Photo Quiz

A Burning Red Rash


Am Fam Physician. 2017 Oct 15;96(8):543-544.

A 43-year-old man presented with a painful rash on the chest and back. The rash started five days earlier on the left side of the chest and then spread to the left side of the back. The pain was burning in nature. He had no history of a similar rash. He had no exposure to chemicals or physical agents. He had diabetes mellitus, hypertension, and dyslipidemia.

On physical examination, the patient was afebrile. Clusters of vesicles with some pustules and crusting (Figures 1 and 2) were noted on the back and chest. The rest of the body was not affected.

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Figure 1.

Figure 1.

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Figure 2.

Figure 2.


Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Bullous impetigo.

B. Contact dermatitis.

C. Herpes simplex virus infection.

D. Herpes zoster.

E. Varicella.


The answer is D: herpes zoster. Herpes zoster is characterized by a unilateral, painful vesicular rash with a dermatomal distribution. It is caused by reactivation of the varicella zoster virus.1 Herpes zoster most commonly affects dermatomes T1 to L2 and the first branch of the trigeminal nerve.1 In this case, the patient had a painful vesicular rash distributed mainly at the T2 to T4 dermatomes. There are four stages of a varicella zoster outbreak: erythematous, vesicular, pustular, and ulcerative.1 Occasionally, crusting develops after one week.2 The pain, which is caused by acute neuritis, can be described as a burning sensation and a deep, prickling, or lancinating pain.2 Reduced immunity states, such as advanced age and immunosuppression (e.g., malignancy, diabetes, human immunodeficiency virus infection), are risk factors for herpes zoster.2

Bullous impetigo is a result

Address correspondence to Suet Yin Chow, MMed (Fam Med), at Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.


show all references

1. Armando S, Nicoletta V, Sara P, Matilde G, Silvia L, Giovanni G. Herpes zoster: new preventive perspectives. J Dermatolog Clin Res. 2015;3(1):1042–1045....

2. Johnson RA, Wolff K, Fitzpatrick TB, eds. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 6th ed. New York, NY: McGraw Hill Professional; 2009.

3. Cole C, Gazewood J. Diagnosis and treatment of impetigo. Am Fam Physician. 2007;75(6): 859–864.

4. Emmert DH. Treatment of common cutaneous herpes simplex virus infections. Am Fam Physician. 2000;61(6):1697–1706.

5. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases, 13th ed. Varicella. Accessed February 11, 2017.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

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