Bilateral Koebner phenomenon in lichen sclerosus et atrophicus

Friction-Aggravated Skin Disorders-A Review of Mechanism and Related Diseases

ABSTRACT

Skin is subject to frequent friction injury. Friction affects different structures of the skin, including keratinocytes, melanocytes, fibroblasts, and follicular units. Friction can also stimulate cytokine production. Friction is sensed by the mechanoreceptors, resulting in signal transduction to the nucleus, activating transcription factors and mechanoresponsive genes. Numerous friction-aggravated diseases have been identified, including inflammatory, depositional, follicular, genetic, infectious, and vesiculobullous disorders. Friction, as a potential modifiable aggravator, should be considered when skin diseases are located at friction-prone areas.

A Listing of Skin Conditions Exhibiting the Koebner and Pseudo-Koebner Phenomena with Eliciting Stimuli

Background:

The Koebner phenomenon was first described in 1872. It occurs after a variety of traumatic insults. New examples of koebnerization are reported each decade.

Objective:

We have compiled, for the first time in the dermatologic literature, an extensive list of the cutaneous diseases reported to demonstrate koebnerization, correlated in each case with the precise source of trauma. Cutaneous diseases reported to show a pseudo-Koebner phenomenon and the corresponding mechanism of trauma are also detailed.

Methods:

A search and review of the English language literature on MEDLINE was made to identify cutaneous diseases exhibiting the Koebner phenomenon and the correlated mechanism of trauma.

Results:

Results of our efforts are cataloged in table format.

Conclusion:

We present an extensive list of cutaneous diseases reported to exhibit the Koebner and pseudo-Koebner phenomena, correlating each entry with the mechanism of trauma.

A Case of Lichen Sclerosus et Atrophicus With Distinct Erythematous Borders

BACKGROUND

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory and fibrosing condition that mostly affects the genital mucosa. Nongenital skin may be affected either in isolation or in association with genital involvement. A distinct, brightly red border may be seen but is poorly documented in major dermatology texts. In the case presented, such a border was noted in all of the patient's very extensive lesions.

OBJECTIVE

To draw attention to this clinical manifestation and to stimulate future observations as to its clinical and prognostic significance.

METHODS AND RESULTS

A 67-year-old woman presented with disseminated LSA with genital involvement. All the lesions had a distinct red border. A review of major textbooks available to the authors revealed that the presence of a marginal erythema is regularly not mentioned.

CONCLUSION

An erythematous border to LSA may be a notable feature. Its frequency and clinical significance remain to be determined.

Significant improvement in extensive lichen sclerosus with tacrolimus ointment and PUVA

Lichen sclerosus is an uncommon, chronic inflammatory skin disorder of unknown origin. It is clinically characterized by sclerotic, whitish, atrophic-type lesions. The most frequent site of the lesions is generally the genital region, with about 15-20% having additional extragenital involvement. We present the case of a 62-year-old woman with a very extensive extragenital lichen sclerosus who showed great clinical and subjective improvement with 0.1% tacrolimus ointment and psoralen plus UVA (PUVA), without any topical or systemic adverse effects. Combined treatment of 0.1% tacrolimus ointment and PUVA may be a good option in extensive cases of lichen sclerosus or when other treatment options have failed, and has a good tolerability and safety profile.

Köbnerization in a woman with generalized lichen sclerosus

A 52-year-old woman presented with an 18-month history of genital and extragenital lichen sclerosus. In addition to the classical genital findings, lesions of lichen sclerosus were present over her back, chest and the medial aspect of her right thigh and leg. On her right thigh and extending to her right leg, lesions of lichen sclerosus displaying the Köbner response were noted over the course of a varicosed long saphenous vein. There were no features of varicose dermatitis in the region displaying the Köbner response. It is proposed that the ambulatory venous pressure within the vein acted as a stimulus for the Köbner response.

