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 Table of Contents  
LETTER TO EDITOR
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 59-61

Vitiligo after knee replacement: Koebnerization?


Department of Dermatology, Dayanand Medical College, Ludhiana, Punjab, India

Date of Submission18-Apr-2019
Date of Decision19-Mar-2020
Date of Acceptance27-Jul-2020
Date of Web Publication07-Apr-2021

Correspondence Address:
Dr. Jaspriya Sandhu
Assistant Professor, Department of Dermatology, Dayanand Medical College, Tagore Nagar, Ludhiana 141001
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:
Sandhu J, Gupta SK. Vitiligo after knee replacement: Koebnerization?. Pigment Int 2021;8:59-61

How to cite this URL:
Sandhu J, Gupta SK. Vitiligo after knee replacement: Koebnerization?. Pigment Int [serial online] 2021 [cited 2021 Aug 2];8:59-61. Available from: https://www.pigmentinternational.com/text.asp?2021/8/1/59/313129



Madam,

Heinrich Köebner (1838–1904), a German dermatologist, first described the isomorphic phenomenon in patients of psoriasis. He observed the development of psoriasis at sites of trauma, tattooing, animal bites, etc., which led him to perform an experiment now known as the Koebner’s experiment.[1] KP has been described in skin diseases including psoriasis, vitiligo and lichen planus. True Koebner’s isomorphic phenomenon is seen classically in Vitiligo.


  Definitions Top


  1. Koebner's phenomenon
    • Development of lesions at site of specifically traumatized, uninvolved skin of patients with cutaneous disease.
  2. Pseudo-Koebnerization
    • The appearance of lesions followed by inoculation after trauma seen in infectious etiology like viral warts, molluscum contagiosum.
  3. Reverse Koebnerization
    • The disappearance of lesion following trauma, e.g. lesion of psoriasis resolve post injury.
  4. Remote reverse Koebnerization[2]
    • The resolution of lesions following trauma occurring at a distant site. For example regimentation of vitiligo lesions at distant site after skin grafting.


We report here an interesting case of a 65-year old male who underwent total knee replacement of the left knee and then presented with de novo vitiligo at the site of surgical incision.

A 65-year-old male who underwent knee replacement for left knee presented to our outpatient department with depigmented lesions over the left knee. The lesions first appeared six months after he underwent left knee replacement. He gave no prior history of similar lesions. No other family member was affected with vitiligo. There was no personal or family history of autoimmune diseases. There was no itching, redness or any oozing suggestive of dermatitis prior to the development of the lesions. No surgical site infection occurred in the post-operative period. There were no significant co-morbidities. Examination revealed linear depigmented macules along the line of surgical incision on the knee with few depigmented macules on the surrounding skin of sizes 0.2 × 0.2 cm2 to 2 × 4 cm2 [Figure 1]. Apart from the left lower limb, no lesions were present anywhere else in the body. A biopsy could not be done, as patient refused consent.
Figure 1 Depigmented macules along incison lines over the knee and lower limb

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The risk of Koebner’s phenomenon (KP) in vitiligo is around 21-62%.[3],[4],[5] Koebner’s phenomenon is more frequently seen in generalized vitiligo as compared to segmental vitiligo.

The sites for predilection for KP in vitiligo include areas of repeated chronic friction/pressure or movement such as waistband, peri-oral/peri-ocular areas, wrists and dorsa of feet). Triggering factors include:-
  1. Physical wound
  2. Mechanical (friction)
  3. Dermatitis (allergic/irritant)
  4. Therapeutic intervention
  5. Chronic pressure.


Various authors have proposed theories regarding the etio-pathogenesis of KP:[6]
  1. Immune-related mechanisms
  2. Defective Melanocyte adhesion (melanocytorrhagy)[7]
  3. Increased oxidative stress[8]
  4. Melanocyte growth factors patho-mechanism[9]


Recently[6] KP has been divided into subtypes [Table 1].
Table 1 Koebner phenomenon subtypes

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In our case the mechanical stress of surgery could have led to a state of oxidative stress. Furthermore, the introduction of the implant possibly triggered an immune response to the foreign body, wherein the inflammatory responses lead to the melanocyte-specific T cells being recruited and activated. Whether this was a true Koebner’s phenomenon or stress which led to the presentation of the disease de novo is debatable.

