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Resident's Page Resident’s Page The isomorphic phenomenon of Koebner Devinder Mohan Thappa Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India. Address for correspondence: Dr Devinder Mohan Thappa, Professor and Head, Department of Dermatology and STD, JIPMER, Pondicherry - 605006, India. E-mail: [email protected] The Koebner (isomorphic) phenomenon (response) is for National Culture, he presented the phenomenon probably one of the most well known phenomena in that bears his name,4 and 4 years later published a paper dermatology and is named after the man who was the describing his original patient. The mechanism of first to describe it.1 The isomorphic phenomenon is experimentally producing such a reaction was known now well documented in a number of skin diseases. as the Koebner experiment.2 Since the time of Koebner, this phenomenon has been the subject of research by DEFINITION several authors. The Koebner phenomenon is the development of TYPES OF KOEBNER PHENOMENON isomorphic pathologic lesions in the traumatized uninvolved skin of patients who have cutaneous Boyd and Neldner have classified all reported cases of diseases.2 It refers to the fact that in persons with Koebner phenomenon into four different groups:4 certain skin diseases, especially psoriasis, trauma is 1. True isomorphic phenomenon: There appear to followed by new lesions in the traumatized but be three disease processes that display the true otherwise normal skin, and these new lesions are isomorphic response of Koebner: psoriasis, lichen clinically and histopathologically identical to those in planus and vitiligo; the diseased skin.3 2. Pseudoisomorphic phenomenon: The Koebner phenomenon seen in infectious diseases, e.g. HISTORICAL BACKGROUND warts, molluscum contagiosum and Behcet’s disease and pyoderma gangrenosum; Heinrich Koebner (1838-1904), one of the outstanding 3. Occasionally occurring isomorphic phenomenon: dermatologists of the 19th century, is not only well In this category, diseases occasionally localize to known as the person who first described the Koebner sites of trauma, e.g. cancer (gastric, testicular or phenomenon in psoriasis, but also as a founder of the mammary), Darier’s disease, erythema multiforme, university dermatology clinic and pioneer of Hailey-Hailey disease, Kaposi’s sarcoma, Kyrle’s dermatology in Breslau.1,2 His initial observations and disease, lichen sclerosus et atrophicus, pellagra, studies resulted from having seen patients who had perforating folliculitis, reactive perforating developed psoriasis at sites of excoriations, horse bites, collagenosis, and and tattoos. In 1872, at a meeting of the Silesian Society 4. Questionable isomorphic phenomenon: There are How to cite this article: Thappa DM. The isomorphic phenomenon of Koebner, Indian J Dermatol Venereol Leprol 2004;70:187-9. Received: April, 2004. Accepted: May, 2004. Source of Support: Nil. 187 Indian J Dermatol Venereol Leprol May-June 2004 Vol 70 Issue 3 Thappa DM: The isomorphic phenomenon of Koebner many conditions that have been associated with Grenz ray therapy, roentgen therapy, iodine application, the Koebner phenomenon, many of which are ultraviolet light).4 single case reports. This includes: anaphylactoid purpura, bullous pemphigoid, dermatitis PATHOGENESIS OF KOEBNER RESPONSE herpetiformis, discoid lupus erythematosus, The pathogenesis of Koebner phenomenon is not eczema, erythrokeratoderma variabilis, known.2 There have been few experimental studies keratoacanthoma, lichen amyloidosis, lichen outside the field of psoriasis.4 Speculative pathogenetic nitidus, multicentric reticulohistiocytosis, factors involved are immunologic, vascular, dermal, nevocytic nevi, pityriasis rubra pilaris, enzymatic, inhibitory, neural, growth, genetic and porokeratosis of Mibelli, urticaria pigmentosa, hormonal factors. There is growing evidence that urticarial eruption of Still’s disease, telangiectasia immunologic factors are involved in the pathogenesis macularis eruptive perstans, transient acantholyic of psoriasis and consequent Koebner response to dermatosis, vasculitis, and xanthoma eruptivum. trauma. According to some investigators, capillary Recently, isomorphic response has been noted in changes in the dermis precede all other morphologic morphea,5 necrobiosis lipoidica diabeticorum,6 changes. Kaposi’s sarcoma,7 pemphigus vulgaris,8 aspergillosis,9 scleromyxoedema,10 granuloma Koebner response in psoriasis annulare,11 and PLEVA.12 In several cases of lupus The reported incidence of Koebner response in erythematosus, the Koebner phenomenon has psoriasis varies from 11-75%. The latent period between been seen in the apparently normal skin of patients injury to uninvolved skin and appearance of disease