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Successful skin grafting in a case of pemphigus vulgaris
SUCCESSFUL
SKIN GRAFTING IN A CASE PEMPHIGUS VULGARIS
By C. BERTENYI, M.D.,
J. ENDRODI,’ M.D.
OF
and A. DOBOZY, M.D.
Plastic Surgical Department of the &rmatologicaE Clinic, Medical University, Szeged, 6701 Szeged, Koranyi rkp. 8-10, Pf. 480, Hungary.
PEMPHIGUS vulgaris is a chronic disease inclined to relapses and frequently fatal. Flaccid intra-epithelial bullae containing serous fluid may occur in the mouth and anywhere on the body. They readily rupture leaving extensive erosions covered persistently with crusts. In the sera of the patients, IgG type circulating auto-antibodies acting against the intercellular substance of the epidermis can be demonstrated (Beutner and Jordon, 1964). These circulating antibodies appear to have a damaging effect on the whole epithelium since a positive Nikolsky sign and immune globulin deposits in the skin of apparently healthy patients with pemphigus have been demonstrated (Cormane et al., 1970).
Traumatic lems in repair.
skin loss in a patient with pemphigus might be expected to present probOn the other hand 3 reports of successful transplantation have been
previously published (Zipikowsky et al., 1960; Rome et al., 1964; McKinney and LeWirm, 1967). Zipikowsky, et al. performed experimental transplants in 2 volunteers. Better than normal recovery could be observed, though the donor sites took 30-35 days to heal because of infection. The following case seems to be the fourth successful free skin graft in a patient with pemphigus. CASE REPORT A labourer aged 24 has been under our care for 3 years with histologically proved pemphigus vulgaris. Repeated haematological and biochemical investigation has given normal He results. x-ray examination shows no sign of osteoporosis in the long bones and vertebrae. has been treated with 1-3 mg. per day of Dexamethasonum (Oradexon; Organon), intermittently with 50-100 mg. per day Azathioprine (Imuran; Burroughs Wellcome) for several weeks, anabolic steroids (Nerobol; Pharmaceutical Factory, Kobanya, Budapest) and preparations containing calcium and potassium. As a result of this he has been dermatologically symptom-free for 14 years. While driving a motor cycle he was involved in a crash with a car. He sustained a fracture of the left tibia and the skin of his lower leg was detached subcutaneously by the shearing nature of the injury. The skin on the medial third of the leg became necrotic and was treated by the traumatologist who administered dry wound treatment and delayed necrotomies in order to protect the fracture from denudation and leave time for the formation of granulations under the necrotic crust. The fracture was immobilised first with splints and 34 days after injury fixed with multiple nails (Hackethal, 1971) and a plaster cast with a window exposing the raw area. After 7 days’ application of saline compresses the granulations became smooth, pinkish, shiny and were considered suitable for grafting on the 46th day (Fig. I). A split skin graft of thicker than medium thickness was taken from the extensor surface of the right thigh with a The thicker cutis was supposed to be needed because of Humby knife under local anaesthesia. The graft was applied in postage-stamp-sized the possibility of rejection of the epithelium. pieces. Tulle gras covered the grafts with a loose dressing on top. On the second day the colour of most of the grafts was perfect and the epithelium was firm, but 3 white grafts were observed at the edge of the wound (Fig. 2, A). Epithelial growth could be seen on the 4th day ’ At present
working
at the
II. Surgical
Department 381
of the Medical
University,
Szeged.
382
BRITISH
JOURNAL
OF PLASTIC
SURGERY
and the wound was covered by continuous epithelium on the 10th day (Fig. 2, B). The wound caused by the bone-king procedure showed no delay in healing and the donor site was healed in IO days.
I.
FIG.
FIG.
2.
