Koebner phenomenon in lupus erythematosus with special consideration of clinical findings
Introduction
Lupus erythematosus (LE) is a systemic autoimmune disease of unknown nature. Cutaneous LE provides a good model for understanding its pathophysiology. The Koebner phenomenon was first described in psoriatic skin by Prof. Heinlich Köbner [1] in 1876. He found new psoriatic lesions on normal healthy skin after horsebites. He observed further that this phenomenon could be provoked by puncturing the normal-appearing skin in psoriatic patients after certain latent periods (three weeks to several months).
This phenomenon was confirmed not only in psoriasis but also in lichen planus, vitiligo vulgaris, and autoimmune blistering dermatoses, and has been accepted as the “Köbner Phänomen” (Koebner phenomenon) or isomorphic response [2], [3], [4], [5], [6]. This phenomenon has been further reported in various systemic diseases [5], [6] including systemic lupus erythematosus (SLE), discoid LE, systemic sclerosis, dermatomyositis, and even in sarcoidosis. All of these are non-infectious inflammatory diseases for which the causes are unknown and most of them are diseases accompanying autoimmune phenomena. The provocating factors of the Koebner phenomenon have been reported to be needling, scratches [7], trauma [8], sun exposure, X-rays, heat, cold, pressure, drug administration, silica granulomas, tattooing, scars, and inflammatory dermatoses [1], [2], [3], [4], [5]. These are non-specific factors, in which inflammatory reactions are common.
The author is particularly interested in the fact that this phenomenon is observed not only in autoimmune inflammatory dermatoses, but also in the skin of patients with systemic diseases, such as collagen diseases and sarcoidosis [5], [6], [9]. This finding raises a question as to whether this phenomenon is limited to the skin and whether it could occur in oral mucosa or various internal organs involved in systemic diseases. If so, all physicians managing these patients should be aware of this phenomenon and try to protect patients from the complications of new lesions. It is extremely important to explore the unclarified pathophysiology of the Koebner phenomenon in LE.
Usually, the Koebner phenomenon reflects the clinical and laboratory activity of the associated diseases. This phenomenon as well as the clinical symptoms in patients with collagen diseases can be suppressed by systemic administration of glucocortico-steroid hormones.
Section snippets
Cutaneous LE lesions developing on scratch-effects
The cutaneous lesions of LE are principally non-itching and non-irritative, but patients with LE sometimes scratch these cutaneous lesions or non-lesional normal-appearing skin. The left picture in the Fig. 1 shows the linearly- and irregularly-arranged discoid lesions occurring on the scratch-effects on the left upper arm, while the right picture shows histologic findings compatible with those of discoid LE. The prurigo-like acanthosis may reflect the effects of self-scratching or rubbing. The
Discussion with speculative views
Clinically, one can realize and understand that the Koebner phenomenon appears in many LE patients not receiving systemic application of corticosteroid hormones. This phenomenon can be found not only in the skin, but also in the oral mucosa and internal organs.
The pathophysiology of the Koebner phenomenon is interesting and important, but it still remains unclarified. As previously noted, most diseases presenting with the Koebner phenomenon are of autoimmune nature. In SLE and discoid LE,
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