Picture taken from the left saphenous vein donor site

Picture taken from the anterior chest, at the post-operative scar.

Laboratory Data

nil

We believe this is a form of post-traumatic eczema.

Hruza LL, Hruza GJ. Saphenous vein graft donor site dermatitis. Case reports and literature review. Arch Dermatol. 1994 Jan;130(1):115-6.

Division of Dermatology, Washington University School of Medicine, St Louis, Mo.

BACKGROUND--Coronary artery bypass grafting for atherosclerotic heart disease is commonly performed throughout the world. Complications of coronary artery bypass grafting include saphenous neuralgia due to injury to the saphenous nerve during harvest of the saphenous vein. Dermatologic complications of coronary revascularization are infrequently reported and include an eruption overlying the vein donor-site scar.

OBSERVATIONS--We describe two cases of saphenous vein donor site dermatitis associated with sensory peripheral neuropathy in the distribution of the dermatitis. Histopathologic studies revealed a subacute spongiotic dermatitis. The course of the eruption was characterized by exacerbations and remissions with gradual resolution of both the dermatitis and neuropathy over a 1- to 2-year period.

CONCLUSIONS--Our cases are unique because the dermatitis developed in the area of the neurologic changes. We propose that the dermatitis may be a trophic change secondary to saphenous neuralgia.

Kato N, Ueno H. Saphenous vein graft donor site dermatitis in Japan. J Dermatol. 1995 Sep;22(9):681-5.

Department of Dermatology, National Sapporo Hospital, Japan.

Four cases of saphenous vein graft donor site dermatitis are reported from Japan for the first time. The patients were four Japanese men aged from 57 to 69. They noted pruritic eruptions along the lower extremity scar after coronary artery bypass graft surgery using the autogenous saphenous vein.

The eruptions appeared mainly on and around the lower end of the venectomy scars from 1.5 to 9 months after graft operations performed at three different hospitals. All four patients showed an objective sensory deficit of the saphenous nerve around the saphenous vein incision scar, although none of them complained of saphenous neuralgia subjectively.

Histologically, two patients showed mild epidermal acanthosis, spongiosis, intraepidermal blisters, and perivascular infiltration of lymphocytes and a few eosinophils around dermal blood vessels. The eruption responded well to topical corticosteroids in all cases, although it recurred again in two patients.

The entity is characterized by a subacute (belatedly appearing, then slowly disappearing) dermatitis and a mild sensory deficit of the saphenous nerve. Apparently, mild impediment of the saphenous nerve due to an ablational procedure of saphenous venectomy can play a role in causing saphenous vein graft donor site dermatitis.

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 on.

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 study.
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 13, 2006

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 13, 2006

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 al?