Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology

Translate this page into:

Short Communication
PMID: 17656943

Many faces of Koebner phenomenon in psoriasis

Somesh Gupta
 Department of Dermatology, Venereology and Leprology Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Somesh Gupta
Department of Dermatology, Venereology and Leprology Postgraduate Institute of Medical Education and Research, Chandigarh
How to cite this article:
Gupta S. Many faces of Koebner phenomenon in psoriasis. Indian J Dermatol Venereol Leprol 2002;68:222-224
Copyright: (C)2002 Indian Journal of Dermatology, Venereology, and Leprology


Two patients with unusual skin stimuli causing koebner phenomenon in psoriasis are reported. First patient, a 33 - year -old man, had psoriasis and multiple keloids for the last 26 - years. At few places, the lesions of psoriasis and multiple keloids for the last 26-years. At few places, the lesions of psoriasis healed with keloid formation, and psoriatic plaques appeared selectively on the top of the keloids in addition to palms, soles and scalp. In the second patient (a 67 - year -old man), the psoriatic lesions appeared at the site of healing herpes zoster lesions.
Koebner phenomenon in psoriasis due to herpes zoster or varicella is rare, while that due to keloid has not been reported.
Keywords: Koebner phenomenon; Psoriasis; Keloid; Herpes zoster


Koebner (isomorphic) phenomenon is defined as a non specific skin stimulus eliciting a disease skin reaction.[1] Various diseases exhibiting this interesting phenomenon include psoriasis, lichen planus, erythema multiforme, vitiligo, warts, molluscum contagiosum, pyoderma gangrinosum, pityriasis rubra pilaris and so on.[1] The prototype of the isomorphic response, however, occurs in psoriasis and has been studied more extensively in this disease.[1] We have recently observed two unusual causes of koebner phenomenon in psoriasis.

Patient 1: A 33 - year -old male patient presented with a 26 - year history of keloid and psoriasis. About 26 years previously, he developed keloids and psoriasis spontaneously. He described that healing of psoriasis at few places resulted in keloid formation and later psoriasis relapsed mainly on the top of the keloids, in addition to other sites like scalp palms and soles. He noted remissions and relapses of psoriasis several times, but the lesions of keloids remained persistent. In the past, he received intralesional triamcinolone and topical steroids for his keloidal lesions and methotraxate orally (total cumulative dose 635 mg) for relapses of psoriasis. At the time of presentation, he was not receiving any treatment for last 6 months. He had 16 typical keloidal growths distributed over chest, shoulder, knees and lower back. This time the lesions of psoriasis spontaneously appeared about 2 months back.He complained of constant pain and irritation in all the keloidal lesions. In addition, he had psoriatic plaques distributed on the plams, soles, scalp and on the top of all the keloidal growths. Surprisingly, the areas adjacent to the keloid and non - keloidal skin of the trunk and extremities were free of psoriatic lesions [Figure - 1]. Topical therapy, in the form of coal tar combined with sun exposure, resulted in resolution of psoriasis, though the keloids persisted.

Patient 2: A 67- year -old man presented with lesions of herpes zoster in thoracic region, which, at the time of presentation, were in the healing stage. The healing was associated with development of scaly lesions at the site of eruption [Figure - 2]. The patient had psoriasis several times in the past 2 - years; he however, was in remission for last 5 months. He received treatment topical medications for psoriasis in the past.

Patient complained of pain and itching in the lesions of herpes zoster. The lesions of psoriasis closely followed with the appearance of the crusting in the herpes zoster lesions. He also developed few guttate lesions of psoriasis elsewhere on the trunk. The lesions were erythematous, scaly, slightly raised, round to oval in shape and less than 1 - cm in size.


The first had lesions of psoriasis and keloids for more than 26 - years. He however, was not aware of which disease came first, though he gave a definite history of some lesions of psoriasis healing with keloid formation and,later the recurrence of psoriasis selectively on the top of the keloids. Various reported diseases provoking isomorphic phenomenon in psoriasis include acne, insect and animal bites, burns,contact dermatitis, lichen planus, miliaria, photosensitivity, pityriasis rosea, tattoo, vasculitis, vitiligo, lymphagitis, furuncle, herpes zoster, syphilis, leprosy and varicella.[1],[2],[3],[4],[5],[6],[7],[8] On the other hand, dermatologic disorders reported to cause keloid formation include dissecting cellulitis of the scalp, acne vulgaris, acne conglobata, hidradenitis suppurativa, pilonidal cyst, foreign - body reaction, burns, chicken pox, folliculitis, herpes zoster, vaccinia and small pox.[9],[10] Some connective tissue diseases such as Ehler - danlos syndrome and scleroderma have also been reported to be associated with keloid formation.[10] Obviously, the keloid does not get a place in the long list of dermatologic disorders causing koebner phenomenon in psoriasis does not get a place in the long list of diseases causing keloid formation. As the patient had pain and irritation in the keloid (not itching), the possibility of scratching as precipitating factor can be eliminated. Moreover he also had lesions on the unapproachable sites like over the back.

