|Year : 2017 | Volume
| Issue : 2 | Page : 61-64
Autonomic denervation dermatitis: A new type of eczematous dermatitis
Bhushan Madke1, Madhulika Mhatre2, Piyush Kumar3, Adarsh Lata Singh1, Anil Patki4
1 Department of Dermatology, Venereology and Leprosy, Jawaharlal Nehru Medical College and AVBR Hospital, Wardha, Maharashtra, India
2 Consultant Dermatologist, Wockhardt Hospitals, Mumbai, Maharashtra, India
3 Department of Dermatology, Katihar Medical College, Katihar, Bihar, India
4 Consultant Dermatologist, Skin Clinic, Pune, Maharashtra, India
|Date of Web Publication||28-Jul-2017|
Department of Dermatology, Venereology and Leprosy, OPD-19, Jawaharlal Nehru Medical College and AVBR Hospital, Sawangi Meghe, Wardha - 442 001, Maharashtra
Source of Support: None, Conflict of Interest: None
We hereby describe a case series of eczematous dermatitis in a peculiar clinical setting. The cases presented with eczematous dermatitis at the site of surgical incision and adjoining skin after a varying lag period. Clinically, all patients presented with xerosis and eczematous rashes around the surgical sites. In our observation, the time taken to develop skin rashes around the surgical sites ranged from 6 months to 3 years. We believe that denervation injury due to dermal nerve transections may lead to autonomic disturbance in the involved area and contribute to the development of dermatitis. Treatment is essentially medical with topical emollients and judicious use of topical corticosteroids. Through this case series, we propose to introduce a new dermatological entity - “autonomic denervation dermatitis” in postsurgical patients.
Keywords: Denervation, eczema, saphenous vein harvesting, skin rash, total knee replacement
|How to cite this article:|
Madke B, Mhatre M, Kumar P, Singh AL, Patki A. Autonomic denervation dermatitis: A new type of eczematous dermatitis. Clin Dermatol Rev 2017;1:61-4
|How to cite this URL:|
Madke B, Mhatre M, Kumar P, Singh AL, Patki A. Autonomic denervation dermatitis: A new type of eczematous dermatitis. Clin Dermatol Rev [serial online] 2017 [cited 2019 Dec 10];1:61-4. Available from: http://www.cdriadvlkn.org/text.asp?2017/1/2/61/211786
| Introduction|| |
Dermatitis (commonly known as “eczema”) refers to a group of dermatoses characterized by inflammation of the skin occurring secondary to a variety of causes (allergic, atopic, irritant, stasis, etc.). The terminology for eczematous eruptions occurring at the site of surgical procedures has been confusing. In the past, various authors have named the dermatoses depending on the site or nature of the surgical procedure. In 2009, Verma and Mody reported a similar presentation in 55 patients as “surgery of the knee, injury to the infrapatellar branch of the saphenous nerve, traumatic eczematous dermatitis” (SKINTED). However, the condition reported by them is region- and procedure-specific. The term “posttraumatic eczema” (PTE) proposed by Mathias is also nonspecific and misleading since all traumas do not lead to a denervation injury of dermal nerves. “Neuropathy dermatitis” was proposed by Sharquie et al., wherein they reported eruptions similar to those observed by Verma and Mody. At present, there is no consensus regarding the correct terminology for these innocuous dermatoses. Through this article, we propose a unifying term for all eczematous dermatitis occurring at previous surgical sites.
| Case Report|| |
Authors across the country pooled their cases after conceptualizing the idea of proposing a new form of eczematous dermatitis by one of the authors. In our study, ten patients (9 males and 1 female) who underwent various surgical procedures on their lower extremities (5 - total knee replacement, 4 - saphenous vein graft harvesting, and 1 - open reduction for fracture femur) presented to the authors at their respective clinics with localized itchy, xerotic, scaly, and erythematous rashes consisting of papules and oozy plaques [Figure 1],[Figure 2],[Figure 3]. [Table 1] gives the patient characteristics in our observational study. The eruption exclusively occurred on the surgical incision sites and adjoining area. The time lag to develop eczematous eruptions after surgical procedures ranged between 6 months and 3 years. All the reported cases had an uneventful postoperative period. These cases did not give any history of use of any topical agent/local disinfectant/contact allergen during the postoperative period. Of the ten cases, six patients underwent standardized patch testing by Contact and Occupational Dermatosis Forum of India technique for suspected contact allergy and results were interpreted as per International Contact Dermatitis Research Group scoring system. None of the patch-tested patients showed any signs of an allergic reaction. Most of the cases reported varying degrees of sensory loss at the surgical sites. Starch-iodine test at the area of dermatitis revealed decreased sweating as compared to the surrounding area. Complete blood counts and serum biochemistry in all cases were within normal reference range. None of the described cases had any signs or symptoms of venous stasis or varicose veins, and hence, vascular duplex scan was not done. Skin biopsy from patients showed changes suggestive of chronic spongiotic dermatitis [Figure 4]. All patients were treated with liberal amount of topical moisturizers and appropriate strength of topical corticosteroids. Severe cases of dermatitis were treated with tapering doses of oral prednisolone. Remission was maintained with topical emollients and intermittent use of topical corticosteroids.
