Silva, C

Torres, T.

Repositório Científico da Unidade Local de Saúde de Santo António

CLINICAL310 AFP VOL.45, NO.5, MAY 2016 © The Royal Australian College of General Practitioners 2016Carla Ferreira da Silva, Tiago TorresDevelopment of erythematous scaly lesions in a cervical surgical scarCase A woman, 58 years of age, presented with a scaly rash along a surgical scar. She had a history of type 2 diabetes mellitus, hypertension and psoriasis, which had been followed up by a dermatologist since adolescence. Previous therapies for the psoriasis included topical therapy, phototherapy, methotrexate and acitretin. Because of a lack of improvement on these therapies, she started etanercept 50 mg/week, experiencing an excellent response. The patient was diagnosed with squamous cell carcinoma of the tongue after 12 months of etanercept therapy. Etanercept was ceased and the patient underwent right partial glossectomy and selective cervical lymph node dissection. Ten weeks after surgery, she developed a 1–3 cm erythematous, non-pruritic, painless, scaly lesion located solely at the cervical surgical scar (Figure 1A, B).Question 1What is the most likely diagnosis in this patient?Question 2What differential diagnoses would you consider?Question 3In which skin disorders can this phenomenon also occur?Question 4What therapeutic measures would you recommend?Answer 1Based on the patient´s history and the appearance of the lesions, the most likely diagnosis is psoriasis located solely at the surgical scar. The development of psoriatic lesions on uninvolved skin of patients with psoriasis as a consequence of trauma can occur and is called Koebner phenomenon (KP). The appearance of lesions typically takes 10–20 days following the trauma. Not all kinds of trauma lead to the phenomenon, and lesions do not follow any anatomical preference as they can occur in areas that are usually spared by the disease.1 The Koebner response usually follows mechanical or thermal trauma, dermatoses, or allergic or irritant reactions.2 Its pathogenesis is unknown, although several theories have been proposed. The impact of KP varies A BFigure 1. Erythematous scaly lesions located at the cervical scaraccording to the underlying disease. A possible explanation for why psoriasis preferentially occurs at scar sites is that changes in vascularity, presence of microscarring or chronic mast cell infiltration may induce memory of an inflammatory event.1 However, the complex mechanisms that trigger the phenomenon are not fully understood.Answer 2Psoriasis lesions may sometimes be confused with eczema, although eczema is usually more pruritic and has less thick scaling than psoriasis.3 Fungal infections can look very similar, especially when compared to partially resolved psoriasis, which typically shows central clearing. Skin tumours can also mimic psoriasis lesions and should be suspected in cases of an isolated lesion similar to a plaque of psoriasis that slowly enlarges despite treatment.4In the case of this patient, the history of neck surgical intervention cannot be overlooked; therefore, another differential diagnosis is surgical wound infection. However, this hypothesis is less likely because the patient did not present with fever, skin swelling, fluid collection or purulent discharge. Answer 3Other skin diseases can arise at sites of cutaneous injury, resulting in an isomorphic response similar to that seen with psoriasis.5 KP can be divided 311ERYTHEMATOUS SCALY LESIONS  CLINICALAFP VOL.45, NO.5, MAY 2016© The Royal Australian College of General Practitioners 2016into four categories depending on the mechanism of trauma:6• True Koebnerisation – KP is reproducible in all patients following a variety of insults (except secondary to infectious or allergenic agents) and is often seen in patients with psoriasis, lichen planus and vitiligo.• Pseudo-Koebnerisation – skin breakdown or the seeding of an infectious agent in the surrounding tissue induces KP. This is often seen in patients with verrucae, impetigo or molluscum contagiosum infection.• Occasional KP – some criteria for KP are present, such as Darier’s disease, erythema multiforme or lupus erythematosus.• Trauma-induced processes – the lesions have a questionable connection to trauma, such as pemphigus vulgaris.Answer 4Koebner lesions are treated in the same way as the associated dermatosis, in this case psoriasis. Cosmetic surgery or therapeutic proceedings should, if possible, be made while the disease is quiescent.1Key points• KP is the development of isomorphic pathological lesions in the traumatised, uninvolved skin of patients who have active cutaneous diseases.• KP is often associated with psoriasis, lichen planus and vitiligo.AuthorsCarla Ferreira da Silva MD, Family Medicine Trainee, USF Ramalde, Porto, Portugal. carlaffsilva@gmail.comTiago Torres MD, PhD, Dermatologist, Department of Dermatovenereology, Centro Hospitalar Porto, Porto, Portugal; Instituto de Ciências Biomédicas Abel Salazar, University of Porto, PortugalCompeting interests: Tiago Torres has, outside this work, received payment for board membership, expert testimony, lectures and educational presentations, and expenses from Pfizer, Abbvie, Novartis, Janssen, MSD and Leo-Pharma; payment from Janssen for consultancy; and grants from MSD and Leo-Pharma.Provenance and peer review: Not commissioned, externally peer reviewed.References1. Camargo CM, Brotas AM, Ramos-e-Silva M, Carneiro S. Isomorphic phenomenon of Koebner: Facts and controversies. Clin Dermatol 2013,31(6):741–49.2. Thappa DM. The isomorphic phenomenon of Koebner. Indian J Dermatol Venereol Leprol 2004,70(3):187–893. Calzavara-Pinton P. Psoriasis differential diagnosis. Clinical Dermatology 2013;2(2):60–66.4. Clarke P. Psoriasis. Aust Fam Physician 2011;40(7):468–73.5. Sagi L, Trau H. The Koebner phenomenon. Clin Dermatol 2011;29(2):231–36.6. Weiss G, Shemer A, Trau H. The Koebner phenomenon: Review of the literature. J Eur Acad Dermatol Venereol 2002;16(3):241–48.

Development of erythematous scaly lesions in a cervical surgical scar

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Development of erythematous scaly lesions in a cervical surgical scar

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