Skin
The
defect covered with preoperatively.
grafts A, 48 hours after after transplantation.
fresh
and
granulation
B,
IO
days
SUCCESSFUL
SKIN
GRAFTING
IN A CASE OF PEMPHIGUS
VULGARIS
383
DISCUSSION
According to the experiments of Bellone and Leone (1957) the serum of patienrs with pemphigus has a greater stimulating influence on the development of a skin tissue culture than that of a control. Zipikowsky et al. also reported a faster than normal wound healing in his pemphigus patients. In the present case during and after injury and operation until the wound was healed the pemphigus was controlled by 3 mg. Dexamethason daily, and the take of the graft and epithelialisation were quite normal. It seems therefore that neither the mitosis-inhibitory effect of the steroid, nor the anti-epidermal auto-aggressive tendency of the disease have any harmful influence on skin grafting in a properly controlled case. The take of a skin graft is similar to other forms of wound healing and establishing the fact of its normality may be of prognostic importance in patients with pemphigus requiring an operation for some intercurrent disease. SUMMARY
Successful postage-stamp reported.
skin grafting in a patient with pemphigus
vulgaris is
REFERENCES BELLONE, A. G. and LEONE, V. (1957).
pemphygus
A study 09 the action of blood sera from healthy p_eople, and severely burned subjects on human skin tissue cultures. Dermatology and Venereology, C 121, II, No. 8.
patients
Excerpta Medica. BEUTNER, E. H. and JORDON,, R. E. (1964). Demonstration of skin antibodies in sera of pemphygus vulgaris pattents by indirect immunofluorescent staining. Proceedirzgs of the Society for exper@ental Biology and Medicine, 117, 505. CORMANE, R. H., SZAB~ E. and HAUGE, L. S. (1970). Immunofluorescence of the skin: the interpretation of the staining of blood vessels and connective tissue aided by new technics. BritishJournal of Dermatology, 82, supplement 5. 26. Berlin-Gottingen-Heidelberg: Springer HACKETHAL,K. H. (1961). “Die Biindelnagelung”. Verlag. MCKINNEY, I’. and LEWINN, L. R. (1967). The closure of a wound of the lower leg in a patient Plastic and Reconstructive Surgery, 40, 77. with pemphygus vulgaris : a case report. ROME, L., ENGELBRECHT, J. and GORDON, W. (1964). Skin graft in pemphygus. South African MedicalJournal, 38, 850-851. ZIPIKOWSKY, I., KRAKOWSKY, A. and BORNSTEIN, L. (1960). Pemphigus vulgaris and skin grafting. Journal of Imestigatiu Dermatolog_v, 34, 285.
SKIN GRAFTING IN A CASE PEMPHIGUS VULGARIS
By C. BERTENYI, M.D.,
J. ENDRODI,’ M.D.
OF
and A. DOBOZY, M.D.
Plastic Surgical Department of the &rmatologicaE Clinic, Medical University, Szeged, 6701 Szeged, Koranyi rkp. 8-10, Pf. 480, Hungary.
PEMPHIGUS vulgaris is a chronic disease inclined to relapses and frequently fatal. Flaccid intra-epithelial bullae containing serous fluid may occur in the mouth and anywhere on the body. They readily rupture leaving extensive erosions covered persistently with crusts. In the sera of the patients, IgG type circulating auto-antibodies acting against the intercellular substance of the epidermis can be demonstrated (Beutner and Jordon, 1964). These circulating antibodies appear to have a damaging effect on the whole epithelium since a positive Nikolsky sign and immune globulin deposits in the skin of apparently healthy patients with pemphigus have been demonstrated (Cormane et al., 1970).
Traumatic lems in repair.
