Elsevier

Autoimmunity Reviews

Volume 4, Issue 4, April 2005, Pages 219-223
Autoimmunity Reviews

Koebner phenomenon in lupus erythematosus with special consideration of clinical findings

https://doi.org/10.1016/j.autrev.2004.11.007Get rights and content

Abstract

The isomorphic response of Koebner can be observed not only in psoriasis, but also in other diseases, such as lichen planus and some systemic diseases including LE (lupus erythematosus) or sarcoidosis. Several clinical findings in LE skin were presented and discussed in this review. The mutually-interactive-, negative-, and internal-Koebner phenomena were introduced and discussed with some speculative views. Many forms of environmental stress on the skin were reported as provocating factors of the Koebner phenomenon, including trauma, scratching, UV-exposure, and various types of dermatitis. Clinical observations of the nature, localization, and movement of lesions should be carefully made. The pathophysiology of the Koebner phenomenon may be classified into two steps. A first non-specific inflammatory step and a second disease-specific step.

The inflammatory products released from the first step would be targeted in the second step. In the first step, there could be many substances including cytokines, stress proteins, adhesion molecules, or autoantigens translocated from intra-cellular areas. In the second step after latent periods, there may be disease-specific reactions, including ones by T-cells, B-cells, autoantibodies, and immune deposits, under the restriction of genetic backgrounds. The Koebner phenomenon may prove useful in understanding the pathophysiology of diseases of unknown origin.

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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