The Association between Koebner Phenomenon and Clinical Features

in Vitiligo

I. G. A. A. Praharsini, Nyoman Suryawati

I. G. A. Sattwika Pramita

Department of Dermatology and Venereology, Faculty of Medicine Udayana University, Sanglah Hospital Denpasar Bali

Keywords: Koebner phenomenon, vitiligo, disease activity, the degree of severity, prognosis.

Abstract: Koebner phenomenon (KP) is one of the phenomena used to determine dermatologic disorders. The

pathogenesis of KP is unclear, and research on KP with characteristics factors on vitiligo and its clinical effect

is limited. Therefore this study aimed to determine the relationship of KP with clinical features of vitiligo.

This study used cross-sectional design, and 60 subjects with vitiligo as samples. Demographic data and

clinical features were obtained from questionnaires. The degree of disease severity was obtained by using a

VASI score and to measure the degree of disease activity using a VIDA score. The data were analyzed using

Mann Whitney and chi square. The median age of the sample was 47.50 ± 20.75, and the majority of samples

were 56.7% male. Vitiligo vulgaris was the majority of clinical type and the proportion of vitiligo with 60%

of KP. There was a statistically significant relationship (p<0.001) between KP and the duration of illness, the

lesion area of vitiligo, the degree of severity, disease activity and age at the onset. There was a significant

association between onset at age with KP with RP 8.85; 95% CI (2.48-31.52); p<0.001. Koebner phenomenon

was associated with various clinical factors of vitiligo and can be used to evaluate prognosis of vitiligo.

1 INTRODUCTION

Koebner phenomenon (KP) is the development of

pathologic lesions of traumatized skin in unaffected

or normal areas. ( Thappa, 2004) This phenomenon is

present in some diseases such as vitiligo, psoriasis,

lichen planus and Darier’s disease.

(Van Geel N,

2011) The prevalence of Koebner phenomena is

reported to be around 21% to 62%. (Barona,1995)

The clinical role of KP is not yet clear, although a

positive KP could be a predictor of disease activity.

Only a few data have been reported the relationship

between this phenomenon and disease activity in

vitiligo, characteristic factors, and its clinical

outcomes.

(Van Geel N, 2012) The objective of this

study was to prove the association between Koebner

phenomenon with various clinical characteristic

factors in vitiligo.

2 METHODS

This research was an observational analytical study

with cross-sectional study design. The number of

subjects with vitiligo fulfilling the inclusion and

exclusion criteria was 60 people who visited the

dermatology and venereology clinic at Sanglah

Hospital, Bali. The study was conducted from

September to December 2017. All vitiligo subjects

were diagnosed clinically and examined using wood

lamps. Sample characteristics data were obtained

using questionnaires including demographic and

clinical data such as the type of vitiligo, lesion

location, duration, the initial location of vitiligo

lesion, lesion area and age onset of vitiligo. VIDA

scores were used to assess the disease activities and

the severity of vitiligo using VASI scores.

Data were analyzed using SPSS 20. Median and

inter-quatile range (IOQ) was presented for

quantitative variable. Frequency variables and

percentages were obtained for qualitative variables.

Normality test of the data used Shapiro-Wilk test.

The Mann Whitney test was used to compare mean

differences between 2 groups. Chi-square test was

used to determine the association between qualitative

variables. The p-values <0.05 were considered

statistically significant.

Praharsini, I., Suryawati, N. and Sattwika Pramita, I.

The Association between Koebner Phenomenon and Clinical Features in Vitiligo.

DOI: 10.5220/0008150500480051

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 48-51

ISBN: 978-989-758-494-7

3 RESULTS

Table 1. Characteristics of vitiligo patients

Variable Value

n=60

Age (yr)

47.50



20.75

Gender

Male 34 (56.7)

Female 26 (43.3)

Duration of illness (yr)

10.00



26.00

Type of vitiligo

Vitiligo vulgaris 26 (43.3)

Acrofacial 23 (38.4)

Focal 9 (15.0)

Segmental 2 ( 3.3)

Location of initial lesion/ Site of onset

Head and face 17 (28.3)

Chest and abdomen 9 (15.0)

Back 1 ( 1.7)

Upper limb 25 (41.7)

Lower limb 8 (13.35)

Lesion of area (%)

4.00



5.50

Koebner phenomenon

Yes 36 (60.0)

No 24 (40.0)

VASI

2.00



3.04

VIDA

1 (0



Age at onset of vitiligo

 17 years old

27 (45.0)

> 17 years old 33 (55.0)

Values are presented as median  interquatile range, number (%).

Table 2. Profil clinical presentation in vitiligo associated with Koebner phenomena

Variable Koebner phenomenon p-value

Yes (n=36) No (n=24)

Disease activity

1 (1



30)

0 < 0.001

Degree of severity

Lesion of area (%)

Duration of illness (year)

Age at onset

17 yr

>17 yr)

3.58



3.24

13.04  3

25.00  31.75

23 (63.9)

13 (36.1)



0.50

1 1

4.50  5.75

4 (16.7)

20 (83.3)

< 0.001

p-values <0.05 are considered statistically significant

The total number of vitiligo samples was 60 people.

