Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Letter to the Editor - Observation Letter
2018:84:2;217-220
doi: 10.4103/ijdvl.IJDVL_1170_16
PMID: 29393080

Wolf's isotopic nonresponse in healed herpes zoster in erythroderma

Surabhi Sinha, Gunjan Verma, PK Sharma, Arvind Ahuja
 Department of Dermatology and STD, Postgraduate Institute of Medical Education and Research (PGIMER) and Dr Ram Manohar Lohia Hospital, New Delhi, India

Correspondence Address:
Gunjan Verma
PGIMER and Dr Ram Manohar Lohia Hospital, New Delhi
India
Published: 02-Feb-2018
How to cite this article:
Sinha S, Verma G, Sharma P K, Ahuja A. Wolf's isotopic nonresponse in healed herpes zoster in erythroderma. Indian J Dermatol Venereol Leprol 2018;84:217-220
Copyright: (C)2018 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Wolf et al. introduced “isotopic nonresponse” to describe the absence of an eruption at the site of another, unrelated, and already healed skin disease.[1] Herein, we describe a case of chronic recurrent erythroderma secondary to atopic dermatitis but sparing the site of herpes zoster affected area, thus demonstrating Wolf's isotopic nonresponse phenomenon.

A 38-year-old male presented with diffuse redness and scaling all over the body for 3 months. He gave history of many such episodes involving the whole skin in the last 4 years. His father had bronchial asthma and patient had dry itchy skin since childhood. Repeated episodes left his skin dark thickened, with increased skin markings on flexural parts. Eight months prior to this episode, he had developed herpes zoster involving the right T11 dermatome. After treatment, the lesions had resolved with minimal scarring. General physical examination was normal. Cutaneous examination showed diffuse erythema with fine whitish scales and mild induration over most of his skin. The forehead and flexural areas were lichenified while the neck had a dirty grey appearance. However, there was only mild erythema and scaling in the right T11 segment, which was previously involved by herpes zoster [Figure - 1]. The patient had not noticed any area of sparing in the earlier similar episodes prior to the development of herpes zoster.

Figure 1: Wolf's isotopic nonresponse: Mild erythema and scaling of the previously affected zone by herpes zoster (Right. T11) while the corresponding area shows lichenification

On investigation, complete hemogram was normal except eosinophilia (12%). Liver, renal, thyroid function tests, and urinalysis were in the normal range. Chest X-ray and electrocardiogram revealed no abnormalities, and Mantoux test was 5 × 5 mm. The serum immunoglobulin E level was >6400 IU/L (normal <70 IU/L). The skin biopsy from erythrodermic site showed mild hyperkeratosis, parakeratosis, acanthosis, and a dense dermal infiltrate of lymphocytes and eosinophils. The skin biopsy from the spared zoster site showed thinned epidermis and scanty dermal infiltrate with absence of eosionphils [Figure - 2]a,[Figure - 2]b,[Figure - 2]c,[Figure - 2]d. CD1a staining in the upper layer of the dermis was significantly more in the erythrodermic site. The intraepidermal region in the spared zoster site had few areas of staining for CD1a, while no such staining was present in the deeper dermis [Figure - 3]a and [Figure - 3]b.

Figure 2a: Dense infiltrate comprising lymphocytes and eosinophil in the dermis in erythrodermic site (×4)
Figure 2b: Scanty infiltrate in herpes zoster affected site (×4)
Figure 2c: Lots of eosinophils in the erythrodermic skin (×40)
Figure 2d: Absent eosinophils in herpes zoster affected site (×40)
Figure 3a: A significantly higher number of CD1a staining (immunohistochemistry) in the upper dermis in the erythrodermic site
Figure 3b: Compared to the healed zoster site having few areas of staining for CD1a, absent staining in the deeper dermis

The term isotopic nonresponse is known as Wolf's postherpetic isotopic nonresponse because the most commonly spared lesion is a previous herpes infection. It is defined as the sparing of an eruption (dysimmune reactions, tumor spread) at the site of another unrelated and already healed skin disease (varicella zoster virus/herpes simplex virus).[2],[3],[4],[5] A large body of evidence has shown that the skin, the nervous system, and immunity are closely associated by cytokines and neuropeptides (neuroimmunocutaneous system). When this system is destabilized in a given district, by any cause (nerve lesion or infection, e.g. herpes zoster, amputation trauma, radiodermatitis), the district itself becomes a vulnerable site, prone to harbor locus minoris resistentiae or be rejected locus maioris resistentiae by a wide range of immunity-related disorders (opportunistic infections, primary or metastatic tumors, immune reactions). This innovative unifying concept has been termed as “the immunocompromised district.”[6] Postherpetic isotopic nonresponse is an example of locus maioris resistentiae. T regulator cells may persist at these sites and Langerhans cells may be less in number, and/or in antigen presenting capacity, which may further lead to increased resistance to dysimmune reactions at these sites. This pathomechanism possibly lies at the heart of the Wolf's isotopic nonresponse.[6] Our patient had decreased staining for CD1a in the previously zoster affected site vis-à-vis erythrodermic site. Also, eosinophils were lesser in the erythroderma-spared site in this case. Skin biopsies from the healed herpes zoster affected dermatomes in earlier studies have shown a similar reduction in the Langerhans cells and the dermal nerve network.[7],[8] Fukuda et al. also found lymphocytic infiltration, eosinophils, CD1a, and ICAM1 expressing cells to be lesser in the spared areas.[9]

