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CORRESPONDENCE COLUMN
Year : 2006  |  Volume : 51  |  Issue : 1  |  Page : 70-72
Bullous pemphigoid on an incision scar of total knee prosthesis


Departments of Dermatology & Orthopaedics, Abant Izzet Baysal University, Duzce Medical School, Duzce, Turkey

Correspondence Address:
Ayse Kavak
Departments of Dermatology & Orthopaedics, Abant Izzet Baysal University, Duzce Medical School, Duzce
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.25219

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How to cite this article:
Kavak A, Parlak AH, Çetinkaya R, Tüzüner T. Bullous pemphigoid on an incision scar of total knee prosthesis. Indian J Dermatol 2006;51:70-2

How to cite this URL:
Kavak A, Parlak AH, Çetinkaya R, Tüzüner T. Bullous pemphigoid on an incision scar of total knee prosthesis. Indian J Dermatol [serial online] 2006 [cited 2019 Dec 12];51:70-2. Available from: http://www.e-ijd.org/text.asp?2006/51/1/70/25219


Some autoimmune bullous disorders such as pemphigus and linear IgA disease may be induced by injection (1), ultraviolet (UV) (2) and burn scar (1) other than drugs. This situation could be attributed as a Koebner phenomenon seen in many dermatoses such as psoriasis and lichen planus.

Bullous pemphigoid (BP) may also occur after those situations listed above. Here, we presented a case whose lesions appeared on the incision scar of total knee prosthesis operation (TKP) as well as on the back and foot simultaneously.

A 72-year-old woman presented with a 2 month history of a simultaneous appearance of a blistering eruption on her back, foot and knee which developed on the incision scar of TKP [Figure - 1]. She underwent the operation 5 months ago. She was hypertensive and has been used Cilazapril and hydrochlorothiazide for 2 years.

Dermatological examination revealed tense bullae with an erythematous base and erosions. No lesion was found on the scalp, nails and oral mucosae. Physical examination was otherwise normal. Skin biopsy showed subepidermal blister formation. Direct immunofluorescence revealed a band of C3 and IgG deposition at the dermoepidermal junction. Indirect immuno-fluorescence showed a low titre (1:20) of circulating antibodies to the basement zone.

On laboratory examination, hepatic and renal function tests, fasting blood glucose, complete blood count, erythrocyte sedimentation rate, peripheral blood analysis and urinalysis were all normal. Serology for HCV was positive. Abdominal, thyroid, breast and pelvic ultrasonographies and chest X-ray were unremarkable. Fecal occult blood testing was negative.

Systemic tetracycline and nicotinic acid therapy together with topical corticosteroid were begun. Creatinine level increased on the first week of treatment and tetracycline was stopped. Therapy was continued with deflazacort 48 mg a day. Lesions faded and no recurrence was observed.

Trauma induced BP is an uncommon variant. UV,[3] radiotherapy,[4],[5] thermal burn,[6] amputation stump,[7] incisional hernia,[7] scar,[8] injection or an adhesive dressing[8] may induce BP. In these cases, BP remained as localised on traumatised site[4],[5],[9],[10] or became generalized from the physical insult.[6] Our patient described simultaneous appearance of lesions on both incisional scar area and other body parts. In this situation, one can also consider another possibility: idiopathic BP might have occurred on the incision scar coincidentally, as well as other parts of the body. It is too hard to comment for this possibility. In the exception of those cases lesions begun to develop and then limited to the traumatised area, similar condition could be valid for generalised trauma induced BP cases as in our case.

Sheerin et al[4] suggested some comments about their RT induced BP case: radiation damage could alter pre-existing basement membrane constituents or unmask structures previously inaccessible to the immune system, thus creating potential autoantigens. Alternatively, the patients may have already had circulating antibasement membrane antibodies at a low titre. The increased vascular permeability caused by radiotherapy could enhance deposition of antibody at the basement membrane.[4] These mechanisms could be valid for other traumatic insults. Whether these factors induce autoimmunity or merely unmasks latent BP remains to be determined.[4]

The time period between physical insult and the emergence of BP varies from soon after trauma to many years [Table 1]. Thus, this wide range of time period shows that it is too difficult to establish the rule for the exact time between stimuli and the appearance of bullous lesions. If stimulation of autoimmunity or latent antibody production have a role in the etiopathogenesis, immune response would have some individual variations.

