This incredible guest post is written by Anna Hovsepian, who can be found on Instagram @mypsoriasistimeline so go follow her! A lot of people who are living with psoriasis have probably experienced the Koebner Phenomenon, but aren’t even aware of what it is. This is a great article that provides extensive information about what it is ending with an interview by Anna of my own experiences with psoriasis and the Koebner Phenomenon.
In order for the Koebner phenomenon to occur, skin injury must damage the outermost layer of our skin (epidermis), and induce immunological dysregulation. Heinrich Koebner first described the Koebner Phenomenon in 1878; he focused on the onset of lesions in areas of the skin that experience trauma in people with no pre-existing dermatosis. According to Arias-Santiago et al (2013), the Koebner phenomenon occurs in approximately 25% of people with psoriasis after several traumatic injuries, but these episodes may be unrecognized. The working mechanisms of this phenomenon are described as: cytokines, stress proteins, adhesion molecules or autoantigens. Whereas provoking factors may include: physical trauma, burns, friction, insect bites, surgical incision, allergic and irritant reactions, and radiation exposure (Arias-Santiago et. al., 2013). Globally, the prevalence of psoriasis incidences occurs with 0.1% to 2.8% of the general population. Whereas psoriasis occurring on previous scars display a different histology in comparison to normal skin lesions (Alolabi et. al., 2011).
The Koebner Phenomenon: Tattoos and Psoriasis
Below is an example of an 18-year-old male who presented skin lesions on his forearm tattoos. A skin biopsy was performed and results were compatible with psoriasis. The patient had no family history of skin problems and never experienced skin conditions. For this particular case, the red, flakey patches formed right on top of the tattoo, which would be the area of skin trauma. Unlike most psoriasis spots, the skin lesions were not itchy nor painful.Figure 1. Psoriasis in Tattoos. (Arias-Santiago et. al., 2013, pg.1 figure 1) The Koebner phenomenon: surgery and psoriasis
Another example of the Koebner phenomenon includes the case of a 36-year old woman who had a prophylactic bilateral mastectomy with immediate breast reconstruction. During the operation, the patient had bilateral tissue expanders placed into the subpectoral space. Roughly 6 months following this procedure, the patient developed psoriasis on the right axillary scar. The patient’s skin complications did not end at this point; 6 years post operation, a grade 3 capsular contracture was detected on the right hand side. Additional skin trauma occurred following the replacement of breast implants. Unfortunately, the patient experienced an infection in this area, and 13 months after, a psoriatic plaque developed over the area of the final operation.
The recurrence of the Koebner phenomenon proves that psoriasis has no bounds when appearing on the skin of persons who do not present a history of skin conditions. Instead, the Koebner phenomenon allows psoriasis to appear at the site of trauma, regardless of whose skin it is. In the case of the 36-year-old, trauma existed on top of surgical sites, as well as areas affected by infection. As mentioned above before the first example, areas of skin that experience irritant reactions are affected by the Koebner phenomenon, supporting the psoriatic breakout that occurred in the 36-year-old woman who experienced infection in the area of her breast implants (Alolabi et. al., 2011).
Are psoriatic patients more susceptible to developing psoriasis following surgery? Unfortunately, psoriatic patients are more likely to see the Koebner Phenomenon occur in areas following skin trauma. Alolabi et al (2011) found that the prevalence of developing psoriatic lesions on scars occurs in 20% to 76% of patients with psoriasis.
How long does it take for psoriasis to appear following skin trauma? The amount of time it generally takes for skin injury to develop into psoriasis is 10 to 20 days.
What are the most common surgeries that later result in the Koebner phenomenon? Although information is limited, there have been studies conducted to demonstrate the correlation between the Koebner phenomenon and surgeries including breast reductions and cosmetic procedures (Alobali et. al., 2011).
What are the most common infections that may later result in the Koebner phenomenon? Studies addressing the correlation between infections and subsequent psoriatic outbreaks show that the most commonly cultured bacteria include Staphylococcus aureus and Staphylococcus epidermidis.