Twersky and Nordlund hypothesized that epidermotropic lymphocytes interact with Langerhans cells, and epidermotropism would be absent in areas without Langerhans cells.[2] Tenea et al. described similar sparing of herpes zoster virus area by Stevens Johnson syndrome due to carbamazepine, and they suggested that the virus increases Th1 cytokine profile with overexpression of tumor necrosis factor-α, interferon-γ, interleukin-2, and limits the presentation of viral peptides by major histocompatibility complex class I, II. [Table - 1] lists reports of this rare phenomenon in the literature. Most authors agree that decreased number of Langerhans cells and a dysregulated immune response (due to less antigen presentation) are probably responsible for the nonresponse.[10],[11],[12] To the best of our knowledge, there are no cases reported showing Wolf's isotopic nonresponse from India. How, if at all, the decreased numbers of the dermal Langerhans cells and denervation are responsible for the sparing of the previously healed herpes zoster site by generalized cutaneous eruptions can only be a matter of speculation.

Table 1: Reported cases of Wolf's isotopic nonresponse phenomenon associated with herpes zoster published till date

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References
1.
Wolf R, Brenner S, Ruocco V, Filioli FG. Isotopic response. Int J Dermatol 1995;34:341-8.
[Google Scholar]
2.
Twersky JM, Nordlund JJ. Cutaneous T-cell lymphoma sparing resolving dermatomal herpes zoster lesions: An unusual phenomenon and implications for pathophysiology. J Am Acad Dermatol 2004;51:123-6.
[Google Scholar]
3.
Kannangara AP, Fleischer AB Jr. Yosipovitch G, Ragunathan RW. Herpes zoster virus associated 'sparing phenomenon': Is it an innate possess of HZV or keratinocyte cytokine (s) mediated or combination? J Eur Acad Dermatol Venereol 2008;22:1373-5.
[Google Scholar]
4.
Tenea D. Carbamazepine-induced Stevens-Johnson syndrome sparing the skin previously affected by herpes zoster infection in a patient with systemic lupus erythematosus: A reverse isotopic phenomenon. Case Rep Dermatol 2010;2:140-5.
[Google Scholar]
5.
KannangaraAP, Fleischer AB, Yosipovitch G. The sparing phenomenon. A case series of the inverse Koebner and related phenomena. Our Dermatol Online2013;4:35-9.
[Google Scholar]
6.
Ruocco V, Brunetti G, Puca RV, Ruocco E. The immunocompromised district: A unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol 2009;23:1364-73.
[Google Scholar]
7.
Muller SA, Winkelmann RK. Cutaneous nerve changes in zoster. J Invest Dermatol 1969;52:71-7.
[Google Scholar]
8.
Oaklander AL. The density of remaining nerve endings in human skin with and without postherpetic neuralgia after shingles. Pain 2001;92:139-45.
[Google Scholar]
9.
Fukuda H, Sato Y, Usami N, Yokouchi Y, Mukai H. Contact dermatitis caused by bufexamac sparing the eruption of herpes zoster. J Dermatol 2012;39:405-7.
[Google Scholar]
10.
Katayama H, Karube S, Ueki Y, Yaoita H. Contact dermatitis sparing the eruption of herpes zoster and its periphery. Dermatologica 1990;181:65-7.
[Google Scholar]
11.
Park H, Kang Y, Lee U. Erythema multiforme sparing regressing herpes zoster lesion: “Reverse isotopic phenomenon?” J Am Acad Dermatol 2008;58:AB40.
[Google Scholar]
12.
Kroth J, Tischer J, Samtleben W, Weiss C, Ruzicka T, Wollenberg A, et al. Isotopic response, Köbner phenomenon and Renbök phenomenon following herpes zoster. J Dermatol 2011;38:1058-61.
[Google Scholar]

Fulltext Views
374

PDF downloads
119
Show Sections