skin which is physically de-formed by the preceding disease could be a factor of the response. However, it is most commonly understood that the affected area has immunological vulnerability due to the preceding diseases. In particular, histological analysis demonstrates that the VZV infection affects the cutaneous nerve fiber, nerve endings and distribution of Langerhans’ cell, causing an altered local immune condition3.Frequently reported isotopic responses were granuloma annulare and other granulomatous reactions. However, there were only 12 cases of comedonic-microcystic re-actions, and only one case of an epidermal cyst with a his-topathological examination was reported3-5. The patient had undergone an allogenic renal transplantation 4 years previously, and was taking an immunosuppressive agent. Similar to our case, the patient developed multiple epi-

Brief Report

Vol. 30, No. 6, 2018 739

Received September 8, 2017, Accepted for publication January 5, 2018

Corresponding author: Alice He, Department of Dermatology, Johns Hopkins University School of Medicine, Cancer Research Building II, 1550 Orleans Street, Baltimore, MD 21231, USA. Tel: 410-955-5933, Fax: 410-955-8645, E-mail: ahe1@jhmi.eduORCID: https://orcid.org/0000-0002-1938-0619

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology

dermal cysts after the presentation of herpes zoster which had occurred 1 year prior5.Various hypotheses about the pathogenesis of the epi-dermal cyst and milia exist. Physical damage and histo-logical inflammation of the skin by herpes zoster and bul-lous disorders may induce the epidermal cyst and milia. In particular, the use of immunosuppressive drugs may con-tribute to the development of a cyst more easily by ex-acerbating the inflammation imbalance and pilosebaceous unit occlusion. Our case is the second case of an epidermal cyst caused by Wolf’s post-herpetic isotopic response, but it is the first case that occurred during a short period in a healthy adult without using of immunosuppressive agents.The incidence of herpes zoster is increasing every year with an increased lifespan and the use of various im-munosuppressive agents. Considering these tendencies, it is also assumed that the isotopic response caused by the herpes zoster would also increase. Based on this case, physicians should keep in mind that multiple epidermal cysts could occur from Wolf’s post-herpetic isotopic re-sponse in healthy adults.

CONFLICTS OF INTEREST

The authors have nothing to disclose.

REFERENCES

1. Wolf R, Brenner S, Ruocco V, Filioli FG. Isotopic response.

Int J Dermatol 1995;34:341-348.2. Wolf R, Wolf D, Ruocco E, Brunetti G, Ruocco V. Wolf’s

isotopic response. Clin Dermatol 2011;29:237-240.

3. Ruocco V, Ruocco E, Brunetti G, Russo T, Gambardella A, Wolf R. Wolf’s post-herpetic isotopic response: infections,

tumors, and immune disorders arising on the site of healed

herpetic infection. Clin Dermatol 2014;32:561-568.4. Gibney MD, Nahass GT, Leonardi CL. Cutaneous reactions

following herpes zoster infections: report of three cases and

review of the literature. Br J Dermatol 1996;134:504-509.5. Sandhu K, Saraswat A, Handa S. Multiple epidermoid cysts

occurring at site of healed herpes zoster in a renal transplant

recipient: an isotopic response? Clin Exp Dermatol 2003;28: 555-556.

https://doi.org/10.5021/ad.2018.30.6.739

Rosacea and Rate of Temperature Change: Examining Real-Time Data from 2004 to 2016

Alice He, Radhika Grandhi1, Shawn Gaurav Kwatra

Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 1Department of Dermatology, University of Cincinnati College of Medicine, Cincinnati, OH, USA

Dear Editor:Rosacea is a chronic inflammatory skin condition with ex-acerbations that may be triggered by heat1. However,

there is limited data on seasonal variations of rosacea exacerbations. In this study we use real-time Google Trends data to examine seasonal variations in rosacea search quer-