Introduction: Zoster sine herpete (ZSH) is an atypical, undiagnosed or misdiagnosed infection with no proper epidemic data. It is due to reactivation of varicella-zoster virus (VZV) that can occur in the enteric nervous system like viscera or autonomic nerve without shingles. It could be the reason for some neuropathic pain of unknown origin. Investigations like VZV DNA, VZV IgM and IgG can be used for diagnosis.

Miescher cheilitis is an idiopathic inflammatory disorder with chronic, persistent painless swelling of the lips with a high recurrence rate. It is a diagnosis of exclusion of other granulomatous lesions showing non-caseating granulomatous infiltration on skin biopsy. Intralesional corticosteroids with or without immunomodulators or oral steroids, azithromycin pulse therapy, infliximab, clofazimine, metronidazole and minocycline are the treatment options. Surgical treatments like cheiloplasty or radiotherapy is reserved for non-responders.Adverse cutaneous drug reactions (ACDR) occur with a frequency of 2-3% and its incidence increases with age and number of drugs. Studies have stated that ophthalmic agents can cause ACDR. Systemic absorption of drugs from topical eye drops can occur through major routes like conjunctiva and nose and minor routes through skin and eye structures.

Results: A 50-year-old female doctor with type-2 DM under good control with medications presented with intolerable burning and deep pain sensation in right iliac fossa over three weeks. Pain aggravated on touch and perception of clothing with no other systemic symptoms. History of fracture in the right leg in the recent past. Clinical examination was normal. Routine blood investigations and USG-abdomen were found to be normal. VZV IgG was markedly elevated (four times the normal) and IgM was negative. Patient was diagnosed to have ZSH. Patient was treated with oral valacyclovir 1gram and gabapentin 100mg three times daily for a week. Pain and burning sensation reduced significantly. Patient is currently on gabapentin 100mg twice daily with no pain and will be tapered gradually to once daily and stopped.

A 20-year-old young male presented with persistent upper lip swelling with no other local or systemic symptoms for 3 weeks with no abnormality with facial nerve, tongue and oral mucosa. Patient was not willing to do biopsy due to cosmetic issue. All the routine investigations were normal including Anti-neutrophilic antibodies (ANA) and thyroid function test. Patient was diagnosed to have Miescher cheilitis. He responded well to oral steroids, topical tacrolimus and lip balm for 2 months and it was stopped.

A 63-year-old female with type-2 DM presented with itchy target lesions of bullous variant over face, neck and ear lobule and erythema over palms & soles with mild oral erosions on buccal mucosa and severe crusting on lips for 1 week. There was a history of cataract surgery a week back and she was on treatment with dexamethasone and ofloxacin eye drops. All cutaneous lesions started on day-3 of topical eye drops. Patient did not respond to oral steroids. ANA was positive with nuclear and cytoplasmic granular types being weakly positive. Complement C3 and C4 were done and it was found to be normal. Patient was diagnosed to have Drug-induced erythema multiforme due to fluroquinolones (ofloxacin) eye drops. Patient stopped developing new lesions after stopping ofloxacin eye drops and responded well to parenteral steroids. Patient was instructed to avoid fluroquinolones in all formulations.  

Mithra Vasanth Vignesh is a prominent figure in the field of dermatology, known for her expertise and commitment to advancing patient care. As the founder & chief dermatologist of Cutis Parasol Skin/Hair/Nail/Laser Clinic in Chennai, she has established herself as a leader in the industry. Additionally, she serves as a consultant dermatologist at prestigious institutions such as Chettinad Super Speciality Hospital and Kauvery Hospital, Radial Road. She completed MD (DVL) at Govt. Stanley Hospitals and Medical College, Chennai. A dermatologist with vivid interest in clinical dermatology and aesthetic medicine. She embarked her journey in research way back during under-graduation and is actively involved in research and publications. A person with a keen interest in adapting to innovative technologies and incorporating evidence based medical practices to improvise the treatment given to the patients