The n e w e ng l a n d j o u r na l
Images in Clinical Medicine
Enrico Streit, M.D.
Lena E. Vogelgsang, M.D.
University of Heidelberg
Heidelberg, Germany
enrico​.­streit@​­med​.­uni-heidelberg​.­de
2180
Downloaded from nejm.org on November 30, 2017. For personal use only. No other uses without permission.
Copyright © 2017 Massachusetts Medical Society. All rights reserved.
of m e dic i n e
Chana A. Sacks, M.D., Editor
ECG-Induced Koebner Phenomenon
A 
53-year-old man who had a history of psoriasis for more than
20 years presented to an outpatient dermatology clinic for further manage-
ment of worsening pruritus and psoriatic lesions. His symptoms had previ-
ously been insufficiently controlled with topical calcipotriene and betamethasone.
Systemic treatment with fumaric acid and methotrexate had been discontinued be-
cause of side effects. Three weeks before this presentation, the patient had under-
gone electrocardiography (ECG), which had been followed 2 weeks later by the
appearance of new lesions in the locations where the ECG electrodes had been
placed. The skin examination also revealed sharply defined erythematous plaques
of different sizes with silvery scale on the trunk, the arms and legs, and the scalp.
In patients with psoriasis, stimuli such as drugs, infection, local irritation, and even
psychological stress can trigger relapses of this chronic inflammatory disease. The
Koebner phenomenon, also known as an isomorphic response, is characterized by
the appearance of new psoriatic lesions after mechanical irritation. The patient was
treated with adalimumab, which led to a rapid response and healing of all psoriatic
lesions.
DOI: 10.1056/NEJMicm1706993
Copyright © 2017 Massachusetts Medical Society.
n engl j med 377;22 nejm.org  November 30, 2017
The New England Journal of Medicine