|Figure 1: Autonomic denervation dermatitis over lateral aspect of right thigh following fractured femur surgery|
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|Figure 2: Lower legs showing eczematous eruption at the site of saphenous vein grafting|
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|Figure 3: Left knee region showing dry sub-acute type of eczematous reaction along suture marks and adjacent skin after total knee replacement|
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|Figure 4: Skin biopsy showing mild epidermal hyperplasia with subacute spongiotic epidermal reaction and superficial perivascular dermatitis (×20, H and E)|
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Autonomic nerve fibers constitute only a minority of cutaneous nerve fibers and are restricted to the dermis, innervating blood vessels, arteriovenous anastomoses, lymphatic vessels, arrector pili muscles, eccrine glands, apocrine glands, and hair follicles. The cutaneous autonomic nervous system plays a crucial part in regulating sweat gland function, vasomotor activity, and skin blood flow. Skin barrier function is a result of complex and poorly understood processes and normal functioning of sweat glands, sebaceous glands, and cutaneous microcirculation (which in turn depends on autonomic nerve activity) appears to be necessary for maintenance of the skin barrier. In addition, acetylcholine and catecholamines secreted from autonomic nerve endings are thought to play a role in keratinocyte proliferation, adhesion, migration, and differentiation - another instance of the role of autonomic nerve activity in skin barrier homeostasis.
Skin incisions lead to traumatic transections of dermal nerves causing denervation of various autonomic organs of the skin, especially those responsible for sudomotor and vasomotor responses. Altered cutaneous anatomy and physiology following injury to peripheral nerves have been termed as “trophoneurosis.” The importance of intact sudomotor activity was highlighted by Takahashi et al. They concluded that impaired sudomotor function is a contributory factor in the cause and aggravation of representative atopic eczema in the cubital fossa. Cicek et al. studied the role of autonomic dysfunction in atopic dermatitis and concluded that sudomotor activity controlled by the sympathetic nervous system, as well as unmyelinated fibers that play a role in this activity are affected in patients with atopic dermatitis. We can extrapolate the above findings to our cases of “autonomic denervation dermatitis (ADD)” and can assume that the pathomechanics which are at play in atopic dermatitis get replayed at postoperative incision sites. Sharquie et al. suggested that release of neuropeptides following nerve regeneration was responsible for eczematous eruptions.
In the past, similar eczematous reactions were reported as “SKINTED” and “PTE” at sites of surgical and traumatic sites, respectively. SKINTED was reported as eczematous lesions developing around the knee, weeks after knee replacement surgery. We would like to suggest that “SKINTED” is a subset of our proposed clinical term - “ADD.” “SKINTED” is a site- and procedure-specific diagnosis while the term ADD would be applicable to all eczematous eruptions at or around surgical sites irrespective of site and nature of the operative procedure.
The infrapatellar branch of the saphenous nerve is a purely sensory nerve that crosses the inferior knee from medial to lateral and innervates the skin below the patella as well as the anterior inferior knee capsule. Verma and Mody proposed that injury to infrapatellar branch during surgery could be responsible for eczematous changes around the knee joint following total knee replacement. It must be stressed that majority of patients exhibit objective numbness of the lateral aspect of the knee following total knee replacement due to injury to the infrapatellar branch of the saphenous nerve, which is a purely sensory nerve. However, they had not described how sensory loss could lead to an eczematous eruption. This functional loss is important since patients can suffer burns if hot fomentation is carried out by older patients over the anesthetic area. Systemic conditions (diabetes, atherosclerotic vessel disease) as well as aging changes as a possible cause of eczematous dermatitis were ruled out since the eruption primarily involved areas of surgical incisions and adjoining skin, while rest of the cutaneous surface was essentially normal.
PTE refers to eczematous lesions developing at and around sites of mechanical, thermal, or chemical injury and usually develops within 2–4 weeks of trauma. The pathomechanism of development of PTE is poorly understood, and atopic diathesis has been implicated as an underlying cause. Inflammatory response following trauma has also been proposed to cause initiation and maintenance of eczematous lesions in PTE. As evident from the discussion, PTE is a totally different entity from our proposed ADD as the later results from transection of dermal nerves during surgical procedures. The term “neuropathy dermatitis” is nonspecific and misleading since there are no other features of sensory or motor neuropathy. It is also interesting to note that most cases had eczematous eruptions of only the lower extremity. Patients who underwent coronary artery bypass grafting along with saphenous vein graft harvesting showed eczematous response only on the lower limb while the surgical site on the anterior chest wall was apparently normal. This differential expression of eczematous response around surgical sites in the same patient could be attributed to a relatively poor blood supply of the lower limbs, which could be compromised even more due to autonomic nerve damage. Relevance of positive results on patch testing is yet to be assessed since few cases showed contact allergy to unrelated antigen. [Table 2] provides distinguishing features between PTE and ADD. We have excluded “SKINTED” and “neuropathy dermatitis” since we believe that both these terms can be clubbed under our proposed entity.
|Table 2: Distinguishing features of posttraumatic eczema and autonomic denervation dermatitis|
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The exact clinical course of ADD is still uncertain. ADD can be a persistent eczematous rash which can show frequent remission and relapse, especially in winter. Patients should be adequately counseled about the chronic course of the dermatoses. Liberal use of emollients and occlusive moisturizers should be encouraged to maintain skin barrier integrity. Since ADD is a steroid responsive dermatosis, patients should be discouraged from long-term use of super-potent topical corticosteroid preparations. We look forward to further research into this entity to unearth its pathogenesis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]