Manuscript type : Letter to EditorTitle : Cutaneous Appendage Damage after Herpes ZosterAuthor : Xiang Chen, MD, Hangzhou Third People’s Hospital, Department of Dermatology, 38West Lake Avenue, Hangzhou, Zhejiang, 904885193@qq.com; 、ORCID:0000-0002-4391-8044Funding : none.Conflict of Interest Disclosures : None reported.The author attest to obtaining written patient consent for the publication of recognizable patient photographs or other identifiable material, with the understanding that this information may be publicly available.The data from the study has not been previously published.Cutaneous Appendage Damage after Herpes ZosterXiang Chen*Herpes zoster(HZ)is characterized by a banded rash on the skin that corresponds to the affected nerves. 1The most common complication of HZ is posthumous neuralgia, rarely with damage to cutaneous appendages. Nail damage after HZ has not been reported in the literature, and hair loss has only been shown in few study. In this case series, we present the cases of two people who had damage to cutaneous appendages after HZ.A 59-year-old male with a history of tuberculosis went through HZ on the left upper limb and shoulder, accompanied by numbness, pain and poor movement. Subsequently, his herpes gradually healed, with received regular antiviral treatment. However, the condition of left upper limb did not significantly improve. It was amazing that all nails on the left hand were damaged and tarnished after half a month, without fungal infection(Figure 1A). Due to an excruciating pain in the left upper limb and shoulder, he had to be took in shoulder joint release surgery. After the operation, the pain and range of motion were significantly improved. The growth of nail was recovered after 8 months (Figure 1B).A 54-year-old woman was presented with a painful vesicular dermatome eruption on right occipital lobe after a week when she got her kidneys. She was timely treated with antiviral therapy for HZ. Subsequently, the occipital rash subsided accompanied by hair loss appeared in the rash area. It has been 3 years since the onset of HZ although no hair has been observed at the site. There was no obvious enlargement of hair loss, and bright red spots can be seen in part(Figure 2A). The dermoscopy showed that the disappeared hair follicle, cutaneous atrophy, no black spot sign and exclamation mark. The patient has been using topical mucopolysaccharide polysulfate for 9 months. The erythema on the scalp has darkened and the scalp has become softer, but no significant hair growth has been observed yet(Figure 2B).Various nail changes in carpal tunnel syndrome have been reported in literature.2Based on the patient’s clinical manifestations, we believed that herpes zoster virus invaded the brachial plexus and cutaneous nerves. The vasomotor dysfunctions of the brachial plexus and cutaneous nerves as a consequence of severe inflammatory reaction can lead to trophic changes of the nails. We reviewed the literature about HZ and hair loss and find some information, such as post herpetic itch leading to frictional alopecia of eyebrow and scalp, alopecia due to hair pulling in region of post-herpetic neuralgia, alopecia areata and atrophic alopecia follow infection with varicella zoster virus. 3,4,5In our case, the patient had scarring alopecia in the region of HZ. Considering the patient with the history of kidney transplantation, is this alopecia related to transplanted anti-host disease? Unfortunately, the woman refused biopsy, which led to the unclear cause. In conclusion, cutaneous appendage damage after HZ is uncommon, and the mechanism of it needs to be further explored. In our view, tuberculosis infection and kidney transplantation may be high risk factors for cutaneous appendage injury after HZ.1. Kenneth S. Herpes Zoster. Annals of internal medicine 2018 08 07;169(3):ITC19-ITC31.2. Andjela E, Antonella T. Carpal tunnel syndrome and associated nail changes: Review and examples from the author’s practice. Journal of the American Academy of Dermatology 2020 Dec;83(6):1724-1729.3. Shyam V, Deepak J. Post Herpetic Itch Leading to Frictional Alopecia of Eyebrow and Scalp-A Hitherto Undescribed Phenomenon. Indian dermatology online journal 2024 Jan-Feb;15(1):86-88.4. Chowdhry S, Gupta H, Dhali T K, Dsouza P. Alopecia due to hair pulling in region of post-herpetic neuralgia–pseudotrichotillomania? Journal of the European Academy of Dermatology and Venereology : JEADV 2014 Aug;28(8):1122-3.5. Lara H, Nazli N T, Arjen F N. Hair Loss after Varicella Zoster Virus Infection. Case reports in dermatology 2013 Jan;5(1):43-7.