The median age of the sample was 47.50 ± 20.75

years old. The average length of illness was 10.00 ±

26.00 years. The majority of vitiligo cases were male,

34 people (56.7%) compare it with 26 females

(43.3%). The most common type of vitiligo was

vitiligo vulgaris, 26 samples (43.3%). The earliest

lesions of vitiligo located highest in the upper limb,

25 samples (41.7%). The proportion of vitiligo

The Association between Koebner Phenomenon and Clinical Features in Vitiligo

patients with KP was 36 (60%). Descriptive data of

respondents were presented in Table 1.

Duration of illness (p<0.001), lesion area of

vitiligo (p<0.001), degree of severity (VASI score)

p<0.001, disease activity (VIDA score) p<0.001 and

age at the onset of vitiligo p<0.001, there was

significant difference in vitiligo with KP versus

vitiligo without KP. The above data were presented in

Table 2. There was a significant association between

the starting age of illness with KP obtained Ratio

Prevalence / RP 8.85, 95% CI (2.48-31.52); p<0.001.

4 DISCUSSION

The etiology and pathogenesis of KP in vitiligo

remains unclear, although various mechanisms have

been described such as immunologic, neural,

enzymatic, genetic, hormonal and vascular factors

that lead to depigmentation. It has also been proved

that the immunologic factors involved in the

pathogenesis of psoriasis are the result of a traumatic

KP.

According to some other researchers that

capillary changes in the dermis cause all

immunologic changes. (Thappa, 2004)

The concept of KP as a sign of the active vitiligo

or as a sign of reduced patient response therapy in

vitiligo remains vague. This study compared the

clinical profile of vitiligo patients with the presence

of KP and vitiligo patients without KP. Several

clinical profiles have been shown to have significant

differences between vitiligo with KP and without KP,

so the results may provide explanations to the patients

regarding the prognosis and the response to therapy.

The result of this study obtained data on the

proportion of vitiligo patients with KP was 60%. A

study from Khurrum et al, reported the proportion of

vitiligo patients with KP was 28.1%, while a research

in India reported 6.6% of vitiligo patients with KP.(

Khurrum, 2017) The initial site of most vitiligo

lesions began at a superior limb of 41.7%, perhaps

this site is often exposed to trauma and chemical

materials at work. Koebner's response caused by

repeated mechanical / pressure and friction or thermal

and irritant reaction to chemicals. ( Thappa, 2004 ;

Nanette, 2014) It can be explained that trauma causes

defects in the adhesion of melanocytes in epidermis

resulting melanocyte damage, increasing expression

inflammatory cytokines and oxidative stress.

Koebner's hidden phenomenon is a chronicity factor

of vitiligo.

(Dakoutrou, 2016) The results of this

study showed the majority of men was 56.6%, more

than women. Wang et al found higher prevalence in

male, similar with Mc Burney reported the male to

female ratio was 1.6 : 1, suggesting that men are more

concerned about vitiligo.

(Ding, 2014)

The total area of vitiligo lesion based on the rule

of nine had a significant difference between vitiligo

with KP and without KP (p<0.001). This was

supported by the theory of generalized vitiligo that

triggered by a complex interaction between stress and

trauma. (Dakoutrou, 2016) Stress may suppress

activation of the HPA axis in the skin through

glucocorticoids causing inhibition of

melanogenesis.(Nanette, 2014)

The mean length of

illness was 16.67±15.49 (p<0.001). Length of illness

more than 5 years had a significant relation to vitiligo

with KP. These findings suggested that KP can be

used as an indicator of active vitiligo. (Dakoutrou,

2016) There was a significant relationship between

age onset of vitiligo with KP, that was RP=8.85; 95%

CI (2.48-31.52); p<0.001, which mean that

respondents with age onset of illness  17 years old

was at risk of KP events 8.85 times greater than the

respondents began to illness aged >17 years old.

Vitiligo in children is often more active than adult

age. Previous studies have shown genetic factors play

a role in children with vitiligo including family

history of vitiligo, comorbid diseases such as atopic

dermatitis and autoimmune diseases including

thyroid disease, Addison disease, diabetes mellitus

and pemphigus vulgaris.

(Lahlou A,2017)

Vitiligo patients with Koebner phenomena tend

to have unstable or active lesions and the depigment

lesions will continue to expand, even if patients are

treated. KP in vitiligo can be used as a clinical

parameter predicting prognosis. ( Khurrum, 2017).

5 CONCLUSION

Koebner phenomenon can be used to predict activity

and prognosis by evaluating the clinical features of

vitiligo that can help to choose the modalities of

therapy in vitiligo patients. Further research is needed

with larger sample quantities to explain the clinical

characteristics of KP.

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The Association between Koebner Phenomenon and Clinical Features in Vitiligo