Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2025;15(3):5363 1 Flagellate Rash in Chikungunya: A Comprehensive Review of Dermatological Manifestations Nikhil Mehta1, Sonali Gupta1, Sathvi K M1, Neetu Bhari1 1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India Key words: Chikungunya fever, Flagellate rash Citation: Mehta N, Gupta S, KM S, et al. Flagellate Rash in Chikungunya: A Comprehensive Review of Dermatological Manifestations. Dermatol Pract Concept. 2025;15(3):5363. DOI: https://doi.org/10.5826/dpc.1503a5363 Accepted: March 10, 2025; Published: July 2025 Copyright: ©2025 Mehta et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Neetu Bhari, MD, Associate Professor, Department of Dermatology and Venereology, All India Institute of Medical Sciences, 110029, New Delhi, India. ORCID: 0000-0002-4604-3917. E-mail: drntbhari@gmail.com Case Presentation A middle-aged male presented with moderately itchy hyper- pigmented streaks over the trunk and upper limbs along with transient fever and severe persistent joint pains over the pre- vious two months. He was diagnosed to have chikungunya fever (CF) through IgM serology and was treated symptom- atically. At the onset, he had severe itching and streaks of erythema which gradually transitioned to flagellate streaky/ whip-lash pattern of hyperpigmentation (Figure 1). He was counselled about its expected resolution with time and was symptomatically treated with antihistamines and had com- plete resolution in the next two months. Teaching Point Cutaneous manifestations in CF are seen in 40%–75% cases, usually within the first week, and resolve without complications/sequelae except for pigmentation [1]. Mac- ulopapular rash is the most common manifestation, ap- pearing at the onset, during, or after the fever, lasting one to seven days. Other manifestations include transient na- sal erythema, generalized erythema, tender swollen hands and feet, multiple aphthous-like ulcers, vesiculobullous, purpuric/hemorrhagic, and vasculitic lesions. Pigmentary manifestations include centrofacial and freckle-like diffuse pigmentation of face, pinna, and extremities. Flagellate pig- mentation is rare, reported in 2/145 (1.38%) suspected chi- kungunya cases [2]. Hypermelanosis is post-inflammatory. Chikungunya virus alters melanin dispersion or retention, with melano- phages contributing to prolonged pigmentation. Flagellate pigmentation may result from microtrauma, inflammatory oncotaxis, increased melanogenesis, or reduced epidermal turnover. Intense itching and scratching due to chemother- apeutic drugs (bleomycin, docetaxel), rheumatological dis- eases (dermatomyositis, Still’s disease), and toxin-induced reactions (shiitake mushroom, poison ivy) can cause flagel- late rashes. In conclusion, CF presents diverse mucocutaneous mani- festations, including flagellate pigmentation, emphasizing its complex dermatological impact. 2 Image Letter | Dermatol Pract Concept. 2025;15(3):5363 References 1. Bandyopadhyay D, Ghosh SK. Mucocutaneous manifestations of Chikungunya fever.  Indian J Dermatol. 2010;55(1):64-67. DOI:10.4103/0019-5154.60356. PMID: 20418979 2. Inamadar AC, Palit A, Sampagavi VV, Raghunath S, Deshmukh NS. Cutaneous manifestations of chikungunya fever: observations made during a recent outbreak in south India. Int J Dermatol. 2008;47(2):154-159. DOI:10.1111/j.1365-4632.2008.03478.x PMID:18289359 Figure 1. Chikungunya fever-associated flagellate rash over the trunk and extremities in a middle-aged male: (A) back; (B) chest; (C,D) closer view of side of chest and axilla.