Chief of Dermatology
University of Baghdad, Iraq
Abstract: Sixty year-old woman with neuropathy dermatitis at the right side of incision scar following right knee-joint replacement.
History: This 60 year-old woman had a right knee joint replacement on 7 Jan 2010. About three months post-op, she noticed non-itchy rash on the right side of the incision scar which has gradually enlarged in size. No other important medical history.
O/E: I saw the patient on 9 June 2010 with the slightly scaly erythematous rash forming a plaque on the front of the right knee joint, on the right side of the incisional scar only. It does not cross to other side. The rash is completely anesthetic as confirmed by neurological assessment, while there is normal sensation on the left side of the scar.
Clinical Photo:
Diagnosis: Neuropathy dermatitis
Comment and question: This is similar to post-bypass dermatitis along one side of the saphenous vein harvesting scar on the front of the leg at the site of sensory neuropaphy. This rash also does not cross to the other side. The present case seems to confirm that many skin diseases might follow the course of neuropathy like vitiligo and dermatitis.
I would like to ask my colleagues about any similar observations simulating the present case and await their fruitful comments.
References:
1. Sharquie KE. Post-Bypass dermatitis. October 10, 2009 VGRD Blog
2. Logue EJ 3rd, Drez D Jr. Dermatitis complicating saphenous nerve injury after arthroscopic debridement of a medial meniscal cyst. Arthroscopy. 1996 Apr;12(2):228-31
Abstract: We report the case of a patient who developed hypesthesia in the distribution of the saphenous nerve after an arthroscopic debridement of a medial meniscal cyst. Dermatitis developed in the area of the hypesthesia 3 months later, Both complications responded to symptomatic treatment. A review of the literature confirms the unusual nature of these complications.
3. Satku K, Fong PH, Kumar VP, Lee YS. Dermatitis complicating operatively induced anesthetic regions around the knee. A report of four cases. J Bone Joint Surg Am. 1993 Jan;75(1):116-8. No Abstract available
4. Mathias CG. Post-traumatic eczema. Dermatol Clin. 1988 Jan;6(1):35-42.
Abstract:
Thirteen cases of eczema that followed acute cutaneous trauma were observed. On the basis of the present case series, the following conclusions may be drawn: 1. Cutaneous trauma may precipitate eczema. 2. The trauma is sufficient to cause obvious tissue damage accompanied by an inflammatory or regenerative response. 3. Eczema usually begins within a few weeks of acute injury at the site of the cutaneous trauma. 4. Eczema may occur as an isolated idiopathic reaction or as an isomorphic reaction either preceding or following the appearance of an endogenous eczematous condition in nontraumatized skin. 5. Individual lesions of post-traumatic eczema may persist or recur for long periods of time. 6. The occurrence of post-traumatic eczema following occupational injury has important medicolegal implications.
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One wonders whether other dermopathies may be similar: some cases of chronic dermatitis, meralgia paresthetica (see the Blog for May 26, 2010), the bypass dermatitis which Professor Sharquie mentions. This is a fascinating concept and may explain a number of obscure rashes. Pito, Norfolk Island
ReplyDeleteThis is from the author of ref. # 3.
ReplyDeleteThe lesion is identical to what my colleagues and I had described. In
addition to the anaesthesia, sweat tests revealed diminished or absent
sweating.
Lesions tend to improve with time, and many disappear as re-inervation
takes place from the surrounding nerves. Re-innervation however is
sometimes incomplete and some persistence of the dermatitis has been observed.
Hope this is helpful.
Satku K Satku
Director of Medical Services
Ministry of Health
Singapore
Your interesting observation prompted me to do a quick search on pubmed. There are a number of possibly relevant articles on the role of neuropeptides,-- receptors for which are on cutaneous cells--, modulating inflammatory reactions in the skin. For example J Dermatolog Sci 2002.30:87-93.
ReplyDeleteThe reports of a contact dermatitis in the area of a trigeminal neuropathy and the overlap of dermatologic and neuropathic side effects of VEGF and protease inhibitors also suggests a pathophysiologic connection.
Good luck in studying your observation further.
Reuven Sobel
This is a common occurrence post surgery - more often in the knee replacement surgery. The sensations will start coming back any time after six months. The malady responds very well to topical steroids. From the picture there is nothing suggestive of leprosy. Bushan Kumar, Chandigarh
ReplyDeleteSkinpathlab, at Boston University, has existing staining protocols worked out to do 3 dimensional nerve imaging. It would be fun if Dr. Sharquie would like to collaborate. I could tell him how to make the biopsy medium, he could then biopsy and send us the specimens (would be nice to have uninvolved skin as control). We could then do the imaging and see what nerves, if any, are gone.
ReplyDeleteThis is not commonly reported, so perhaps with the staining information, we could publish a case report. If he is interested, I can do a literature search to see if this has in fact already been done.
thanks for the great post!
Deon
Suspect he has numular or stasis eczema.If you don't treat it, it may come out on the other leg.
ReplyDeleteAlso known as post-traumatic eczema . See Mathias, Toby. Fran.
ReplyDeleteNote. This is an important reference and I added it to the case report. DJE