Abstract

Herpes zoster typically presents in the thoracic dermatomes and cranial nerve distributions, while cervical involvement, especially over the posterior scalp is rarely reported. A 51-year-old Malay man with type 2 diabetes mellitus, ischemic heart disease, end stage renal disease on dialysis, and retinitis pigmentosa presented with a non-specific headache over the posterior scalp following wet cupping ("bekam") and vesicular eruptions along the C2–C4 dermatomes emerged a few days later. Examination revealed grouped painful vesicular rash in dermatomal distribution consistent with C2–C4 herpes zoster over the posterior scalp and upper neck region. The patient was diagnosed with herpes zoster involving the dermatomal distribution of the cervical nerves, specifically C2, C3, and early involvement of C4 and was treated with renal-adjusted acyclovir and symptomatic care. Despite his co-morbid state, he showed a good response with no systemic complications or progression to post-herpetic neuralgia. This case highlights the diagnostic challenges of atypical zoster presentations and the importance of early recognition to prevent complications. Early recognition is crucial, especially in immune-compromised individuals, including those on dialysis. Herpes zoster involving the scalp should be considered in the differential diagnosis when patients present with dermatomal pain and localized rash. The presence of disrupted skin barriers and impaired immune response in such patients increases the risk of both infection and severe sequelae. Prompt clinical suspicion, supported by appropriate diagnostic evaluation is vital to reduce morbidity and improve patient outcomes.

Key words: Anti-viral treatment, Cervical dermatomes (C2, C3, C4), Herpes zoster, Neuralgia, Shingles, Vesicular rash