Case and Research Letters
Koebner Phenomenon in a Patient With Lichen Sclerosus Following a Jellyfish Sting: An Exceptional Morphology
Fenómeno de Koebner en un liquen escleroso tras una picadura de medusa: una morfología excepcional
I. Pérez-López
, C. Garrido-Colmenero, G. Blasco-Morente, J. Tercedor-Sánchez
Corresponding author
Unidad de Gestión Clínica de Dermatología Médico Quirúrgica y Venereología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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Pérez-López, C. Garrido-Colmenero, G. Blasco-Morente, J. Tercedor-Sánchez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Pérez-López" "email" => array:1 [ 0 => "ipl_elmadrono@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Garrido-Colmenero" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Blasco-Morente" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Tercedor-Sánchez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico Quirúrgica y Venereología, Hospital Universitario Virgen de las Nieves, Granada, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fenómeno de Koebner en un liquen escleroso tras una picadura de medusa: una morfología excepcional" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 947 "Ancho" => 667 "Tamanyo" => 85469 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Complete and more detailed frontal view. A, Papular plaques in a linear pattern (17<span class="elsevierStyleHsp" style=""></span>cm) on the right abdomen. B, Whitish atrophied plaque (maximum diameter of 5<span class="elsevierStyleHsp" style=""></span>cm) at the edge of the lesion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Lichen sclerosus is a chronic inflammatory disease that has a particular affinity for the anogenital region. Only 6% of patients present solitary extragenital lesions, although this percentage can rise to 15% during childhood.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a patient with lichen sclerosus lesions following a jellyfish sting in the context of Koebner phenomenon.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 13-year-old girl with an unremarkable family history who consulted for a whitish, atrophic, and pruriginous plaque on the vulva and gluteal cleft, together with whitish indurated papules spread throughout the trunk. A skin biopsy revealed orthokeratotic hyperkeratosis in the epidermis, with hydropic degeneration and atrophy of the basal layer, in addition to edema and homogenization of collagen. The patient was treated with topical tacrolimus and her lesion improved considerably after 4 months. One year later, while asymptomatic, she was stung by a jellyfish. Papules and plaques appeared in a linear pattern (17<span class="elsevierStyleHsp" style=""></span>cm long) on the right abdomen. These were clinically compatible with lichen sclerosus lesions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and very probably originated as a result of Koebner phenomenon (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The patient refused a second skin biopsy, since she was receiving treatment with topical tacrolimus and was progressing favorably. She now has small active lesions on the genital region.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Lichen sclerosus can occur at any age, although the peak incidence is noted in childhood and after the menopause.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> It most commonly appears on the anogenital region and, even though it is not unusual for it to be accompanied by extragenital lesions, involvement of these areas alone is very infrequent. The etiology of lichen sclerosus is unknown. Possible causes include a hormonal disorder, autoimmune mechanisms, infection (eg, human papilloma virus, hepatitis C, <span class="elsevierStyleItalic">Borrelia burgdorferi</span>), genetic factors associated with various HLA subtypes, and repeated insults associated with the appearance of new lesions due to the Koebner phenomenon that is typical of lichen sclerosus.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a> Koebner phenomenon is caused by damage to the dermis and, especially, the epidermis, which is the main event in its development. This event causes an increase in levels of CD4 lymphocytes, cytokines, and adhesion molecules that could lead to the appearance of lesions that are typical of associated diseases, such as, in the present case, lichen sclerosus.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> The lesions of lichen sclerosus are typically ivory-white papules and macules that are clearly defined and can coalesce to form plaques, as occurred in the case we report. Furthermore, the presence of dilated pilosebaceous openings containing keratin plugs, purpura, and telangiectasia are usually characteristic signs.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a> The differential diagnosis for the case we present included lichen planus, lichen simplex chronicus, vitiligo, and lichen planus–like lesions. Bullous diseases affecting the mucosa, pemphigoid, and intraepithelial neoplasms of the penis and vulva should be taken into consideration in anogenital lichen sclerosus.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Our case is exceptional because of the way the lesions appeared and their morphology, since the mark left by the jellyfish tentacles was visible. Jellyfish stings usually cause acute local reactions characterized by a burning sensation and pruritus. The lesions are most often erythematous papules or papulovesicles and may be accompanied by regional vascular and lymphatic reactions.