Parslew and Verbor[8] described a BP patient with lesions localised on both abdominal scar and injection sites. The past medical history of the patient was remarkable for seminoma (diagnosed and treated with RT 25 years ago without metastasis) and adenocarcinoma of caecum (isolated hepatic metastasis). In addition, RT induced BP cases had already a malignancy.[4],[5],[9] It is known that there is a small but significant increase in incidence of BP with a coexistent or previous carcinoma.[11] Probably, BP may occur after RT for treating of a malignant tumour. In another word, BP may actually be triggered by a malignancy itself. However, in cases of BP developed after UV, scar or burn, this explanation seems to be insufficient.

As an interesting finding, reported trauma induced BP cases were mostly older than 50 years. Some speculations could be considered for this condition. In general, malignancy risk increases with the age. On the other hand, some events such as burn and UV of course can be seen in any age. In addition, BP has not been reported in some malignancies seen in young adults and treated with RT mostly, such as Hodgkin's lymphoma. With these findings, it seems that there is no exact rule in the appearance of trauma induced BP. The advanced age together with additional factors (UV, thermal burn, RT etc.) may contribute to the development of BP.

Our handicap for this case was the lack of salt-split skin study for epidermolysis bullosa acquisita considered in the differential diagnosis because of technical impairment. Our clinical clues were lack of milia and good response to systemic steroid in our patient. BP developed after TKP has not been mentioned to our knowledge. However, trauma on the knee was a surgical procedure and BP developed on the scar tissue as reported in the past literature. With time, one can predict a long list of triggering factors in BP will occur as in Koebner phenomenon. Since, some of these patients were diagnosed as a skin infection initially,[9] trauma induced BP should be included in the differential diagnosis.



 
  References Top

1.Ginarte M, Sαnchez-Aguilar D, Pereiro-Ferreirós MM, Toribio J: Pemphigus vulgaris exhibiting Koebner phenomenon, J Eur Acad Dermatol Venereol, 10: 90-92, 1998.  Back to cited text no. 1    
2.Salmhofer W, Soyer HP, Wolf D, F φdinger D, H φdl S, Kerl H: UV light-induced linear IgA dermatosis, J Am Acad Dermatol, 50: 109-115, 2004.  Back to cited text no. 2    
3.Perl S, Rappersberger K, Fodinger D, Anegg B, Honigsmann H, Ortel B: Bullous pemphigoid induced by PUVA therapy, Dermatology, 193: 245-247, 1996.  Back to cited text no. 3    
4.Sheerin N, Bourke JF, Holder J, North J, Burns DA: Bullous pemphigoid following radiotherapy, Clin Exp Dermatol, 20: 80-82, 1995.  Back to cited text no. 4    
5.Ohata C, Shirabe H, Takagi K, Kawatsu T, Hashimoto T: Localized bullous pemphigoid after radiation therapy: two cases, Acta Derm Venereol (Stockh) 77: 157, 1997.  Back to cited text no. 5    
6.Balato N, Ayala F, Patruno C, Turco P, Ruocco V: Bullous pemphigoid induced by a thermal burn, Int J Dermatol, 33: 55-56, 1994.  Back to cited text no. 6    
7.Macfarlane AW, Verbov JL: Trauma-induced bullous pemphigoid, Clin Exp Dermatol 14: 245-249, 1989.  Back to cited text no. 7    
8.Parslew R, Verbov JL: Bullous pemphigoid at sites of trauma, Br J Dermatol 137: 825-826, 1997.  Back to cited text no. 8    
9.Knoell KA, Patterson JW, Gampper TJ, Hendrix JD: Localized bullous pemphigoid following radiotherapy for breast carcinoma, Arch Dermatol 134: 514-515, 1998.  Back to cited text no. 9    
10.Yesudian PD, Dobson CM, Ahmad R, Azurdia RM: Trauma-induced bullous pemphigoid around venous access site in a haemodialysis patient, Clin Exp Dermatol 27: 70-72, 2002.  Back to cited text no. 10    
11.Venning VA, Wojnarowska F: The association of bullous pemphigoid and malignant disease: a case-control study, Br J Dermatol 123: 439-445, 1990.  Back to cited text no. 11    


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