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Management of urticaria. Allergy 2006;61:321-31. 2. Hurst M, Spencer CM. Ebastine: An update of its use in allergic disorders. Drugs 2000;59:981-1006. 3. Sastre J. Ebastine in allergic rhinitis and chronic idiopathic urticaria. Allergy 2008;63:1-20. 4. Godse KV. Updosing of antihistamines to improve control of chronic urticaria. Indian J Dermatol Venereol Leprol 2010;76:61-2. 5. Frossard N, Benabdesselam O, Purohit A, Mounedji N, Pauli G. Activity of ebastine (10 and 20 mg) and cetirizine at 24 hours of a steady state treatment in the skin of healthy volunteers. Fundam Clin Pharmacol 2000;14:409-13. 6. Magerl M, Schmolke J, Metz M, Zuberbier T, Siebenhaar F, Maurer M. Prevention of of dermographic urticaria by single-dose ebastine 20 mg. Clin Exp Dermatol Figure 1: Multiple purpuric lesions present all over the legs, barring the 2009l;34: E137-40. area over left upper leg which was covered by pressure bandage. Arrow points to the site of biopsy 7. Gillen MS, Miller B, Chaikin P, Morganroth J. Effects of supratherapeutic doses of ebastine and terfenadine on the QT interval. Br J Clin Pharmacol 2001;52:201-4. complain of arthralgia, abdominal pain, dyspnea or any other significant systemic symptom. On examination, multiple Access this article online palpable purpura were present over both legs extending up Quick Response Code: to the thighs. There was no ulceration, necrosis, vesiculation Website: www.e-ijd.org or livido reticularis. Systemic examination was normal. Complete hemogram, liver function tests, kidney function tests, serum electrolytes, urine routine examination, DOI: 10.4103/0019-5154.87168 stool for occult blood and chest X-ray did not reveal any abnormality. Anti-nuclear antibodies and rheumatoid factor were negative. Histopathological examination of a skin biopsy specimen taken from the purpuric lesion on left leg showed features consistent with leukocytoclastic vasculitis. Direct immunofluorescence of another skin biopsy specimen showed IgG immune complex and C3 REVERSE KOEBNER complement deposits in vessel walls. Patient returned for follow-up after 10 days. Till then, she had not opened the PHENOMENON IN pressure bandage applied at the biopsy site. After removal LEUKOCYTOCLASTIC VASCULITIS of the bandage, we observed that the vasculitic lesions in the bandage covered areas had disappeared [Figure 1]. S Yadav, D De, A J Kanwar There were many new lesions elsewhere over the limbs, barring the area which was covered by the bandage. From the Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, The exact etiopathogenesis of Koebner phenomenon and Chandigarh, India. E-mail: [email protected] reverse Koebner phenomenon are poorly understood. Koebner phenomenon has been recently reviewed by Weiss Indian J Dermatol 2011:56(5):598-9 et al.[5] Koebnerization can be induced by various modes Sir, of trauma. Chronic pressure leading to both epidermal described Koebner phenomenon and dermal injury is known to elicit Koebner response.[6,7] for the first time in patients.[1] Since then, it There are few reports of Koebner phenomenon occurring has been reported in various dermatoses. Contrary to in patients with vasculitis.[8,9] However, there is no previous Koebner phenomenon, reverse Koebner response is the report of reverse Koebner phenomenon in vasculitis. nonappearance or disappearance of the lesions of particular Reverse Koebner phenomenon is a rarely reported entity. dermatoses at the site of injury. It is a very rare condition It was first described in psoriasis patient[2] and subsequently with only few cases reported till date.[2-4] We present to the reported in cases.[3] Our understanding of reverse best of our knowledge, the first case of reverse Koebner Koebner phenomenon is poor because of its scant phenomenon occurring in a patient of cutaneous small occurrence and limited research into its pathogenesis. vessel immune complex vasculitis. In our patient, purpuric lesions cleared and new lesions A 32-year-old female patient presented to our outpatient failed to appear at the pressure site, probably because department with recurrent crops of reddish palpable spots the mechanical pressure led to diminished blood flow in over both the lower limbs for last 6 months. She did not the small vessels of dermis and the immune complexes

