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Letter to the Editor
2022
:2;
29
doi:
10.25259/CSDM_25_2022

Decoding eczematous lesions occurring post-surgery

Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
Department of Dermatology, Christian Medical College, Vellore, Tamil Nadu, India
Corresponding author: Arunachalam Narayanan, Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India. narayanan359@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Narayanan A, Ram Kumar KR, Kotekar S, Krishna J, Thappa DM. Decoding eczematous lesions occurring post-surgery. CosmoDerma 2022;2:29.

Dear Sir,

Surgical procedures can result in a broad spectrum of cutaneous changes. Eczematous lesions at surgical sites include autonomic denervation dermatitis, post-traumatic eczema, and “surgery of the knee, injury to the infrapatellar branch of the saphenous nerve, traumatic eczematous dermatitis (SKINTED).” We describe two patients presenting with postsurgical eczema.

CASE 1

A 45-year-old male patient presented with itchy, hyperpigmented, scaly eczematous plaques with oozing and excoriations over the left medial aspect of the left distal leg Figure 1a for 6 months. The patient was a known diabetic on regular treatment. He was involved in a road accident 2 years ago, resulting in his right little toe amputation. He had undergone skin graft transfer from the left distal part of the leg to the right foot [Figure 1b]. The patient started developing eczematous lesions over the graft site 1.5 years later. There was a moderate sensory deficit to touch and pain. We made a final diagnosis of autonomic denervation dermatitis based on the history. We treated our patient with topical corticosteroids with good improvement.

Figure 1a:: Hyperpigmented, scaly eczematous plaque with oozing and excoriations over the left medial aspect of left distal leg
Figure 1b:: Skin graft site over the right foot

CASE 2

A 62-year-old female patient with itchy, hyperpigmented, scaly eczematous plaques linearly distributed along the medial aspect of the left leg [Figure 2]. The patient had undergone a saphenous vein graft as a part of coronary artery bypass graft two years ago. She started developing eczematous lesions from where a saphenous vein graft was taken 6 months after surgery. The patient had minimal sensory deficit over the incision scar. We made a final diagnosis of autonomic denervation dermatitis and treated it with topical corticosteroids with good improvement.

Figure 2:: Hyperpigmented, scaly eczematous plaque linearly distributed along the medial aspect of the left leg

Autonomic nerve fibers play an important role in sweat gland function, vasomotor activity, and cutaneous blood flow. The skin barrier function is maintained by the normal functioning of sweat glands, sebaceous glands, and cutaneous blood flow. Impaired sudomotor activity has a role in the development of dermatitis. Acetylcholine and catecholamines secreted from autonomic nerve endings modulate keratinocyte proliferation, adhesion, migration, and differentiation. During nerve regeneration, there is a release of neuropeptides from nerve terminals during nerve regeneration. The neuropeptides, including substance P, calcitonin gene-related protein, vasoactive intestinal peptide, and neurotensin, modulate the presentation of epidermal antigen. They also play a role in immediate and delayed-type hypersensitivity reactions resulting in dermatitis.

Cutaneous surgeries result in traumatic damage to dermal nerve fibers. This nerve damage results in the denervation of various autonomic organs of the skin. The altered cutaneous anatomy and physiology following autonomic nerve injury is termed “trophoneurosis.” Verma and Mody described “surgery of the knee, injury to the infrapatellar branch of the saphenous nerve, traumatic eczematous dermatitis (SKINTED).”[1] The condition was region and procedure-specific. It occurs 3 weeks to 4 months after knee surgery. The condition was accompanied by hypoesthesia/anesthesia, which develop soon after surgery and resolved once the skin lesions appeared.[2] Mathias proposed the term “post-traumatic eczema.”[3] Sharquie et al. proposed “neuropathy dermatitis” to describe eruptions similar to SKINTED.[4] Madke recently suggested the term “autonomic denervation dermatitis.”[5] Table 1 lists the differences between autonomic denervation dermatitis, post-traumatic eczema, and SKINTED.

