Wolf's isotopic response--lichen planus at the site of healed herpes zoster in an Indian woman

Wolf's Isotopic Response After Herpes Zoster Infection in Chronic Lichen Sclerosus-Like Graft versus Host Disease: Case Report and Literature Review

Wolf's isotopic response (WIR) refers to the occurrence of a new skin disease at the exact site of an unrelated skin disease that had previously healed, often subsequent to virus infection. Secondary cutaneous diseases that are frequently observed in WIR include granulomatous reactions, dysimmune reactions, malignancies, and infections. However, secondary chronic graft-versus-host disease (GVHD) is rare. We describe a patient with lichen sclerosus-like GVHD who developed lichen planus-like GVHD lesions secondary to herpes zoster infection.

Wolf's isotopic response, presenting as lichen planus

The term "Wolf's isotopic response" describes the occurrence of a new skin disorder at the site of another unrelated and already healed skin disease. In most cases, herpes zoster is the inicial disease. Different disorders may develop on the same site, most commonly granulomatous and lichenoid reactions, infiltration of hematologic diseases, skin tumors and infections. There are few related cases of lichen planus presenting as isotopic response. We report a case of a 74 year-old woman, with multiple itchy, rose-colored and shiny papules that developed at site of previously healed herpes zoster, on the right arm and shoulder. The pathogenesis of this phenomenon is still unknown and further studies are needed.

Wolf's post-herpetic isotopic response: Infections, tumors, and immune disorders arising on the site of healed herpetic infection

Herpes simplex viruses (HSV-1/HSV-2) and varicella-zoster virus (VZV) have several characteristics in common. Both are epidermoneurotropic, cause skin eruptions accompanied by sensory symptoms (itch, pain), damage peripheral sensory nerve fibers and cutaneous nerve endings, and interfere with neuromediator release, which can alter local mechanisms of immune control. For this reason, herpes-infected areas may become a preferential location for the subsequent onset of immunity-related skin disorders (infections, tumors, and dysimmune reactions), an event first reported by a neurologist and focused on by two brothers, a dermatologist and a pediatrician. The phenomenon therefore named Wolf's post-herpetic isotopic response (PHIR) refers to the occurrence of a new skin disorder at the site of a previous and already healed herpetic eruption (herpes zoster in most cases). Until now, we have been able to gather 189 well-documented cases of PHIR (all reported in the reference section), but our list is far from being complete. Some of the most emblematic cases are briefly described here. In some circumstances, the opposite of PHIR occurs, with diffuse skin disorders or eruptions that selectively spare herpes-infected areas (Wolf's post-herpetic isotopic nonresponse). Experimental investigations with patch testing have been performed in seven patients who were sensitized to nickel and had had herpes zoster in the past years. The tests were carried out bilaterally on the affected dermatomes and on the unaffected contralateral ones. The uneven immune responses we obtained have shown that the immune behavior of an herpes zoster-affected dermatome can be different from that of the corresponding contralateral dermatome, thus supporting the existence of immune dysregulation in herpes-infected areas.

Wolf's Isotopic Response: Report of a Case and Review of Literature

“Wolf's isotopic response” refers to the occurrence of a new dermatosis at the site of previously healed dermatosis. A number of factors including viral, neural, vascular, and immunologic factors have been implicated in the causation of this peculiar response but none has been proven conclusively. Here, we report a case where lichen planus developed at the site of dermatofibrosarcoma protruberans that had been previously treated with surgery and radiotherapy. We also put forth a hypothesis on the genesis of isotopic response considering the above mentioned factors.

Wolf Isotopic Response Manifesting as Postherpetic Granuloma Annulare: A Case Series

Context.— Wolf isotopic response has infrequently been reported in the literature, mainly as isolated case reports.

Objective.— To aid in recognition of the occurrence of postherpetic granuloma annulare for accurate histologic interpretation of granulomatous dermatitides.

Design.— We report 5 cases of patients with Wolf isotopic response manifesting as granuloma annulare, developing in a site of previous herpes zoster, and discuss the clinicopathologic findings.

Results.— Previous infection with herpes zoster or herpes simplex virus was found in 5 of 5 cases reported. The differential diagnosis of a dermal lymphohistiocytic infiltrate with multinucleated giant cells includes postherpetic granuloma annulare.

Conclusions.— All cases of postherpetic Wolf isotopic response reported in this series revealed granuloma annulare, with a perineurovascular or perifollicular pattern of lymphohistiocytic infiltration including multinucleated giant cells, and occurred following herpes zoster or herpes simplex infection, although herpes viral infection was not always associated with a subsequent isotopic eruption. Awareness of this entity can aid in the clinicopathologic diagnosis of granuloma annulare occurring at the site of prior herpes viral infection.

Volf’s isotopic response

The term of “isotopic response” was offered by R. Wolf and co-authors in 1995 and means the development of the new dermatosis at the place of already existing initial one, which has already regressed and is not directly referred to the first one. The article describes the essence of the phenomena and most important clinical cases. Such pathogenic mechanisms as viral, immunologic, vascular, neurogenic theory are being discussed, as well as the immunocompromised site concept. The commonality and the difference of the isotopic response and of the isomorphic Kobner’s phenomenon are being analyzed. Two clinical cases are provided.

Localization of sclerotic-type chronic graft-vs-host disease to sites of skin injury: potential insight into the mechanism of isomorphic and isotopic responses

BACKGROUND

The mechanisms responsible for the variable manifestations of chronic cutaneous graft-vs-host disease (cGVHD) are poorly understood. Localization of sclerotic-type chronic graft-vs-host disease to sites of skin injury (isomorphic and isotopic responses), a recognized phenomenon in morphea, suggests a potential common pathway between cGVHD and other sclerotic skin conditions.

OBSERVATIONS

Four cases of sclerotic-type cGVHD developed at the site of disparate skin injuries (ionizing radiotherapy, repeated needle sticks, central catheter site, and varicella-zoster virus infection). We review the spectrum of previously reported cases of sclerotic and nonsclerotic cGVHD relating to external forces on the skin.

CONCLUSIONS

Localization of sclerotic-type cGVHD may occur after many types of skin injury, including UV and ionizing radiotherapy, needle sticks, viral infection, and pressure or friction. Recognition of this phenomenon may be helpful for the early diagnosis of sclerotic disease. Recent insights into the immunological consequences of minor skin injury may provide important clues to the underlying pathogenesis of cGVHD-mediated skin disease.