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   Abstract
   Introduction
   Material and Methods
   Results
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STUDIES
Year : 1992  |  Volume : 58  |  Issue : 6  |  Page : 372-375

Koebner's phenomenon - A clinical test to determine therapy and prognosis in vitiligo




Correspondence Address:
V Panvelkar


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Source of Support: None, Conflict of Interest: None


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  Abstract 

Over a period of 5 years, 490 patients with vitiligo were treated with either steroid or psoralen and their response to therapy was observed. Koebner's negative patients showed satisfactory response to psoralen. Patients who were Koebner's positive initially and then turned negative after steroid therapy showed better response to combination of steroids and psoralen.


Keywords: Vitiligo, Koebner′s phenomenon, Steroids, Psoralens


How to cite this article:
Panvelkar V, Talwar S, Tiwari V D. Koebner's phenomenon - A clinical test to determine therapy and prognosis in vitiligo. Indian J Dermatol Venereol Leprol 1992;58:372-5

How to cite this URL:
Panvelkar V, Talwar S, Tiwari V D. Koebner's phenomenon - A clinical test to determine therapy and prognosis in vitiligo. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2019 Jun 24];58:372-5. Available from: http://www.ijdvl.com/text.asp?1992/58/6/372/3855



  Introduction Top


PUVA alone or in combination with corticosteroids is the mainstay of treatment of vitiligo. The response to these drugs or their combination has varied in different studies. It ranged from 50% response to topical corticosteroids, [1],[2] 25-75% to systemic steroids [3][4] 50-70% to oral PUVA, [5] and 93% to a combination of oral PUVA and steroids. [6] The response of individual patient to treatment is unpredictable.

Koebner's phenomenon or isomorphic response is seen in a variety of dermatological conditions including vitiligo. [5] An effort was made in our patients to note whether this response could be used to predict the prognosis and response to therapy in vitiligo.


  Material and Methods Top


Four hundred and ninety patients of vitiligo in age group of 18-60 years were studied over a period of 5 years. They were divided into 2 groups depending on their response to Koebner's phenomenon viz. Koebner's positive and Koebner's negative groups. The response was elicited by using a blunt injection file and result noted after 1 month. Each of this group were further subdivided into a steroid regimen group and psoralen regimen group. Thus patients were divided in 4 subgroups; Koebner's negative steroid group, Koebner's negative psoralen group, Koebner's positive steroid group, and Koebner's positive psoralen group. Steroids were given topically in patients having less than 20% of body surface involvement and systemically in the doses of 20 mg of prednisolone or equivalent in patients having more than 20% involvement. Psoralen was given in the dose of 0.6 mg/kg on alternate days in the form of 8-methoxy psoralen followed by sun exposure of 15-30 minutes.

Patients were subsequently followed bimonthly for a period of 2 years. In addition to 'observation for clinical improvement and side effects, Koebner's test was repeatedly elicited in all patients. Appearance of follicular pigmentation and nonappearance of new lesions were considered as good improvement while changes like appearance of new lesions, hair depigmentation, and increase in size of the lesions were considered as pointers to the failure of therapy.

Patients who were initially Koebner's positive and who turned negative subsequently were revaluated and 15 of these were subjected to combination therapy with psoralen and corticosteroids.

Each patient was carefully monitored for side effects of steroids and psoralen.


  Results Top


[Table - 1] shows the distribution of patients as per Koebner's phenomenon, age, and sex. Both sexes were more or less equally represented, 258 patients being males and 232 females. The highest incidence was found to in 30-40 age group which accounted for 35.71% of the total number of patients. Both extremes of age were avoided in view of the risks involved with long term steroid and psoralen therapy.

These patients were divided into 2 groups as per their response to Koebner's testing. Koebner's positivity was seen in 40.40% and Koebner's negativity in 59.59%.

It is seen from [Table - 2] that in patients with Koebner's positivity at the end of 12 months of treatment, 82.5% showed clinical improvement and 17.5% showed no or minimal response. In comparison patients who were Koebner's negative showed clinical improvement in 85.57% of cases after 12 months. The results in both the groups appear to be comparable.

It will be observed that continuation of therapy beyond 12 months has not shown any additional advantage. If the results are compared to those who received only psoralen [Table - 3], it can be seen that only 18% showed good response in 12 months in Koebner's positive group which improved to 33.33% at the end of 24 months.