Table 1:: Clinical features of autonomic denervation dermatitis, post-traumatic eczema, and SKINTED
Clinical features Autonomic denervation dermatitis Post-traumatic eczema SKINTED
Onset Months to years after surgery 3-4 weeks after trauma Months to years after surgery to the knee
Nature of trauma Surgery Mechanical/ thermal/ chemical trauma Knee surgery
Site At surgical site At traumatic site Surgical site over knee
Nature of wound Healed surgical site Wound in healing phase Healed surgical site
Recurrent Persistent/ recurrent lesions Recurrent lesions Recurrent lesions

Post-traumatic eczema occurs 2-4 weeks after mechanical, thermal, or chemical injury. The lesions occur in and around the wound, often during healing. The pathogenesis of post-traumatic eczema includes atopic predisposition and post-traumatic inflammatory response (koebnerization).[5] The condition frequently recurs over multiple years.

Autonomic denervation dermatitis presents with xerosis and anesthesia/hypoesthesia months to years after surgical trauma,[6] after the surgical site has healed [Table 2]. Autonomic denervation dermatitis results from transection of dermal nerves during cutaneous surgery.[7] The lesions of autonomic denervation dermatitis are persistent or recurrent. Patients often present with relapses in winters and should be counselled regarding the chronic nature of the disease.[8] SKINTED is a site and procedure specific subset of autonomic denervation dermatitis.

Table 2:: Case reports of autonomic denervation dermatitis
Author Age Gender Time lag between surgery and development of ADD Nature of trauma Site Clinical features
Madke et al. 5 60 F 10 months Total knee replacement Left knee Eczematous, scaly, oozy lesion
Madke et al. 5 58 M 18 months Saphenous vein graft harvest Medial aspect of right leg Dry, scaly, ill-define lesion
Madke et al. 5 59 M 2 years Total knee replacement Right knee Dry, scaly, pruritic lesions
Madke et al. 5 49 M 6 months Saphenous vein graft harvest Medial aspect of right leg and ankle joint Eczematous lesion with dry skin
Madke et al. 5 59 M 1 year Total knee replacement Left knee Pruritic, oozy papulovesicular lesion
Madke et al. 5 55 M 1 year Saphenous vein graft harvest Right leg and ankle Eczematous lesion
Madke et al. 5 55 M 2 years Open reduction and internal fixation of femur fracture Lateral aspect of right thigh
Madke et al. 5 60 M 3 years Saphenous vein graft harvest Right leg and ankle joint Eczematous lesion
Madke et al. 5 61 M 9 months Total knee replacement Left knee Oozy, papulovesicular lesion
Madke et al. 5 65 M 2 years Total knee replacement Right knee Oozy papulovesicular lesion
Mathur et al. 8 70 M 1 year 4 months Bilateral total knee replacement Bilateral knees Itchy, dry lesions
Mathur et al. 8 49 F 11 months Bilateral total knee replacement Bilateral knees Itchy, red lesions
Pathania et al. 1 60 F 9 months Bilateral knee replacement surgery Bilateral knees Oozy, red lesions on left knee
Hyperpigmented, raised lesion on right knee
Bose et al. 6 48 M 6 months Saphenous vein graft harvest Right medial malleolus to upper thigh Oozy, crusted lesion with xerosis
Biswas et al. 7 54 M 11 months Saphenous vein graft harvest Left leg Red, oozy, lesions

The presentation of post-traumatic eczema and autonomic denervation dermatitis are very similar. Dermatologists should be aware of the differences between these two entities to make a proper diagnosis.

Declaration of patient consent

Patient’s consent not required as patients identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , . SKINTED: An autonomic denervation dermatitis. Int J Dermatol. 2020;59:613-4.
    [CrossRef] [PubMed] [Google Scholar]
  2. , . Explaining a hitherto nameless condition: ‘SKINTED’. Clin Exp Dermatol. 2009;34:e465-e466.
    [CrossRef] [PubMed] [Google Scholar]
  3. , . Idiopathic post-traumatic eczema. Contact Dermatitis. 2006;54:178.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , . Neuropathy dermatitis following surgical nerve injury. Case Rep Dermatol Med. 2011;2011:234185.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , . Autonomic denervation dermatitis: A new type of eczematous dermatitis. Clin Dermatol Rev. 2017;1:61-4.
    [CrossRef] [Google Scholar]
  6. , . Autonomic denervation dermatitis following saphenous vein grafting: A case report. 202134817854.
    [CrossRef] [Google Scholar]
  7. , , , . Autonomic denervation dermatitis. Indian J Surg. 2021;10:1-2.
    [CrossRef] [Google Scholar]
  8. , . Autonomic denervation dermatitis in two patients. Indian J Clin Dermatol. 2019;2:96-7.
    [Google Scholar]

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