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A 47-year-old Korean man presented with a 1-month history of a pearly, erythematous, annular eruption on the right side of his posterior neck (Fig. 1). The eruption had a dermatomal distribution (C2-3 areas) exactly corresponding to an area which had been affected by a bout of herpes zoster 2 months before. The patient complained of a per­sistent burning pain, which was thought to be postherpetic neuralgia following complete healing of the herpes zoster, but he had no tenderness on the eruption itself. The patient also had a history of malignant melanoma of the paranasal sinus with cervical lymph node metastasis and had undergone endoscopic sinus surgery with bilateral radical neck dissection 18 months before. Laboratory tests in­cluding complete blood count, chemical battery and urine analysis were within normal limits.

Fig. 1. Pearly, erythematous, confluent papules and plaques on the site of a previous herpes zoster. Note the dermatomal distribution (C2-3 areas) of the erup­tion.

A 3-mm punch biopsy was obtained from a papule near the border of the lesion. The biopsy specimen showed granulomatous inflammation with many multi­nucleated giant cells engulfing elastotic material in the upper to mid dermis (Fig. 2A). A marked reduction of elastic fibers was noted within the zone of granulomatous inflammation (Fig. 2B). An alcian blue stain showed no mucin deposition on the granuloma (Fig. 2C). The histopathologic findings were consistent with actinic granuloma. The patient was treated by triamcinolone intralesional injection. Six weeks later, the lesions had improved.
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Fig. 2. (A) Granulomatous inflammation with many multinucleated giant cells in the dermis (H&E, X 100). Note some multinucleated giant cells engulfing blue- gray elastotic material (inset) (H&E, X 400). (B) Loss of elastic fibers within the zone of granulomatous in­flammation (Verhoeff van Gieson, X 100). (C) No mucin deposition (Alcian blue, X 100).