cutaneous leishmaniasis is caused by transmission of the leishmania spp . through the bite of the female sandfly . while most of the clinical manifestations are characteristic and pose no diagnostic difficulties , there are several infrequent and atypical features of the disease which can delay correct diagnosis and proper treatment . here we report on a case of zosteriform cutaneous leishmaniasis , which was diagnosed with the help of dermoscopy . a 55-year - old female , without known health - related problems , presented with an upper right chest and upper right back eruption for six weeks . the patient had traveled to an endemic area for cutaneous leishmaniasis inside israel a month before the rash appeared . on examination , two erythematous nodules , with a central ulcer covered with a yellow crust , were evident on the upper right back ( figure 1a ) . three similar additional lesions were found on the right upper chest ( figure 1b ) , forming a seemingly dermatomal distribution of lesions , leading to the clinical impression of herpes zoster . however , dermoscopic examination revealed erythema , hyperkeratosis , burst star whitish appearance and hairpin vessels ( figure 1c , d ) , compatible with cutaneous leishmaniasis . while several uncommon presentations of cutaneous leishmaniasis have been reported , a zosteriform presentation is especially rare , and has been described only anecdotally in the literature [ 36 ] . our case posed a special challenge , since the patient reported on pain in the relevant region , while leishamania lesions are usually asymptomatic . the lesions were also arranged in a seemingly dermatomal distribution , without crossing of the midline . however , the chronic course of the rash raised the suspicion of a different diagnosis than herpes zoster , and dermoscopy proved to be a useful diagnostic tool . several dermoscopic findings have been described in cutaneous leishmaniasis , the most common ones include erythema , a large number of different vascular structures , white starburst - like patterns , central ulcers , yellow tears and hyperkeratosis [ 79 ] . since erythema , hyperkeratosis and hairpin vessels can be observed in many dermatological conditions , they are not considered to be very useful or specific for diagnosing cutaneous leishmania . however , the presence of a whitish starburst pattern was a strong indicator for cutaneous leishmaniasis in our patient . our case demonstrates the importance of including cutaneous leishmaniasis in the differential diagnosis of herpes zoster in endemic areas . furthermore , since dermoscopy can be easily utilized to diagnose this condition , dermatologists in endemic areas should be familiar with its typical dermoscopic features .
cutaneous leishmaniasis is usually easy to recognize ; however , several atypical features exist , which may pose a diagnostic challenge . here 
 we report a 55-year - old female patient , who presented with an itchy and painful eruption localized in a dermatomal distribution along the right upper chest . although the clinical appearance of the lesions suggested the diagnosis of herpes zoster , dermoscopic evaluation revealed erythema , hyperkeratosis , burst star whitish appearance and hairpin vessels , compatible with the diagnosis of cutaneous leishmaniasis . 
 indeed , leishmania amastigotes were detected by smear from the lesions . 
 zosteriform presentation of cutaneous leishmaniasis , as exemplified by our patient , is especially rare . in our case dermoscopy 
 has proven to be an accessible and easy tool to diagnose such atypical presentation of cutaneous leishmaniasis , and dermatologists in endemic areas should be familiar with its typical dermoscopic features .