The Koebner phenomenon
Introduction
The Koebner phenomenon (KP) was first described in 1876 by Heinrich Koebner, a German dermatologist who was the founder of the dermatology department at the University of Breslau. He reported the formation of psoriasiform lesions in uninvolved skin of psoriatic patients after cutaneous trauma, such as excoriations, tattoos, and horse bites.1
The recognition that many other skin diseases, such as vitiligo, lichen planus, Darier disease, and bullous dermatoses also arise at sites of cutaneous injury,2, 3, 4, 5 led to the extension of the definition and to the attachment of the term isomorphic (from Greek, “equal shape”) response. Today, the definition of KP has been extended even further to describe patients who did not have preexisting dermatosis before trauma or in whom the response did not reoccur on additional trauma.
Section snippets
Types of Koebner response
Variations in the definition of KP led Boyd and Nelder to classify KP into four different groups6:
- 1.
True koebnerization: Where the phenomenon is reproducible in all manner of patients, by a variety of insults, and not due to disbursement of external infective or allergic elements such as psoriasis, lichen planus (Figure 1), and vitiligo.
- 2.
Pseudo-koebnerization: Where the phenomenon is produced by seeding of an infectious agent to surrounding tissue (eg, verrucae, molluscum contagiosum) or by skin
Associated conditions
Table 1 lists the skin conditions exhibiting the Koebner response.7 KP has been studied most extensively in psoriasis, but the pathogenesis of this phenomenon is still obscure. KP occurs in approximately 25% of psoriatic patients after various traumatic insults, but these might be unrecognized or forgotten.6 Various environmental stress factors on the skin have provoked KP, including trauma, such as burns, friction, insect bites, and surgical incision, as well as allergic and irritant
Possible drug induction
Certain pharmacologic agents, such as lithium, β-adrenergic blockers, nonsteroidal antiinflammatory drugs, and local application of crude coal tar and anthralin, may exacerbate psoriasis and induce koebnerization by chemical interaction with genetically susceptible epidermal cells. Potential mechanisms include alteration of polymorphonuclear leucocyte chemotaxis, diminished or enhanced synthesis of arachidonic acid metabolites, changes in the cyclic nucleotide system, and modified lymphokine
Miscellaneous types
Topical application of white soft paraffin was reported to have an inhibitory action,38 probably due to the antimitotic effect that bland ointments have been shown to possess. In contrast, other topical application did not prove useful in preventing or inhibiting KP.9 These include transient applications of heat or cold, topical, or intradermal methotrexate, lidocaine, antimycin A, and colchicine.
Reverse koebnerization is defined as clearing of a psoriatic plaque after injury. One of the early
Conclusions
The Koebner response has been described in numerous diseases since its early recognition at the end of the 18th century. This response is important dermatologists and also for surgeons, who should be aware of this entity and its consequences. The pathogenesis of this unique phenomenon is not well understood and requires further investigation. Understanding the mechanism of KP may contribute to unveiling the pathogenesis of psoriasis and other underlining diseases.
Acknowledgment
Mrs Yael Sagi assisted in the preparation of the manuscript.
References (44)
- et al.
The Koebner phenomenon and the microbial basis of psoriasis
J Am Acad Dermatol
(1988) - et al.
Stress, symmetry, and psoriasis: possible role of neuropeptides
J Am Acad Dermatol
(1986) Koebner phenomenon in lupus erythematosus with special consideration of clinical findings
Autoimmun Rev
(2005)- et al.
Revisiting the Koebner phenomenon: role of NGF and its receptor system in the pathogenesis of psoriasis
Am J Pathol
(2008) Time-dependent immunohistochemical detection of proinflammatory cytokines (IL-1beta, IL-6, TNF-alpha) in human skin wounds
Forensic Sci Int
(2002)Zur Aetiologie der Psoriasis
Vjschr Dermatol
(1876)- et al.
Koebner phenomenon in pemphigus vulgaris
Br J Dermatol
(1996) Disease of the skin
New Sydenham Society
(1874)The provocative action of light in Darier's disease
Ann Dermatol Syphilol
(1946)- et al.
The isomorphic response of Koebner
Int J Dermatol
(1990)
The Koebner phenomenon: review of the literature
J Eur Acad Dermatol Venereol
Response to injury of skin involved and uninvolved with psoriasis, and its relation to disease activity: Koebner and ‘reverse’ Koebner reactions
Br J Dermatol
The biology of psoriasis. an experimental study of the Koebner phenomenon
Acta Derm Venereol
Biochemical and physiological clues to the nature of psoriasis
AMA Arch Dermatol
Sur le phenomene de Koebner dans le psoriasis (Psoriasis factice)
Ann Dermatol Syphilol
Fenomeno di Kobner e patogenesi della psoriasi
G Ital Dermatol
[Experiences with Koebner's reaction.]
Minerva Dermatol
Experimental analysis of isomorphic (Koebner) response in psoriasis
Arch Dermatol
The Koebner (isomorphic) response in psoriasis. Associations with early age at onset and multiple previous therapies
Arch Dermatol
Epidermal rupture is the initiating factor for the Koebner response in psoriasis
Acta Derm Venereol
Role of trauma in isomorphic response in psoriasis
Arch Dermatol
Microvascular injury
Cited by (153)
Nerve growth factor mediates activation of transient receptor potential vanilloid 1 in neurogenic pruritus of psoriasis
2023, International ImmunopharmacologyVitiligo and atopic dermatitis in young girls: may Koebner phenomenon play a role?
2023, Anais Brasileiros de DermatologiaCitation Excerpt :Vitiligo risk factors are family history of autoimmune disorders, and trigger factors like trauma, skin burns, pregnancy, and systemic diseases. The isomorphic phenomenon of Koebner (KP) was reported in 20%‒60% of vitiligo patients, especially before 12 years of age.5 In Case 1, KP may have not directly caused vitiligo but promoted it due to a synergy between the AD pro-inflammatory effect and scratching.
Psoriasis and Post-Surgical Infections in Primary Total Knee Arthroplasty: An Analysis of 10,727 Patients
2022, Journal of ArthroplastyThe molecular profile of urethral stricture disease
2022, Scientific Advances in Reconstructive Urology and Tissue EngineeringFrequent FGFR3 and Ras Gene Mutations in Skin Tags or Acrochordons
2021, Journal of Investigative Dermatology