Pseudo-koebnerization in viral warts

Pseudo-koebnerization refers to the appearance of new lesions of an infectious dermatosis along sites of trauma due to autoinoculation of the pathogen, rather than a true isomorphic response. It is commonly seen in viral infections such as cutaneous warts caused by human papillomavirus (HPV). Minor trauma – scratching, shaving, friction, or maceration – facilitates implantation of viral particles into adjacent skin, leading to the linear spread of lesions along the direction of injury.^[1]

In viral warts, this phenomenon often manifests as linear or grouped verrucous papules corresponding to scratch marks or areas subjected to repeated friction. The lesions typically have a rough, hyperkeratotic surface and may show punctate black dots representing thrombosed capillaries.

In the present case, the image demonstrates multiple linear streaks of small verrucous papules over the extensor aspect of the elbow, arranged along scratch lines. These papules follow a linear pattern suggestive of autoinoculation, representing pseudo-koebnerization. In addition, a larger hyperkeratotic wart with a rough, papillomatous surface is visible inferiorly, likely representing the primary lesion from which viral particles were spread through scratching [Figure 1].

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Figure 1:

Multiple linear rows of small verrucous papules arranged along scratch marks over the extensor aspect of the elbow. A larger hyperkeratotic, papillomatous wart is seen inferiorly, likely serving as the primary lesion from which viral spread occurred.

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Recognition of pseudo-koebnerization is clinically important because it highlights the role of mechanical spread of HPV, emphasizing patient counseling regarding avoidance of scratching and early treatment of primary lesions to limit dissemination.