Transforming growth factor (TGF) - β is a cytokine that enhances extracellular matrix production by a variety of cells in vivo and in vitro. It is associated with increased procollagen gene expression in keloids.[11] The production of TGF - β has been found to be increased in psoriasis.[12] TGF - β along with other growth factors regulate keratinocyte proliferation/ differentiation process[13] and, it has been shown that TGF - β 1 levels are increased in psoriatic plaques and correlated with Psoriasis area severity index (PASI) score.[14] It Is possible that increased levels of TGF - β in keloidal lesions are responsible for localization of psoriasis in the kelodis. Similarly, increased expression of TGF - β in psoriatic plaques might be responsible for development of keloid formation on the healing of psoriatic plaques.

The koebner phenomenon in our second patient is less strange. Literature search revealed few reported patients with development of psoriatic lesions at the site of lesions of herpes zoster as well as varicella.[6],[7],[8] Farber et al[15] proposed a role of neuropeptides in the etiopathogenesis of psoriasis. They suggested that neurogenic inflammation mediated by agents such as substance P could be the underlying mechanism. Substance P also plays important role in the pain associated with herpes zoster. It is an endogenous neuropeptide that acts as a chemomediator of nociceptive impluse from periphery to central nervous system. The pain associated with herpes zoster responds to capsacin, which acts by depleting substance p from nerve endings. There are evidences that viral infection could potentiate the effect of substance P by decreasing the degradation of its breakdown enzyme, neural endopaptide.[7] This could be the possible explanation of koebner phenomenon in psoriasis occurring at the site of healing herpes zoster lesions. In conclusion, the first case is the first report of an association of keloids and psoriasis, i.e. keloid appearing at the site of healing psoriasis and recurrence of psoriasis selectively on the top of the keloids. The second case further documents the rare occurrence of koebner phenomenon in herpes zoster.

Boyd AS, Neldna KH. The isomorphic response of koebner. Int J Dermatol 1990;29:401-10.
[Google Scholar]
Pavithran K. Psoriasis developing in a patch of leprosy as a koebner phenomenon. Indian J Lea 1992;64:197-9.
[Google Scholar]
Talanin NY, Shelly ED, Kopkeev RA, et al. Koebner reaction in psoriasis due to secondary syphilis. Cutis 1994;54:532.
[Google Scholar]
Julian CG, Bowers PW. Strick anatomical coexistence of vitiligo and psoriasis vulgaris - a koebner phenomenon? Clin Exp Dermatol 1996;21:464.
[Google Scholar]
Farber EM, Roth RJ, Aschheim E, et al. Role of trauma in isomorphic response in psoriasis. Arch Dermatol 1965;91:246-249.
[Google Scholar]
Veraldi S, Rizzitelli G. Vericella, koebner phenomenon and psoriasis. Int J Dermatol 1994;33:673-674.
[Google Scholar]
Abraham A, Farber EM. The Koebner response to vericella in psoriasis. Int J Dermatol 1993;32:919-920.
[Google Scholar]
Shelley WB, Arthur RP Biochemical and physiological clues to the nature of psoriasis. Arch Dermatol 1958;78:14-29.
[Google Scholar]
English RS, Shenefelt PD. Keloids and hypertrophic scars. Dermatol Surg 1999;25:631-8.
[Google Scholar]
Murray JC. Scars and keloids. Dermatol Clin 1993;11:697-705.
[Google Scholar]
Low RQ, May RL. Scar wars strategies, Dermatol Sung 1992;18:981-986.
[Google Scholar]
Bonifati C, Ameglio F Cytokines in psoriasis. Int J Dermatol 1999;38:241-251.
[Google Scholar]
Kane JM, Knapp AM, Mansbrige JN, et al. Transforming growth factor- beta- 1, localisation in normal and psoriatic kerotinocytes in situ. J Cell 1990;144:114-50.
[Google Scholar]
Bonifati C, Carducci M, Mussi A, et al. The levels of transforming growth factors - beta - 1 are increased in the serum of patients with psoriasis and correlate with disease severity. Eur J Dermatol 1996;6:486-490.
[Google Scholar]
Farber EM, Rein G, Lanigan SW. Stress and psoriasis. Psychoneuroimmunogenic mechanisms. Int J Dermatol 1991;30:8-12.
[Google Scholar]
Show Sections