skin loss in a patient with pemphigus might be expected to present probOn the other hand 3 reports of successful transplantation have been
previously published (Zipikowsky et al., 1960; Rome et al., 1964; McKinney and LeWirm, 1967). Zipikowsky, et al. performed experimental transplants in 2 volunteers. Better than normal recovery could be observed, though the donor sites took 30-35 days to heal because of infection. The following case seems to be the fourth successful free skin graft in a patient with pemphigus. CASE REPORT A labourer aged 24 has been under our care for 3 years with histologically proved pemphigus vulgaris. Repeated haematological and biochemical investigation has given normal He results. x-ray examination shows no sign of osteoporosis in the long bones and vertebrae. has been treated with 1-3 mg. per day of Dexamethasonum (Oradexon; Organon), intermittently with 50-100 mg. per day Azathioprine (Imuran; Burroughs Wellcome) for several weeks, anabolic steroids (Nerobol; Pharmaceutical Factory, Kobanya, Budapest) and preparations containing calcium and potassium. As a result of this he has been dermatologically symptom-free for 14 years. While driving a motor cycle he was involved in a crash with a car. He sustained a fracture of the left tibia and the skin of his lower leg was detached subcutaneously by the shearing nature of the injury. The skin on the medial third of the leg became necrotic and was treated by the traumatologist who administered dry wound treatment and delayed necrotomies in order to protect the fracture from denudation and leave time for the formation of granulations under the necrotic crust. The fracture was immobilised first with splints and 34 days after injury fixed with multiple nails (Hackethal, 1971) and a plaster cast with a window exposing the raw area. After 7 days’ application of saline compresses the granulations became smooth, pinkish, shiny and were considered suitable for grafting on the 46th day (Fig. I). A split skin graft of thicker than medium thickness was taken from the extensor surface of the right thigh with a The thicker cutis was supposed to be needed because of Humby knife under local anaesthesia. The graft was applied in postage-stamp-sized the possibility of rejection of the epithelium. pieces. Tulle gras covered the grafts with a loose dressing on top. On the second day the colour of most of the grafts was perfect and the epithelium was firm, but 3 white grafts were observed at the edge of the wound (Fig. 2, A). Epithelial growth could be seen on the 4th day ’ At present
working
at the
II. Surgical
Department 381
of the Medical
University,
Szeged.
382
BRITISH
JOURNAL
OF PLASTIC
SURGERY
and the wound was covered by continuous epithelium on the 10th day (Fig. 2, B). The wound caused by the bone-king procedure showed no delay in healing and the donor site was healed in IO days.
I.
FIG.
FIG.
2.
Skin
The
defect covered with preoperatively.
grafts A, 48 hours after after transplantation.
fresh
and
granulation
B,
IO
days
SUCCESSFUL
SKIN
GRAFTING
IN A CASE OF PEMPHIGUS
VULGARIS
383
DISCUSSION
According to the experiments of Bellone and Leone (1957) the serum of patienrs with pemphigus has a greater stimulating influence on the development of a skin tissue culture than that of a control. Zipikowsky et al. also reported a faster than normal wound healing in his pemphigus patients. In the present case during and after injury and operation until the wound was healed the pemphigus was controlled by 3 mg. Dexamethason daily, and the take of the graft and epithelialisation were quite normal. It seems therefore that neither the mitosis-inhibitory effect of the steroid, nor the anti-epidermal auto-aggressive tendency of the disease have any harmful influence on skin grafting in a properly controlled case. The take of a skin graft is similar to other forms of wound healing and establishing the fact of its normality may be of prognostic importance in patients with pemphigus requiring an operation for some intercurrent disease. SUMMARY
Successful postage-stamp reported.
skin grafting in a patient with pemphigus
vulgaris is
REFERENCES BELLONE, A. G. and LEONE, V. (1957).
pemphygus
A study 09 the action of blood sera from healthy p_eople, and severely burned subjects on human skin tissue cultures. Dermatology and Venereology, C 121, II, No. 8.
patients
Excerpta Medica. BEUTNER, E. H. and JORDON,, R. E. (1964). Demonstration of skin antibodies in sera of pemphygus vulgaris pattents by indirect immunofluorescent staining. Proceedirzgs of the Society for exper@ental Biology and Medicine, 117, 505. CORMANE, R. H., SZAB~ E. and HAUGE, L. S. (1970). Immunofluorescence of the skin: the interpretation of the staining of blood vessels and connective tissue aided by new technics. BritishJournal of Dermatology, 82, supplement 5. 26. Berlin-Gottingen-Heidelberg: Springer HACKETHAL,K. H. (1961). “Die Biindelnagelung”. Verlag. MCKINNEY, I’. and LEWINN, L. R. (1967). The closure of a wound of the lower leg in a patient Plastic and Reconstructive Surgery, 40, 77. with pemphygus vulgaris : a case report. ROME, L., ENGELBRECHT, J. and GORDON, W. (1964). Skin graft in pemphygus. South African MedicalJournal, 38, 850-851. ZIPIKOWSKY, I., KRAKOWSKY, A. and BORNSTEIN, L. (1960). Pemphigus vulgaris and skin grafting. Journal of Imestigatiu Dermatolog_v, 34, 285.