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 Table of Contents  
LETTER TO EDITOR
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 59

Vitiligo koebnerizing in striae distensae and gravidarum: An interesting clinical phenomenon


Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication29-May-2018

Correspondence Address:
Davinder Parsad
Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education Research, Sector 12, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/Pigmentinternational. Pigmentinternational

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How to cite this article:
Bishnoi A, Vinay K, Kumaran MS, Parsad D. Vitiligo koebnerizing in striae distensae and gravidarum: An interesting clinical phenomenon. Pigment Int 2018;5:59

How to cite this URL:
Bishnoi A, Vinay K, Kumaran MS, Parsad D. Vitiligo koebnerizing in striae distensae and gravidarum: An interesting clinical phenomenon. Pigment Int [serial online] 2018 [cited 2018 Dec 19];5:59. Available from: http://www.pigmentinternational.com/text.asp?2018/5/1/59/233471



Madam,

A variety of phenomena present on the skin owing to complex interactions amongst the epidermis, dermis, and immune effector cells. Koebner’s isomorphic phenomenon (KP) refers to the development of new lesions of a dermatosis at previously uninvolved sites, after trauma. Vitiligo has classically been associated with true KP.[1],[2] Trauma responsible for KP can be penetrating, like in the case of wounds, abrasions, surgical incisions, excoriations, bite-marks, tattooing; or blunt like pressure, friction, vibration, and compression. Trauma exposes the cryptic antigens and simultaneously leads to the production of inflammatory cytokines and immune response. Striae distensae is characterized by an injury to dermal collagen. We came across two interesting cases, who presented with koebnerization of existing vitiligo in striae distensae and striae gravidarum.

The index case was a 22-year-old male who had established acrofacial vitiligo for 2 years. He complained of recent onset depigmentation in stretch marks on his abdomen. He had received systemic steroids for vitiligo, and in the process he developed striae. He was not obese, nor were there any family history of obesity, striae or connective tissue disease. Examination revealed linear depigmented streaks of varying widths confined precisely to the atrophic striae, chiefly over the lateral aspect of his abdomen [[Figure 1]a and [Figure 1]b].
Figure 1: (a and b) Linear depigmented streaks of varying widths confined precisely to atrophic striae alba on the lateral aspect of the abdomen. Acral vitiligo on the tips of the fingers is visible

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Subsequently, we came across a 29-year-old female who had clinically established vitiligo vulgaris for 4 years, and presented with 2-month duration of depigmented lesions on her abdomen. She had delivered around 5 months back and had developed striae gravidarum in last trimester of her pregnancy. Examination demonstrated linear depigmented streaks of varying width and length, confined to the striae gravidarum, with normal intervening skin [Figure 2]. There was no evidence of thyroid dysfunction in both the patients.
Figure 2: Linear depigmented streaks of varying width and length are visible, confined to the striae gravidarum, with normal intervening skin

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The reported koebnerization risk in vitiligo is around 21–62%.[1] Though KP usually follows penetrating injuries, the one following pressure and friction is equally common with lesions readily apparent on elbows, knees, and ankles. Three types of KP have been previously described in vitiligo. Type 1 refers to the positive revelation by a patient when enquired about the development of vitiligo after trauma. Type 2 is visible on clinical examination (type 2a − friction/pressure sites, type 2b − at the sites of obvious trauma). Type 3 refers to the experimentally induced KP in controlled-laboratory conditions.[1] Few previous reports from Indian subcontinent have described koebnerization of psoriasis, vitiligo, and lichen planus in striae gravidarum and distensae.[3],[4],[5]