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Although less frequent, delayed reactions are not uncommon; the most frequents reactions are keloids, pigmented striae, lichenified lesions, granuloma, ulceration, and necrosis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> Gangrene, fat atrophy, and retractile scars are less typical, although they have been reported in the literature.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> In the case we report, the lesions were clinically compatible with lichen sclerosus, although they had taken on the morphology of the tentacles of the jellyfish that had stung the patient, thus constituting another potential late complication that should be taken into account in the differential diagnosis of jellyfish stings.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez-López I, Garrido-Colmenero C, Blasco-Morente G, Tercedor-Sánchez J. Fenómeno de Koebner en un liquen escleroso tras una picadura de medusa: una morfología excepcional. Actas Dermosifiliogr. 2015;106:238–239.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 947 "Ancho" => 667 "Tamanyo" => 85469 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Complete and more detailed frontal view. A, Papular plaques in a linear pattern (17<span class="elsevierStyleHsp" style=""></span>cm) on the right abdomen. B, Whitish atrophied plaque (maximum diameter of 5<span class="elsevierStyleHsp" style=""></span>cm) at the edge of the lesion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Childhood. Lichen sclerosus–a challenge for clinicians" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Lagerstedt" 1 => "K. Karvinen" 2 => "M. Joki-Erkkilä" 3 => "R. Huotari-Orava" 4 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 11 | 18 |
| 2024 October | 80 | 52 | 132 |
| 2024 September | 123 | 33 | 156 |
| 2024 August | 151 | 84 | 235 |
| 2024 July | 128 | 47 | 175 |
| 2024 June | 135 | 40 | 175 |
| 2024 May | 98 | 44 | 142 |
| 2024 April | 95 | 33 | 128 |
| 2024 March | 91 | 37 | 128 |
| 2024 February | 100 | 39 | 139 |
| 2024 January | 75 | 31 | 106 |
| 2023 December | 65 | 23 | 88 |
| 2023 November | 100 | 38 | 138 |
| 2023 October | 110 | 47 | 157 |
| 2023 September | 92 | 31 | 123 |
| 2023 August | 66 | 31 | 97 |
| 2023 July | 62 | 31 | 93 |
| 2023 June | 73 | 32 | 105 |
| 2023 May | 99 | 43 | 142 |
| 2023 April | 59 | 26 | 85 |
| 2023 March | 50 | 24 | 74 |
| 2023 February | 43 | 29 | 72 |
| 2023 January | 32 | 24 | 56 |
| 2022 December | 47 | 36 | 83 |
| 2022 November | 29 | 32 | 61 |
| 2022 October | 22 | 18 | 40 |
| 2022 September | 24 | 33 | 57 |
| 2022 August | 32 | 22 | 54 |
| 2022 July | 25 | 33 | 58 |
| 2022 June | 25 | 24 | 49 |
| 2022 May | 54 | 25 | 79 |
| 2022 April | 68 | 37 | 105 |
| 2022 March | 64 | 53 | 117 |
| 2022 February | 53 | 21 | 74 |
| 2022 January | 69 | 32 | 101 |
| 2021 December | 52 | 28 | 80 |
| 2021 November | 64 | 42 | 106 |
| 2021 October | 68 | 52 | 120 |
| 2021 September | 49 | 39 | 88 |
| 2021 August | 53 | 23 | 76 |
| 2021 July | 55 | 37 | 92 |
| 2021 June | 39 | 31 | 70 |
| 2021 May | 42 | 20 | 62 |
| 2021 April | 85 | 42 | 127 |
| 2021 March | 57 | 12 | 69 |
| 2021 February | 80 | 19 | 99 |
| 2021 January | 35 | 19 | 54 |
| 2020 December | 33 | 13 | 46 |
| 2020 November | 43 | 17 | 60 |
| 2020 October | 15 | 5 | 20 |
| 2020 September | 45 | 14 | 59 |
| 2020 August | 31 | 23 | 54 |
| 2020 July | 30 | 15 | 45 |
| 2020 June | 35 | 31 | 66 |
| 2020 May | 27 | 31 | 58 |
| 2020 April | 42 | 21 | 63 |
| 2020 March | 20 | 20 | 40 |
| 2020 February | 3 | 7 | 10 |
| 2020 January | 4 | 13 | 17 |
| 2019 December | 8 | 10 | 18 |
| 2019 November | 4 | 6 | 10 |
| 2019 October | 0 | 5 | 5 |
| 2019 September | 4 | 8 | 12 |
| 2019 August | 4 | 5 | 9 |
| 2019 July | 4 | 13 | 17 |
| 2019 June | 6 | 23 | 29 |
| 2019 May | 4 | 51 | 55 |
| 2019 April | 2 | 44 | 46 |
| 2019 March | 5 | 11 | 16 |
| 2019 February | 1 | 8 | 9 |
| 2019 January | 6 | 4 | 10 |
| 2018 December | 2 | 4 | 6 |
| 2018 November | 3 | 5 | 8 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 5 | 0 | 5 |
| 2018 August | 0 | 5 | 5 |
| 2018 July | 0 | 2 | 2 |
| 2018 May | 0 | 2 | 2 |
| 2018 April | 0 | 1 | 1 |
| 2018 March | 1 | 3 | 4 |
| 2018 February | 23 | 2 | 25 |
| 2018 January | 28 | 4 | 32 |
| 2017 December | 29 | 7 | 36 |
| 2017 November | 27 | 5 | 32 |
| 2017 October | 21 | 5 | 26 |
| 2017 September | 16 | 8 | 24 |
| 2017 August | 12 | 10 | 22 |
| 2017 July | 16 | 3 | 19 |
| 2017 June | 30 | 7 | 37 |
| 2017 May | 17 | 6 | 23 |
| 2017 April | 26 | 9 | 35 |
| 2017 March | 18 | 31 | 49 |
| 2017 February | 19 | 3 | 22 |
| 2017 January | 16 | 11 | 27 |
| 2016 December | 27 | 11 | 38 |
| 2016 November | 38 | 10 | 48 |
| 2016 October | 30 | 18 | 48 |
| 2016 September | 0 | 12 | 12 |
| 2016 August | 0 | 2 | 2 |
| 2016 July | 11 | 1 | 12 |
| 2016 June | 14 | 2 | 16 |
| 2016 May | 13 | 8 | 21 |
| 2016 April | 9 | 2 | 11 |
| 2016 March | 7 | 0 | 7 |
| 2016 February | 6 | 1 | 7 |
| 2016 January | 8 | 3 | 11 |
| 2015 December | 13 | 0 | 13 |
| 2015 November | 15 | 0 | 15 |
| 2015 October | 8 | 2 | 10 |
| 2015 September | 0 | 2 | 2 |
| 2015 August | 0 | 2 | 2 |
| 2015 July | 3 | 6 | 9 |
| 2015 June | 4 | 2 | 6 |
| 2015 May | 4 | 6 | 10 |
| 2015 April | 3 | 8 | 11 |
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