Questionnaire for Joni Kazantzis
Q: When did you first experience psoriasis? (date and/or age)
A: My symptoms of psoriasis first appeared when I was 15 years old.
Q: What specific type of psoriasis do you suffer from?
A: I have been diagnosed with both plaque and guttate psoriasis, but guttate has been the most prevalent type.
Q: What has persuaded you to raise awareness about psoriasis?
A: When I was growing up with psoriasis, it was very rare to find someone who knew what psoriasis was. If I can help just one person by talking about my experience with psoriasis, then I have been a success.
Q: Do you think there will be a cure for psoriasis in your lifetime?
A: I sure do hope so! The medical community has made great strides since my initial diagnosis in identifying treatment solutions and understand what psoriasis is. I recently attended the National Psoriasis Foundation Research Symposium and there are some really innovative approaches to potential treatments
Q: What do you think triggers your psoriatic outbreaks most?
A: Stress and anxiety are my personal leading causes of flares.
Q: What is your favorite treatment or combination of treatments for your psoriatic outbreaks?
A: The formula that is working best for me right now is my current treatment, which includes a biologic, Humira, complimented with a topical skin cream. I also know that when I maintain an overall healthy lifestyle that my psoriasis symptoms are better.
Q: If you were to change one thing about your current skin regimen, what would you change?
A: I struggle with compliance to my treatments. I wish I could find a topical that did not have to be applied so frequently. The biologic is taken less frequently but does require I give myself a shot so doesn’t require some psyching myself up. I set reminders to try to ensure I remember to do it.
Q: Do you believe management of psoriasis is multidimensional, such as it consists of emotional, mental, and physical treatment?
A: Absolutely! Living with psoriasis can be physically and emotionally exhausting.
Koebner phenomenon questions:
Q: How did you learn out about the Koebner phenomenon?
A: Initially, I learned that damage to my skin could leave to psoriasis spots and/or a flare from a nurse but independent research led me to understanding more about the koebner phenomenon.
Q: What were your initial thoughts on psoriasis and the Koebner phenomenon?
A: It makes sense why it happens. It is frustrating that not only are you damaging your skin from an accident but now you have to worry about psoriasis on top of it.
Q: Were you aware of the Koebner phenomenon when you had undergone a C-section?
A: Yes, I’m pretty clumsy so I learned pretty early on after my initial psoriasis diagnosis about it! I played lacrosse in high school and college, so had my fair share of bumps and cuts.
Q: With the surgery, were you afraid that you would be affected by the Koebner phenomenon knowing you have preexisting psoriatic outbreaks?
A: My C-Section was an emergency and everything happened really quickly, so didn’t really think about it until after it was over and I was healing. I did ensure to talk to my doctor about possible treatment option before I did flare, so I would know what to do.
Q: Do psoriatic outbreaks following skin trauma take longer to heal or is there no difference?
A: I have personally not seen a difference when attributing a flare to TKP, but I’ve also never pinpointed a pattern in flares making this disease incredibly frustrating.
Q: Has the Koebner phenomenon affected anyone you know that had no preexisting skin conditions or history of autoimmune disorders?
A: Not that I am aware of.
Q: Do you have any tattoos?
A: Yes, just one.
Q: Would you recommend tattoos to anyone with preexisting skin conditions or history of autoimmune disorder, knowing that there is a risk of the Koebner phenomenon occurring?
A: I think it’s a personal choice, as long as people do their research and understand the potential risks. I’d also recommend researching if your current topical treatments can be applied to a newly tattooed area to ensure you do not irritate the skin any more than it has been already.
Q: Besides surgery and tattoos, do you know of any other incidences of the Koebner phenomenon occurring following trauma to the skin?
A: I’ve been affected on areas where I’ve gotten a simple cut or scrape to the skin, so it can even be a minor injury that gets affected that turns into a psoriasis spot or flare.
Note from Joni: I hope you enjoyed reading this article from Anna as much as I did. She’s awesome and you should go follow her on Instagram – @mypsoriasistimeline