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failed to deposit in adequate concentration. Consequently, 2Department of Pathology, Kasturba Medical College, 3Derma- adequate immune response was not elicited, which is of care, Skin and Cosmetology Centre, Mangalore, India. E-mail: paramount importance for precipitation of clinical lesion. It [email protected] is difficult to explain the fast clearance of the old lesions Indian J Dermatol 2011:56(5):599-600 covered under the bandage. Sir, Reverse Koebner phenomenon has never been reported A 14-year-old girl presented with an exuberant warty before in vasculitis. Further research is needed to study the brownish growth on her right great toe. A history revealed pathogenesis of this phenomenon. that when she was 4 years old, she had a small similar lesion, a part of which was biopsied by a general surgeon References and was reported as angiokeratoma. 1. Kobner H. Zur aetologie der psoriasis. Vierteljahrsschr Dermatol Examination revealed a solitary hyperpigmented, Syphil 1877;8:559. hyperkeratoic plaque consisting of closely set warty 2. Grekin DA, Van Scott EJ. Dermal role and controls in psoriasis. Arch Dermatol 1973;108:425. papules measuring 3 cm × 3.5 cm involving the pulp space of the right great toe. Surface of the lesion was firm 3. Malakar S, Dhar S. Spontaneous repigmentation of vitiligo patches distant from the autologous skin graft sites: A remote and verrucous with no ulceration, bleeding or atrophy reverse Koebner’s phenomenon? Dermatology 1998;197:274. [Figure 1]. The lesion was non-compressible and diascopy 4. Martin JM, Conde A, Pinazo I, Garcia L, Sanchez AL, Pinazo J, was negative. Regional lymph nodes were not enlarged. et al. Reverse Koebnerization after radiotherapy in a woman Systemic examination was normal. Routine laboratory with a mastectomy for a breast carcinoma. J Am Acad Dermatol investigations and X-ray chest were also found to be 2006;55: S90-1. normal. 5. Weiss G, Shemer A, Trau H. The Koebner phenomenon: Review of the literature. J Eur Acad Dermatol Venereol 2002;16:241-8. The patient was then considered for surgery. A wide 6. Farber EM, Roth RJ, Aschheim E, Eddy DD, Epinette WW. Role local excision of the lesion was done and the defect was of trauma in isomorphic response in psoriasis. Arch Dermatol closed by an islanded plantar digital artery flap in a V-Y 1965;91:246-51. fashion adjacent and just prominal to the excision wound. 7. Bernstein EF, Kantor GR. Treatment-resistant psoriasis due to The excised specimen was sent for histopathological a mastectomy sleeve: An extensive Koebner response. Cutis examination. We considered a clinical diagnosis of 1992;50:65-7. tuberculosis verrucosa cutis and angiokeratoma. 8. De D, Dogra S, Kanwar AJ. Isomorphic response of Koebner in a patient with cutaneous small vessel vasculitis. J Eur Acad Hematoxylin and eosin stained section of the specimen Dermatol Venereol 2008;22:1125-6. showed marked hyperkeratosis, parakeratosis, 9. Chan LS, Cooper KD, Rasmussen JE. Koebnerization as a papillomatosis, and elongation of the rete ridges. To our cutaneous manifestation of immune complex-mediated vasculitis. surprise, it extended from the derma-epidermal junction J Am Acad Dermatol 1990;22:775-81. into the deeper dermis, where numerous small to large vascular channels were seen lined by flattened endothelial Access this article online cells and filled with blood. Intervening dermal fibrosis and Quick Response Code: chronic inflammatory infiltrate was also present [Figure 2]. Website: www.e-ijd.org This is not a finding of angiokeratoma as it involves only the papillary dermis without any extension to the deep dermis and the subcutaneous fat. DOI: 10.4103/0019-5154.87169 Based on this clear histopathological evidence, a correct diagnosis of verrcuous hemangioma was made which had earlier been interpreted as angiokeratoma on superficial biopsy. Verrucous hemangioma is a rare variety of angiomatous nevi usually involving the lower extremities.[1] Lesions are VERRUCOUS HEMANGIOMA OR mostly seen at birth or appear during childhood. Initially, they are soft, bluish-red vascular lesion, but with time they ANGIOKERATOMA? A MISSED enlarge and develop keratotic and verrucous features.[2] DIAGNOSIS Clinically verrucous hemangioma simulates angiokeratoma, but histopathologically they can be clearly differentiated as 1 2 3 S Pavithra, H Mallya , H Kini , G S Pai the former involves the dermis and subcutaneous fat and the latter involves only the papillary dermis.[1] From the Derma-care, Skin & Cosmetology Center, 1Departments of Obstetrics and Gynaecology, The K S Hegde Medical Academy, This differentiation is important for the management of

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