Atypical Dermatological Condition Affecting Tattoo Timing

Case at a Glance

A 32-year-old transgender female patient presents with an uncharacteristic unilateral skin eruption, questioning the safety of proceeding with a scheduled tattoo procedure while undergoing treatment for a presumptive herpes zoster diagnosis.

Patient's Story

The patient is a 32-year-old assigned male at birth, transgender female, 6 feet tall, weighing 190 pounds, of Caucasian ethnicity. Current medications include daily sertraline, Adderall, and progesterone, with weekly estradiol injections for hormone replacement therapy. One week prior to presentation, the patient developed a unilateral skin eruption initially suspected to be urticaria. Over-the-counter antihistamines provided relief from pruritus but did not resolve the erythema or associated swelling. Topical antifungal treatments were subsequently attempted without improvement. The patient has a significant family history of herpes zoster, with both siblings experiencing the condition at similar ages.

Initial Assessment

Upon medical evaluation, the patient was clinically diagnosed with herpes zoster (shingles) based on the unilateral distribution pattern and family history. However, the presentation was atypical, lacking characteristic vesicular lesions, associated pain, fever, or constitutional symptoms. The primary complaint was intense pruritus rather than the typical burning or shooting pain associated with herpes zoster.

The Diagnostic Journey

The diagnostic process involved ruling out other dermatological conditions including urticaria, fungal infections, and contact dermatitis based on the patient's treatment response history. The unilateral distribution and family history of herpes zoster supported the working diagnosis, despite the absence of classic symptoms and morphology.

Final Diagnosis

Atypical herpes zoster (shingles) without vesiculation, presenting primarily with erythema, swelling, and intense pruritus in a dermatomal distribution.

Treatment Plan

The patient was prescribed topical triamcinolone cream for anti-inflammatory effect and oral valacyclovir 1 gram for antiviral therapy. Treatment was initiated approximately 4 days prior to follow-up assessment. The patient was advised to postpone any elective procedures, including tattooing, until complete resolution of the skin condition.

Outcome and Follow-up

After one week of combination topical steroid and oral antiviral therapy, the patient showed some improvement but continued to have visible erythema and swelling at the affected site. The patient appropriately postponed a scheduled tattoo appointment and sought medical guidance regarding the safety of proceeding with the procedure and the duration of recommended delay.