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Severe ulcerative herpes zoster

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A 78-year-old man presented to a regional emergency department with a severe progressive rash, on a background history of chronic lymphocytic leukaemia, dementia and malnourishment.

The rash was multidermatomal, with patchy areas of ulceration, crusting, excoriation and necrosis (Figure, A and B). Active bleeding, seborrhoeic discharge and occasional vesicles were also noted, extending to the left pelvis. Subsequently, the patient developed concurrent Pseudomonas aeruginosa cellulitis and bacteraemia.

Punch biopsies were non-specific with dermal necrosis, excoriation and possible lichenoid reactivity. However, swabs revealed varicella-zoster virus. The patient was successfully treated with intravenous piperacillin–tazobactam, intravenous acyclovir, normal saline (0.9% sodium chloride) washes, and 50% liquid paraffin with 50% white soft paraffin cream (Figure, C and D). Multifactorial immunodeficiency was deemed to be the aetiology.