Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
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
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
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 - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
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 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
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obervation Letter
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
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
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Letter to the Editor
2010:76:2;194-196
doi: 10.4103/0378-6323.60564
PMID: 20228559

Pityriasis rubra pilaris with Koebner's isomorphic phenomenon

Jayanta K Das1 , Asok Kr Gangopadhyay1 , Sujata Sengupta2
1 Department of Dermatology, Ramakrishna Mission Seva Pratisthan, VIMS, 99, Sarat Bose Road, Kolkata 700 026, W. B, India
2 B P Poddar Hospital and Medical Research Centre, New Alipore Block-G, Kolkata 700053, West. Bengal, India

Correspondence Address:
Sujata Sengupta
9RB, Greenwood Nook. 369/2, Purbachal Kalitala Rd. Kolkata-700 078
India
How to cite this article:
Das JK, Gangopadhyay AK, Sengupta S. Pityriasis rubra pilaris with Koebner's isomorphic phenomenon. Indian J Dermatol Venereol Leprol 2010;76:194-196
Copyright: (C)2010 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Pityriasis Rubra Pilaris (PRP) is a heterogeneous group of disorders showing circumscribed follicular keratoses, branny scale, orange-red erythema, and palmoplantar keratoderma. [1] In addition to the well-accepted five types, designated as type I to type V, type VI, has been suggested as occurring in patients with HIV infection. [1] The onset of juvenile onset classical (Type III) PRP is between the ages of 5 to 10 years. It often follows an acute infection. Spontaneous clearing is common within 1-2 years. [1]

The isomorphic response of Koebner, named after Heinrich Koebner (1838-1904), is a well-known phenomenon commonly associated with psoriasis. [2] It has also been described in conjunction with a host of other disorders. [3] It involves the development of lesions in previously normal skin that has been traumatized either externally or internally.

A seven-year-old girl presented with the history of erythematous scaly and slightly itchy eruption all over the body that started about a month back on the scalp. She gave no history of fever or any acute infection preceding the skin disease. Cutaneous examination on the first visit showed numerous lesions, each consisting of erythematous perifollicular papules with a central keratotic acuminate plug, on the upper chest, upper back, neck, shoulders, and dorsum of hands and feet. Face was uniformly erythematous with mild ectropion. Scalp showed diffuse bran-like scaling. Palms and soles were hyperkeratotic. Nails were thickened. On the second visit, after two weeks, the clinical condition had worsened. The most notable new finding was the typical erythematous perifollicular papules with central keratotic plug in linear distribution on the chest and abdomen. [Figure - 1] They were seen along a few almost straight lines coursing through the right lateral border and the lower border of the main group of erythematous perifollicular papules. On detailed questioning, it was learnt that about 10-12 days ago the patient suffered from injury by the sharp tip of a stick while playing. The trauma caused oozing of very little blood, and was on the chest and abdomen just along the lines where the new lesions in linear distribution came up later.

Histopathology of skin biopsy sample taken from a typical lesion on the dorsum of the right hand showed features of PRP, such as acanthosis, and a follicle filled with dense, horny plugs, with a few parakeratotic cells in the perifollicular shoulder and in other parts of the epidermis, alternating with orthokeratotic epidermis. There was a mild mononuclear infiltrate in the dermis. Skin biopsy sample taken from a lesion on the abdomen induced by trauma showed histopathological picture similar to that of the hand lesion.

Koebner phenomenon has been described in association with a lot of diseases; so the need for more stringent criteria for defining the isomorphic phenomenon has been stressed. [3] Boyd has proposed to ′reserve the isomorphic phenomenon solely for those diseases in which the phenomenon is reproducible in all manner of patients, by a variety of insults, and not due to dispersement (sic) of external infective or allergic element.′ [4] It is difficult to agree with his contention that the phenomenon must be reproducible in all manner of patients, for it is a well-known fact that even in psoriasis, lichen planus, or vitiligo, the three diseases showing uncontestable Koebner phenomenon, not all patients show the phenomenon, however hard they might be prodded. In his otherwise excellent review, Boyd has classified the reported Koebner Responses in four categories: [3],[4]

  1. True isomorphic response of Koebner
  2. Pseudo-isomorphic response of Koebner
  3. Occasional traumatic localization of lesions
  4. Poor or questionable trauma-induced process

Boyd categorized Koebner phenomenon in PRP in class 4, i.e., as ′Poor or questionable trauma-induced process′ [4] For this particular disease Boyd mentioned an article by Farber et al. as his only reference. [4],[5] However, the Farber et al. study deals only with isomorphic response of Koebner in psoriasis, without mentioning Koebner phenomenon in PRP anywhere at all in his text. In the ′Discussion′ appended at the end of Farber′s article, Dr. Rees B. Rees commented, inter alia, that Koebner phenomenon occurs in PRP too; but Dr. Rees never cited any reference to substantiate his assertion. On the other hand, extensive search of the ′Pub med′ and ′Medline′ by us failed to yield any article documenting Koebner phenomenon in PRP. The large series by Clayton et al. also fails to record Koebner phenomenon in PRP. [6] In our case, previously normal skin was traumatized externally, and the exact site, time and type of trauma could be recorded and this was duly followed by development of characteristic lesions of PRP. As inducing Koebner phenomenon experimentally raises a lot of ethical questions, we have not tried that. Our case is possibly the first reported case of PRP showing almost uncontestable Koebner phenomenon, occurring in a case of type III, i.e., juvenile onset, classical PRP.

References
1.
Judge MR, McLean WHI, Munro CS. Disorders of keratinization. In: Burns T, Breathnach S. Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. Vol 2. 7 th ed. Massachusetts/Oxford/Victoria: Blackwell Science Ltd; 2004. p. 34.1-111.
th ed. Massachusetts/Oxford/Victoria: Blackwell Science Ltd; 2004. p. 34.1-111.'>[Google Scholar]
2.
Bruch-gerharz, Ruzicka T. Pityriasis rubra pilaris. In: Wolff K, Goldsmith LA, Katz SI, Gilchrist BA, Paller AS, Leffell DJ editors. Fitzpatrick's Dermatology in General Medicine. 7 th ed. New York: McGraw-Hill; 2008. p. 232-6.
th ed. New York: McGraw-Hill; 2008. p. 232-6.'>[Google Scholar]
3.
Thappa DM. The isomorphic response of Koebner. Indian J Dermatol Venereol Leprol 2004;70:187-9
[Google Scholar]
4.
Boyd AS, Neldner KH. The isomorphic response of Koebner. Int J Dermatol 1990;29:401-10.
[Google Scholar]
5.
Farber EM, Roth RJ, Aschheim E, Eddy DE, Epinette WW. Role of trauma in isomorphic response in psoriasis. Arch Dermatol 1965;91:246-51.
[Google Scholar]
6.
Claytonz BD, Jorizzo JL, Hitchcock MG, Fleischer Jr AB, Williford PM, et al. Adult pityriasis rubra pilaris: a 10-year case series. J Am Acad Dermatol 1997;36:959-64.
[Google Scholar]

Fulltext Views
173

PDF downloads
139
Show Sections