In contrast, amongst Koebner's negative patients, 84.57% individuals showed good response within 12 months and only 15.42% showed no response.

The side effects seen with psoralen therapy were less as compared to steroid therapy.

With steroids, it was seen that 88.88% showed conversion from Koebner's positivity to Koebner's negativity within 12 months while 11.11% showed no conversion even after 2 years. Maximum conversion (41.91%) was seen within a period of 6 months [Table - 4].

Of the Koebner's positive individuals who were treated with psoralens, only 33.59% showed conversion after, 24 months and 66.41% showed no conversion even after 24 months of therapy. In this group maximum conversion was seen in 9 months (11.30%).

Fifteen patients of Koebner's positive group who did not show response to steroid group but had shown Koebner's negativity after treatment were treated with combination of steroids and psoralens. After 12 months of the combination therapy 10 of these patients showed good clinical improvement.


  Comments Top


Steroids are known to help regain the lost pigmentation in vitiligo when used topically [1],[2]sub or systemically. [3],[4] But the long duration of treatment invariably brings about side effects of steroids in a substantial number of cases.

Psoralens in different forms have been used in vitiligo for a long time. Though a success rate of 50-70% has been claimed with PUVA [5],[6] certain cases where vitiligo spreads in spite of systemic psoralens are not uncommon.

In our series we tried to elicit Koebner's response in all patients in an effort to determine whether the disease is active or inactive. Similar test is used in psoriasis as well to determine the activity of the disease.

In patients who received steroids, it was seen that maximum patients showed clinical response within 6 months to 12 months but patients who were Koebner's positive tended to show better and earlier response as compared to patients who were Koebner's negative. On the contrary, in patients who were treated with PUVASOL, it was noted that very few individuals who were Koebner's positive, tended to show satisfactory clinical response even after 12 months of therapy. In fact a significant number of patients tended to show new lesions and depigmentation of the hair indicating spread of the disease. On the contrary in Koebner's negative individuals treated with PUVASOL, it was seen that a high percentage (82.97%) showed good clinical response after a period of 3-9 months. Out of a total of 188 patients, only 29 (15.24%) did not show good improvement with psoralens and were lost to follow-up. Majority of these, patients had acral lesions with known poor prognosis. These figures clearly indicate that psoralens have a major role to play in Koebner's negative individuals only.

Steroids showed a failure of 17.5% in Koebner's positive cases and 14.42% in Koebner's negative cases. However the side effects of steroids were encountered much more frequently as compared to psoralen in our series and despite all efforts to minimise the side effects, they were a major cause of dissatisfaction among patients.

In patients, who were. Koebner's positive initially and who subsequently turned Koebner's negative on steroid therapy, an alternating regime with steroids and psoralen brought about clinical improvement in majority of the cases.

It was observed that most of the treatment failures had acral or lip-tip type of vitiligo. It is suggested that these individuals who did not respond to either steroids or psoralens or a combination of them should not be subjected to long term treatment with these drugs and should be managed with camouflage creams.

 
  References Top

1.Kandil E. Treatment of vitiligo with 0.1% betamethasone 17- valerate in isopropyl alcohol - a double blind trial. Br Dermatol 1974; 91 457-60.  Back to cited text no. 1    
2.Clayton R. A double blind trial of 0.05% clobetasol propionate in the treatment of vitiligo. Br J Dermatol 1977; 96 : 71 - 3.  Back to cited text no. 2  [PUBMED]  
3.Imamura S, Tagani H. Treatment of vitiligo with oral cortico-steroids. Dermatologica 1976; 153: 179- 85.  Back to cited text no. 3    
4.Brostoff H, Brostoff J. Vitiligo and steroids. Lancet 1978; 2 : 688.  Back to cited text no. 4  [PUBMED]  
5.Mosher DB, Fitzpatrick TB, Ortonne JP, et al. Disorders of pigmentation. In : Dermatology in General Medicine (Fitzpatrick T B, Eisen A Z, Wolff K, et al, eds),3rd edn. New York : Mc Graw Hill Book Company, 1987, 818 - 21.  Back to cited text no. 5    
6.Farah FS, Kurban AK, Chaglassian HT. The treatment of vitiligo with psoralens and triamcinolone by mouth.wBr J Dermatol 1967; 79: 89 - 91.  Back to cited text no. 6  [PUBMED]  


    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4]



 

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