Another explanation could be an allergic response to the knee implant. Allergic phenomenon occurring after knee implants commonly manifests in the early post-operative period as oozing, erythema, delayed wound healing at the site of infection (provided infectious causes have been ruled out).[10] Delayed effects may include recurrent joint effusions, pain and rarely urticaria. Traditional cobalt-chromium (CoCr) implants have a higher allergenicity. Hypoallergenic implants include ceramic, coated and titanium implants. The allergic response may be elicited by the bone cement, used during surgery, containing benzoyl peroxide, hydroquinone, acrylates, N,N-dimethyl-p-toluidine (DMT), zirconium dioxide and barium sulfate. In a study by Treudler et al.[11], among 13 patients with suspected allergic response to bone cement-particularly benzoyl peroxide none of the patients reported any depigmentation or hypopigmented lesions.

In our case, there was no history of an allergic eczematous response after surgery which could have possibly resolved with hypopigmentation; rather the lesions were depigmented than hypopigmented and present at sites distant to the incision.

Apart from the implant associated mechanical oxidative stress, there could be the role of severe psychological stress brought on by a major surgery. A case of a 44-year-old woman operated upon for complicated Crohn’s disease developed extensive vitiligo lesion all over the body.[12] However, unlike our patient she did have a small vitiligo patch on her hand prior to the surgery as well.

In conclusion, though KP is well known in vitiligo, this case may be worth mentioning as onset of vitiligo was triggered by surgical insult following knee replacement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kuner N, Hartschuh W, Khan-Durani B. Heinrich Köbner and the “isomorphic phenomenon”. History and review of the literature. Hautarzt Z Dermatol Venerol Verwandte Geb 2003;54:274-8.  Back to cited text no. 1
    
2.
Malakar S, Dhar S. Spontaneous repigmentation of vitiligo patches distant from the autologous skin graft sites: a remote reverse Koebner’s phenomenon? Dermatol Basel Switz 1998;197:274.  Back to cited text no. 2
    
3.
Barona MI, Arrunátegui A, Falabella R, Alzate A. An epidemiologic case-control study in a population with vitiligo. J Am Acad Dermatol 1995; 33:621–5.  Back to cited text no. 3
    
4.
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. 4
    
5.
Mazereeuw-Hautier J, Bezio S, Mahe E, Bodemer C, Eschard C, Viseux V et al. Segmental and nonsegmental childhood vitiligo has distinct clinical characteristics: a prospective observational study. J Am Acad Dermatol 2010;62:945-9.  Back to cited text no. 5
    
6.
van Geel N, Speeckaert R, Taieb A, Picardo M, Böhm 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. 6
    
7.
Gauthier Y, Cario-Andre M, Lepreux S, Pain C, Taïeb A. Melanocyte detachment after skin friction in non lesional skin of patients with generalized vitiligo. Br J Dermatol 2003;148:95–101.  Back to cited text no. 7
    
8.
Schallreuter KU, Moore J, Wood JM, Beazley WD, Gaze DC, Tobin DJ et al. In vivo and in vitro evidence for hydrogen peroxide (H2O2) accumulation in the epidermis of patients with vitiligo and its successful removal by a UVB-activated pseudocatalase. J Investig Dermatol Symp Proc 1999;4:91-6.  Back to cited text no. 8
    
9.
Lee A-Y., Kim N-H., Choi W-I., Youm Y-H. Less keratinocyte-derived factors related to more keratinocyte apoptosis in depigmented than normally pigmented suction-blistered epidermis may cause passive melanocyte death in vitiligo. J Invest Dermatol 2005;124:976-83.  Back to cited text no. 9
    
10.
Saccomanno MF, Sircana G, Masci G, Cazzato G, Florio M, Capasso L et al. Allergy in total knee replacement surgery: Is it a real problem? World J Orthop 2019;10:63-70.  Back to cited text no. 10
    
11.
Bircher A, Friederich NF, Seelig W, Scherer K. Allergic complications from orthopaedic joint implants: the role of delayed hypersensitivity to benzoyl peroxide in bone cement. Contact Dermatitis 2012;66:20-6.  Back to cited text no. 11
    
12.
Triantafillidis JK. Vitiligo aggravated after major surgery for Crohn’s disease: a consequence of severe surgical stress? Ann Gastroenterol 2013;26:278-9.  Back to cited text no. 12
    


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