The Koebner phenomenon: review of the literature

First described in 1877 as the appearance of psoriatic lesions in the uninvolved skin of psoriatic patients as a consequence of trauma, the Koebner phenomenon has since been described in numerous diseases. Other authors have tried to implicate either infections or parasitic causes as the pathogenesis of this phenomenon. Subsequent research by many authors have contributed to our poor understanding of this reaction in the hope of understanding the pathogensis of psoriasis. We present a review of the literature covering the following topics as they relate to the Koebner phenomenon: diseases that koebnerize and their possible causes, predisposing and provoking factors, type, site, depth and degree of trauma, the all or none phenomenon, time lag, site preference, medications, inhibition of koebnerization and reverse koebnerization.

Histologic features of lichen sclerosus et atrophicus in a surgical scar

A 76-year-old woman presented with a 7-mm, hard, pink nodule at the site of an appendectomy scar of more than 70 years' duration. The clinical impression at the time of biopsy was that of a keloid. Surprisingly, light microscopic examination revealed classic histologic features of late-stage lichen sclerosus et atrophicus (LSA) overlying a scar. Elastic tissue stain highlighted the unusual presence of abundant nodules of elastin in the reticular dermis only.

Lichen sclerosus following the lines of Blaschko

A case of lichen sclerosus that developed in a pattern corresponding to the lines of Blaschko is described. This pattern of extragenital lichen sclerosus has not, to our knowledge, previously been reported and could result from an epidermal clone with altered androgen sensitivity supporting a hormonal pathogenesis for this disease.

Lichen sclerosus

Lichen sclerosus, usually appearing in the dermatologic literature under the names of lichen sclerosus et atrophicus, balanitis xerotica obliterans, and kraurosis vulvae, is an inflammatory disease with a multifactorial origin. A past association of lichen sclerosus and genital squamous cell carcinoma is not as close as once thought. Once considered primarily a surgical problem, especially when the genitals were involved, lichen sclerosus will respond to a variety of systemic and topical therapies.

Extensive lichen sclerosus et atrophicus with bullae and ulceration--improvement with hydroxychloroquine

A 55-year-old woman is described with a short history of generalized lichen sclerosus et atrophicus in whom extensive blistering and ulceration occurred. The disease was confined to extragenital sites at presentation, with no clinical evidence of mucosal involvement. The degree of blistering, rapid evolution and widespread involvement of non-genital skin in this case are uncommon features. There was evidence of improvement following treatment with hydroxychloroquine. We suggest that this drug may be of therapeutic benefit in cutaneous lichen sclerosus.

Lichen sclerosus and the Köbner phenomenon

Two patients with lichen sclerosus (et atrophicus) are described in whom there was conspicuous localization of lesions to sites subjected to friction from tight clothing. This was highly suggestive of the Köbner phenomenon. Both patients experienced symptomatic improvement following avoidance of pressure on the skin from tight clothing.

The Koebner phenomenon in eruptive xanthoma

A 49-year-old woman with Type V hyperlipidemia had yellow papules smaller than 3 mm in diameter with red haloes on her elbows, shoulder, buttocks, and hands. Two linear lesions composed of papules arising at the sites of skin previously injured by a cat scratch were observed. Histopathological examination of these papules revealed the presence of many foam cells in the dermis which stained positively with oil red O stain. A survey of the literature found only 5 cases of the Koebner phenomenon in xanthoma.

Lichen sclerosus et atrophicus in children and young adults

We performed a retrospective study of 52 children and young adults (average age 18 yrs) with lichen sclerosus et atrophicus. In 56% of patients the eruption was still present after a follow-up of 7.5 years. Younger patients were most likely to show improvement. The histologic appearance of both groups (patients with persistent lesions and those with resolution of lesions) showed classic features of lichen sclerosus et atrophicus: homogenized collagen with an underlying bandlike lymphocytic infiltrate. Epidermal changes such as atrophy, hyperplasia, and follicular plugging were slightly more prominent in patients with persistent lesions. Menarche, pregnancy, and the presence of extragenital lesions had no effect on the prognosis, but since the condition resolved, on average, during adolescence, unknown developmental factors may be implicated.