Temporal Association of Herpes Zoster Eruption Post-Aminolevulinic Acid Hydrochloride Photodynamic Therapy for Actinic Keratoses

August 2017 | Volume 16 | Issue 8 | Case Report | 817 | Copyright © 2017

Katie Manno MDa and Joel L. Cohen MD FAADb,c,d

aJohn H. Stroger, Jr. Hospital of Cook County, Chicago, IL bAboutSkin Dermatology and Derm Surgery, Greenwood Village and Lone Tree, CO cUniversity of Colorado, Department of Dermatology, Aurora, CO dUniversity of California Irvine, Department of Dermatology, Irvine, CA


Herpes zoster is a common and painful disease caused by the reactivation of the varicella-zoster virus with a higher incidence and severity associated with increasing age as well as compromised immune status. Acute inciting events for this eruption are not always known, but can include illness, stress, and mechanical injury. Photodynamic therapy (PDT) is a widely used treatment modality for precancerous skin lesions that has not been previously associated with provoking a herpes zoster outbreak. We present a case of herpes zoster eruption occurring after PDT for actinic keratoses in a patient with Non-Hodgkin Lymphoma (NHL).

J Drugs Dermatol. 2017;16(8):817-818.

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Herpes zoster is a well-known viral disease characterized by reactivation of the varicella-zoster virus in previously exposed individuals causing a painful, dermatomal vesicular eruption of the skin. Higher incidence and severity is associated with increasing age and compromised immune status -- likely due to waning of specific cell-mediated immunity.1,2,3 Additional risks for seemingly an increased chance of developing an acute eruption can include stress, mechanical injury, or recent illness, but often the specific cause of viral reactivation is unknown.4 In the following case, we present a patient with a history of NHL that subsequently developed a herpes zoster eruption.



A 63-year-old male with a history of NHL on idelalisib 150 mg daily was recommended to undergo PDT for field treatment of numerous actinic keratoses of the scalp. The patient had undergone the same treatment approximately one year prior with a good response. On March 10th, 2016, the patient’s scalp was treated with 10 J/cm2 of 417 nm blue light for 16 minutes and 40 seconds after incubation with aminolevulinic acid hydrochloride (ALA) for 2.0 hours. He tolerated the procedure well. May 14th, 2016, the patient developed burning pain and swelling over the left forehead, left periorbital area, down to the nasal tip, with subsequent overlying vesicular eruption (Figure 1). The patient was diagnosed with herpes zoster by his oncologist, and was treated with the appropriate course of valcyclovir, as well as gabapentin for burning pain. He was referred to an ophthalmologist, as well as a neurologist with expertise in zoster and related neurologic problems, who attributed the zoster flare to his PDT treatment. The eruption improved with complete resolution of symptoms noted at follow-up five months later. He denied any additional new illnesses or significant life stressors prior to the event. Of note, the patient was diagnosed with NHL in February of 2009, and had previously been treated with rituximab, cladribine, and bendamustine. His idelalisib had been started in January of 2016.


The incidence of herpes zoster in the United States general population is 3.2-4.47 cases per 1000 person-years, with a higher incidence and severity associated with increasing age and compromised immune status – including patients with diabetes mellitus, autoimmune disease, human immunodeficiency virus, transplant recipients, patients with malignancy, and cancer-related treatment.1-3 NHL is the most common hematologic malignancy. Patients with NHL treated with either conventional chemotherapy or rituximab-containing chemotherapy have been reported to have a higher incidence of herpes zoster reactions (11.79% and 12.76%, respectively). The majority of the cases were reported to occur within the first two years of NHL diagnosis.3 Our patient was diagnosed in 2009, and although he had previously been treated with rituximab and cladribine, he was only actively taking idelalisib at the time of the event, an FDA-approved NHL targeted therapy that inhibits the delta isoform of phosphatidylinositol 3-kinase (PI2K), a cytoplasmic tyrosine kinase involved in several B-cell signaling pathways. The most common adverse events reported with idelalisib include pyrexia,

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