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Pemphigus Foliaceus Masquerading as Postoperative Wound Infection: Report of a Case and Review of the Koebner and Related Phenomenon following Surgical Procedures

BACKGROUND The Koebner phenomenon, also known as the isomorphic response, is the development of preexisting skin disease following trauma to uninvolved skin. Various cutaneous disorders have been described to arise at surgical wounds and scars. Moreover, dermatologic procedures, such as cold-steel and laser surgery, can evoke koebnerization. OBJECTIVE To describe a case of pemphigus foliaceus arising in postoperative wounds and to present a review of dermatologic disorders triggered by surgical procedures. METHODS We report a case of pemphigus foliaceus initially presenting at sites of Mohs' micrographic surgery, shave biopsy, and cryotherapy and, subsequently, at a nonsurgical site. We reviewed the English literature in MEDLINE from November 1955 to April 2004 for reports of Koebner and related phenomenon following surgical procedures. RESULTS To our knowledge, this is the first reported case of pemphigus foliaceus erupting at surgical and cryotherapy wounds. The clinical appearance can mimic wound infection. In addition to inducing preexisting disease, cutaneous procedures can also trigger the onset of new disease, which can either be limited only to the surgical site or subsequently become generalized. CONCLUSION Postoperative Koebner or related responses should be included in the differential diagnosis of poorly healing surgical wounds. Skin biopsies for histopathology and immunologic studies may be necessary for definitive diagnosis and optimal management.