Introduction: Herpes zoster (HZ) is the prototypical cause of zosteriform   dermatoses. Additionally, many infectious, inammatory, and neoplastic   conditions may mimic this distribution pattern. Immuno compromised patients, such as those with end-stage renal disease (ESRD), are predisposed to both  infectious and reactive skin conditions. In these cases, HZ may present with  atypical morphologies, leading to diagnostic challenges. This report presents a case   of atypical herpes zoster in a patient with chronic kidney disease (CKD) showing   dimorphic ulcerative ecthymatous lesions and crusted umbilicated papulonodules   mimicking reactive perforating collagenosis (RPC). This report highlights the  importance of histopathology in distinguishing these conditions.  Case Report: A 48-year-old male with stage - VCKD on haemodialysis, presented  with acute onset of unilateral, multiple painful papulonodules culminating into ulcers over the right lower back and abdomen. The lesions were diverse ranging  from punched out ulcersto umbilicated papules with central keratotic crusting.  This evoked the differentials of ecthyma or segmental RPC. None of the past or  present lesions were vesicular. Investigations revealed anaemia, deranged sugar  levels and renal function parameters. Bacterial cultures showed no growth, while  Tzanck smear demonstrated multinucleated giant cells. Skin biopsy revealed viral   cytopathic changes and follicular involvement typifying herpes viral infection.  The patient responded well to renal-adjusted acyclovir therapy, with signicant   improvement in symptoms and healing of ulcers.