is following trauma, excoriation, operation scars, usually 10-14 days, but it may range from 3 days to contact dermatitis, pressure from sock tops, several years.4 The Koebner response is more likely to application of liquid nitrogen, exposure to strong occur when psoriasis is unstable or flaring and less likely sun light, etc.13 with quiescent or resolving psoriasis. More severe injury may result in more extensive skin lesions. The CAUSES OF THE KOEBNER RESPONSE involuting central portion of a psoriatic plaque is refractory to the experimental induction of psoriasis Koebner response may follow: (1) mechanical or thermal and has been called the “zone of immunite locale”.2 trauma (due to animal bites, burns, electrodesiccation, The Koebner response appears to have no anatomic excoriation, freezing, friction, gunshot wounds, insect site preferences. It occurs more frequently in the winter bites, lacerations, nail manicuring, poor fitting shoes, than in the summer.4 Medications may provoke an pressure, shaving, surgical grafts, surgical incision, tape allergic, irritant, or photosensitive type reaction in a stripping, thumb sucking), (2) dermatoses (such as patient, any of which may be considered a potential, carbuncles/furuncles, dermatitis, dermatitis albeit nonspecific, precipitator of the Koebner herpetiformis, dermatophytosis, diaper dermatitis response. secondary to Candida infection, eczema, epidermal inclusion cyst, folliculitis, herpes simplex, herpes zoster, In vitiligo, Koebner phenomenon has been recorded in lichen planus, lymphangitis, measles, miliaria, perianal 5% of cases in an Indian study.14 Corynebacterium minutissimum infection, perianal neurodermatitis, pityriasis rosea, psoriasis, scabies, All or none phenomenon in isomorphic response seborrheic dermatitis, varicella, vitiligo), (3) allergic or Pedace et al15 found that if a patient reacted to one irritant reactions (following BCG vaccination, hair spray, experimental stimulus, he would react to all. hair tints, influenza vaccination, photosensitivity, Conversely, lack of a positive response to a known positive patch testing, scratch skin test, tattoos, Koebner inducing stimulus predicted failure of other tuberculin skin test, urticaria), and (4) therapy (such as stimuli in the series. They termed this positive and Indian J Dermatol Venereol Leprol May-June 2004 Vol 70 Issue 3 188 Thappa DM: The isomorphic phenomenon of Koebner negative reactivity, the all or none phenomenon.15 lesions and fundamentals of diagnosis. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, Fitzpatrick TB, editors. Fitzpatrick’s Dermatology in general medicine. 5th The “reverse” Koebner response Ed. New York: McGraw-Hill 1999:32-3. The reverse Koebner reaction is seen when an area of 4. Boyd AS, Neldner KH. The isomorphic response of Koebner. psoriasis clears following injury.4 It has followed Int J Dermatol 1990;29:401-10. electrodesiccation, sandpaper abrasion, following 5. Tosti A, Manuzzi P, Bardazzi F. Isomorphic phenomenon in morphea. Dermatologica 1988;177:92. infections (rubeola, colds, and acute tonsillitis) and 6. Llajam MA. Koebner’s phenomenon and necrobiosis lipoidica surgery. Spontaneous repigmentation of vitiligo diabeticorum. Br J Clin Pract 1990;44:765. patches distant from the autologous skin graft sites 7. Berkowitz KD, Bonner AC, Makimaa B, Flash JP, Sasken H, Blaise has been termed as a “remote reverse Koebner JF. Trauma-induced Kaposi’s sarcoma of the hallux. An unusual phenomenon”.16 case. J Am Podiatr Med Assoc 1998;88:500-5. 8. Cerottini JP, Burren R, Panizzon RG. Pemphigus vulgaris occurring simultaneously on a recent and an old surgical scar due to a CLINICAL SIGNIFICANCE OF KOEBNER PHENOMENON Koebner’s phenomenon. Eur J Dermatol 2000;10:546-7. 9. Williams G, Moiemen N, Frame JD. Aspergillosis presenting as Apart from its importance in clinical diagnosis, the Koebner’s phenomenon in a healed scald. Burns 2000;26:92-6. 10. Durani BK, Kurzen H, Hartschuh W, Naeher H. Koebner 4 Koebner phenomenon signifies activity of the disease. phenomenon due to scratch test in scleromyxoedema. Br J It guides the clinician to avoid physical/chemical irritants, Dermatol 2001;145:306-8. surgical procedures and to treat underlying or concurrent 11. Borgia F, Cannavo SP, Guarneri F, Manfre C, Vaccaro M. diseases in order to better manage their cases. Koebner Isomorphic response after saphenectomy in a patient with granuloma annulare. J Am Acad Dermatol 2004;50:31-3. phenomenon can occur in distant wounds of patients 12. Inamdar AC, Palit A. Koebner phenomenon in PLEVA. Indian J 17 with pre-existing cutaneous diseases. Thus, surgeons Dermatol Venereol Leprol 2003;69:225-6. should be aware of this entity and should warn their
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