Striae formation is associated with stretching of skin, and epidermal and dermal alterations similar to scarring.[4] Precise mechanism for vitiligo appearing in striae is not known. We hypothesize that striae constitute an immunocompromised cutaneous district. Increased vascularity and influx of inflammatory cells associated with formation of striae rubra result in homing of effector cells targeting melanocytes in genetically predisposed individuals. Subsequently, striae alba forms, where the epidermis and dermis have sufficiently thinned out. Susceptibility of thinner skin to everyday trauma and friction, including wearing clothes is more than the surrounding skin and might lead to melanocyte loss exclusively from striae by melanocytorrhagy. Recently, the importance of epidermal-dermal cross talk for optimal function of melanocytes was discussed.[6] It needs to be seen, whether striae are associated with senescence of dermal fibroblasts, and how this would affect the melanocytes located in the epidermal compartment of the striae.[6] Alternatively, the localization of vitiligo over striae might represent Wolf’s isotopic response, where a new dermatosis (vitiligo) has occurred at the sites of an unrelated and healed dermatosis (stria alba).

The prevalence of striae in vitiligo is high owing to inadvertent use of steroids by patients to treat this potentially disfiguring disease and stigma associated with it. Rationale treatment approach for patients presenting with vitiligo in striae should be sought, apart from screening for potential adrenal suppression. The recent European Dermatology Forum guidelines recommend the use of potent topical corticosteroids for the treatment of vitiligo at extra facial sites, but also advise to exercise caution when using these agents on thin skin.[7] Using corticosteroids for vitiligo in striae may further accentuate thinning. An interesting approach would be to combine topical tretinoin with topical corticosteroids, as the addition of tretinoin prevents the atrophy induced by corticosteroids without abrogating their anti-inflammatory effects.[8] Moreover, the combination has been seen to have a better response than using corticosteroids alone in the treatment of vitiligo,[8] and tretinoin is a useful adjunct for the treatment of striae as well. In view of the localized disease, targeted phototherapy can also be used and it poses no risk of cutaneous atrophy.

In conclusion, besides reflecting an active disease, the development of vitiligo in striae can adversely affect the quality of life of patients while wearing sarees and swimming apparel. Striae should be added to the list of potential koebnerization inducing factors for vitiligo.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
van Geel N, Speeckaert R, Taieb A, Picardo M, Bohm M, Gawkrodger DJ et al. Koebner’s phenomenon in vitiligo: European position paper. Pigment Cell Melanoma Res 2011;24:564-73.  Back to cited text no. 1
    
2.
van Geel N, Speeckaert R, De Wolf J, Bracke S, Chevolet I, Brochez L et al. Clinical significance of Koebner phenomenon in vitiligo. Br J Dermatol 2012;167:1017-24.  Back to cited text no. 2
    
3.
Lahiri K, Malakar S. Vitiligo and lichen planus in striae: Is it Koebner phenomenon? Indian J Dermatol Venereol Leprol 2004;70:375. Author reply 6.  Back to cited text no. 3
    
4.
Verma SB. Striae: : Stretching the long list of precipitating factors for ’true koebnerization’ of vitiligo, lichen planus and psoriasis. Clin Exp Dermatol 2009;34:880-3.  Back to cited text no. 4
    
5.
Iftikhar N, Rahman A, Janjua SA. Vitiligo appearing in striae distensae as a Koebner phenomenon. J Coll Physicians Surg Pak 2009;19:796-7.  Back to cited text no. 5
    
6.
Kovacs D, Bastonini E, Ottaviani M, Cota C, Migliano E, Dell’Anna ML et al. Vitiligo skin: Exploring the dermal compartment. J Invest Dermatol 2018;138:394-404.  Back to cited text no. 6
    
7.
Taieb A, Alomar A, Bohm M, Dell’anna ML, De Pase A, Eleftheriadou V et al. Guidelines for the management of vitiligo: The European Dermatology Forum consensus. Br J Dermatol 2013;168:5-19.  Back to cited text no. 7
    
8.
Kwon HB, Choi Y, Kim HJ, Lee AY. The therapeutic effects of a topical tretinoin and corticosteroid combination for vitiligo: A placebo-controlled, paired-comparison, left-right study. J Drugs Dermatol 2013;12:e63-7.  Back to cited text no. 8
    


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