Tzanck smear

Author: Dr Julie Fraser, Intern, Modbury Hospital, Adelaide, Australia. Chief Editor: Hon
A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. October 2015.

What is a Tzanck smear?

The Tzanck smear test is a simple and cheap test that relies on viewing and interpretation of
single cells (cytology).
Arnault Tzanck described the technique in 1947 to distinguish various blistering conditions.
The test is not often performed, due to the development of histology, virological culture,
polymerase chain reaction (PCR) and electron microscopy.1

Indications for Tzanck smear

The Tzanck smear is mainly used in an acute setting to rapidly detect a herpes infection or to
distinguish Stevens- Johnson syndrome / toxic epidermal necrolysis (SJS/TEN) from
staphylococcal scalded skin syndrome. However, it can be used to diagnose a variety
cutaneous infections and blistering diseases.

How is a Tzanck smear prepared?

Select a fresh blister on the patient.

Using a blunt scalpel blade, gently deroof the lesion

Scrape the base of the lesion

Smear the tissue onto a clean microscope slide

Allow it to dry in the air

Fix the specimen with preservative

Taking a Tzanck smear

Deroof blister

Smear onto slide

Air dry

Add fixative

What happens in the laboratory?

The slide is stained. The choice of stain depends on the sample and diagnostic possibilities.

Giemsa stain
Giemsa stain is poured over the slide. After 15 minutes, the slide is washed with sterile water.

Cell cytoplasm stains blue

Nuclei stain purple/red/pinkish

Toluidine blue
Toluidine blue is more rapid, as it only requires staining for 60 seconds.2

Tzanck smear interpretation

Characteristic cytological findings of Tzanck smears follow.3

Cutaneous infections

Bacterial infections
o Bullous impetigo: dyskeratosis, acantholytic cells, clusters of cocci, abundant
neutrophils
o Staphylococcal scalded skin syndrome: dyskeratosis, acantholytic cells, no or
little inflammation, cocci, absence of abundant neutrophils

Viral infections
o Herpes simplex and herpes zoster: Ballooning multinucleated giant cells and
eosinophilic inclusion bodies
o Viral warts: koilocytes
o Molluscum contagiosum: intracytoplasmic inclusion bodies ("HendersonPatterson's bodies")
o Hand foot and mouth disease: syncytial nuclei, absence of acantholytic cells

Fungal infections
o Candidiasis: pseudohyphae and spores
o Histoplasmosis
o Cryptococcosis
o Sporotrichosis: spherical, oval or cigar-shaped yeasts and asteroid bodies

Parasites
o Scabies: Sarcoptes scabiei (4 pairs of legs and multiple dorsal cuticular spines)
o Leishmaniasis: ellipsoid-shaped Leishman-Donovan bodies, Wright's cells

Tzanck smear in herpes simplex (B&W)

Blistering diseases

Pustular disease of the newborn: exclude infection, neutrophils observed in toxic

erythema of the newborn

Pemphigus vulgaris: acantholytic cells

Stevens- Johnson syndrome / toxic epidermal necrolysis (SJS/TEN: necrotic basal

cells, leukocytes, fibroblasts

Cutaneous neoplasms

Melanoma: atypical melanocytes

Basal cell carcinoma: clusters of basaloid cells.

Seborrhoeic keratosis: hyperkeratosis, horny cysts

The Tzanck smear test was found to have similar diagnostic accuracy to dermatoscopy in
pigmented skin lesions.4

Inflammatory skin diseases

Allergic contact dermatitis: tadpole cells, lymphoctyes

Irritant contact dermatitis: tadpole cells, polymorphonuclear leukocytes

Necrobiosis lipoidica: palisading granuloma, necrobiotic material

Foreign body granuloma: foreign body

Advantages and disadvantages of Tzanck smear test

Initial results from a Tzanck smear should normally be confirmed by other techniques, such
as biopsy or PCR.

Advantages

Tzanck smear has the following benefits:

It is inexpensive

It results in minimal discomfort to patients

It is quick: useful for initial evaluation, or when rapid diagnosis required or in

recurrences of disease. Faster diagnosis leads to early initiation of treatment.

Disadvantages
Tzanck smear requires expertise:

In preparing the slide

In interpreting cytology

False negatives may occur in early or late disease.

Related information
References:
1. Weller, Richard; Hunter, Hamish; Mann, Margaret W. Clinical Dermatology.[Internet]
5th Ed. Wiley, 11 January 2014 p39 [cited 20 September 2015]
2. Kelly B, Shimoni T Reintroducing the Tzanck Smear, Am J Clin Dermatology 2009;
10 (3): 141-152. PDF Downloaded from Gale Expanded Academic 28th September
2015
3. Dey VK, Thawani M, Dubey N. Accuracy and reliability of Tzanck test compared to
histopathology for diagnosis of basal cell carcinoma. Indian J Dermatopathol Diagn
Dematol 2015:2:8-13. Downloaded from http://www.ijdpdd.com September 18 2015.
IP:118.210.84.241
4. Durdu M, Baba M, Sekin D. Dermatoscopy versus Tzanck smear test: a comparison
of the value of two tests in the diagnosis of pigmented skin lesions. J Am Acad
Dermatol. 2011 Nov;65(5):972-82. doi: 10.1016/j.jaad.2010.08.019. Epub 2011 May
11. PubMed PMID: 21565420.