Robert I. Rudolph, M.D., FACP, Clinical Professor
of Dermatology, University of Pennsylvania, Philadelphia. PA,
USA on Feb 12, 2006
Nice case and good pictures. I've seen a number of these: especially
on the lower portion of lower leg. The vascular docs shrug it
off, as unimportant, but the rash often drives the patients
crazy. Potent topical steroids work.
In this case, since every single spot is "lit up",
I'd certainly consider a contact dermatitis to a topical antibiotic
ointment - or other preparation the patient has been putting
Khalifa Shaquie MD, PhD, Professor of Dermatology,
College of Medicine, University of Baghdad, Baghdad, Iraq
on Feb 12, 2006
Dermatitis at the site of operation on the legs is well known
feature although it is not well documented in the literature.
The site of operation when it is changing into a hypertrophic
scar or even keloid, it becomes very itchy as it contains plenty
of mast cells, even with a Darier's sign. This will lead into
traumatic dermatitis. With frequent use of antiseptics, this
will cause contact dermatitis whether irritant or allergic type.
All these offending agents will be responsible for this picture
seen in this interesting case presented here. The management
will be accordingly.
Sharquie KE, Al-Dhalimi MA. Keloid in Iraqi patients: a clinicohistopathologic
Dermatol Surg. 2003 Aug;29(8):847-51.
David Elpern MD, Williamstown, MA, USA on
Feb 12, 2006
This is an important case because it speaks to the nature and
etiology of "eczema." Injury to the skin (surgical
in this case) seems to predispose to the development of eczema
by an allergic or irritant mechanism. This is probably mediated
by activated T cells - the so-called "killer T cells."
Here is an article which attempts to address this subject.
Trautmann A, Disch R, Brocker EB, Akdis CA, Gillitzer R. [How
does eczema arise?
[Article in German] J Dtsch Dermatol Ges. 2003 Jan;1(1):8-11.
New experimental results on the role of T cells and keratinocytes
have led to a better understanding of eczematous inflammation
and can help explain both the clinical and histological pictures
of eczema. Besides activated endothelial cells and adhesion
molecules, a complex interaction of numerous chemokines controls
the recruitment of T cells from the blood vessels and their
migration into the dermis and epidermis. Activated T cells damage
the epidermis by pro-inflammatory cytokines and can induce apoptosis
of individual keratinocytes through "killer molecules".
Cleavage of adhesion molecules on keratinocytes leads to spongiotic
changes. Keratinocytes then activate repair mechanisms, which
cause acanthosis and parakeratosis in chronic eczema.
I suspect this patient would be helped greatly by the "Soak
and Smear" protocol described by William James in the January
2006 Archives of Dermatology.
Babu Thomas MD, Kollam, Kerala, India on February
Differential Diagnoses considered include (1) post-operative
psoriatic lesion with Koebner phenomenon and (2) allergic eczematous
dermatitis secondary to dressing materials, topical applicants,
etc. Patch test is advisable.
Steven Deliduka MD, Atlanta, GA, USA on February
Interesting cases and comments. My question/comment is as follows:
Why is this something new? Can these cases be a great example
of the "Isotopic Response" as described by Wolf et