10.5826/dpc.1302a99
text/xml
2160-9381
2708
en
Luca Vaienti
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Pustular Psoriasis Triggered by a Subcutaneous Tissue Expander
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Image Letter
2023-04-29
2022-07-19
2023-04-29
2023-06-05
e2023099
Dermatol Pract Concept
Luca Vaienti
2023/04/29
10.5826/dpc.1302a99
e2023099
Department of Reconstructive and Aesthetic Plastic Surgery, I.R.C.C.S. Istituto Galeazzi, University of Milan
2160-9381
en
e2023099
Qiao P, Guo W, Ke Y, et al. Mechanical Stretch Exacerbates Psoriasis by Stimulating Keratinocyte Proliferation and Cytokine Production. J Invest Dermatol. 2019;139(7):1470-1479. DOI: 10.1016/j.jid.2018.12.019.
Pustular Psoriasis Triggered by a Subcutaneous Tissue Expander
https://dpcj.org/index.php/dpc/article/download/2708/2089
      Pustular Psoriasis Triggered by a Subcutaneous
                     Tissue Expander
 Mario Alessandri-Bonetti1, Claudio Conforti2, Francesco Amendola1, Riccardo Carbonaro1,
                              Manuela Cirami3, Luca Vaienti1


1 Department of Reconstructive and Aesthetic Plastic Surgery, University of Milan, I.R.C.C.S. Istituto Galeazzi, Milan, Italy
2 Dermatology Clinic, Maggiore Hospital of Trieste, Trieste, Italy
3 Department of Pathology, I.R.C.C.S. Policlinico San Donato, Piazza Edmondo Malan, San Donato Milanese, Italy



Citation: Alessandri-Bonetti M, Conforti C, Amendola F, Carbonaro R, Cirami M, Vaienti L. Pustular Psoriasis Triggered by a
Subcutaneous Tissue Expander. Dermatol Pract Concept. 2023;13(2):e2023099. DOI: https://doi.org/10.5826/dpc.1302a99
Accepted: September 23, 2022; Published: April 2023
Copyright: ©2023 Alessandri-Bonetti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Mario Alessandri-Bonetti, MD, Department of Reconstructive and Aesthetic Plastic Surgery,
University of Milan, IRCSS Istituto Galeazzi, Via Riccardo Galeazzi 4 - 20161 Milan, Italy. Telephone number: +393385033483;
E-mail: m.alessandribonetti@gmail.com




Case Presentation                                                         were taken. Histology revealed parakeratosis, acanthosis,
                                                                          epidermal spongiotic pustules, perivascular inflammatory
An African 50-year-old female presented to our department                 infiltrate with neutrophils in the epidermis and psoriasiform
complaining of retracting, painful and dystrophic scarring                hyperplasia. Although the negative family history of the
caused by a previous childhood burn in the right pectoral                 patient, our findings were compatible with pustular psoriasis
area. Past medical history was unremarkable.                              (Figure 1, C and D).
    We chose a two-step approach to treat her burn sequelae.
First, we inserted a 400-cc silicone smooth rectangular tissue
expander (Mentor, Irvine, USA) in the right suprascapular
                                                                          Teaching Point
area. The expander was progressively filled during ambu-
latory visits. Secondly, three months later, the dystrophic               Pustular psoriasis (PP) is clinically characterized by sterile
area was excised and reconstruction was performed using                   pustules corresponding to a neutrophilic infiltrate in the
the expanded skin flap. At 12-months follow-up, the patient               dermis. Usually, PP affects palms and soles while sometimes
complained of itch above the advancement flap. We noticed                 it may present in a generalized form associated with systemic
an indurated purple plaque within the distal part of the flap,            symptoms.
measuring 15x16 cm and surrounded by erythematous bor-                        We hypothesized that the keratinocytes stretching
ders (Figure 1A). Multiple pruritic pustules were noted in the            and skin insult provoked by tissue expansion could have
upper arms, abdomen and dorsum (Figure 1B). Biopsies of                   triggered the development of cutaneous psoriasis presenting
the right pectoral plaque and of a left supraclavicular pustule           as a plausible Koebner phenomenon [1,2].



Image Letter | Dermatol Pract Concept. 2023;13(2):e2023099                                                                              1
Figure 1. (A) Hyperchromic psoriatic plaque in the right pectoral area, developed above the expanded skin flap. (B) Multiple psoriatic
pustules developed above abdominal area and upper arms. (C) Psoriasiform acanthosis and thinning of suprapapillary plates. Mild inflam-
matory infiltrate (H&E, x10). (D) Subcorneal pustules, parakeratosis and hypogranulosis. Mild inflammatory perivascular and interstitial
infiltrate composed predominantly of lymphocytes (H&E, x20).




References                                                             2. Qiao P, Guo W, Ke Y, et al. Mechanical Stretch Exacerbates Pso-
                                                                          riasis by Stimulating Keratinocyte Proliferation and Cytokine
1. Okamoto T, Ogawa Y, Kinoshita M, et al. Mechanical stretch-­           Production. J Invest Dermatol. 2019;139(7):1470-1479. DOI:
   induced ATP release from keratinocytes triggers Koebner phe-           10.1016/j.jid.2018.12.019. PMID: 30641039
   nomenon in psoriasis. J Dermatol Sci. 2021;103(1):60-62. DOI:
   10.1016/j.jdermsci.2021.06.001. PMID: 34187740




2                                                                            Image Letter | Dermatol Pract Concept. 2023;13(2):e2023099
