Resident’s Linear lesions in dermatology

Page

Dipali D. Malvankar, S. Sacchidanand, M. Mallikarjun, H. V. Nataraj

INTRODUCTION than one type of cell lines within the body.[2,3] The
causes for mosaicism are half chromatid mutation,
Linear lesions in dermatology are commonly lyonization, post zygotic mutation, chromosomal
encountered. They vary in cause; being congenital non disjunction, and chimerism.[3] The most common
or acquired; vary in morphology and can present as disorders following Blaschko’s lines are enlisted in
macules, papules, patches, plaques, vesicles or nodules; Table 1.[2-5]
they can be inflammatory or non inflammatory; it can
be a single lesion which is linear or multiple lesions Figures 1-3 show a few conditions following Blaschko’s
which are arranged in a linear pattern. The causes lines.
for occurrence in a linear pattern include lesions
following Blaschko’s lines, blood vessels, lymphatics There are case reports of hypermelanotic macules
and dermatomes; due to Koebner’s phenomenon and of McCune-Albright syndrome,[6] extragenital lichen
auto inoculation; external factors; infestations like sclerosis,[7] eosinophilic cellulitis,[8] erythematous rash
cutaneous larva migrans and burrows of scabies. We
of scarlet fever,[9] Bart syndrome,[10] linear scalp lupus
review each of these causes one by one.
profundus,[11] all following Blaschko’s lines.

BLASCHKO’S LINES
BLOOD VESSELS
Blaschko’s lines are imaginary skin lines which
Blood vessels have a longitudinal course in the body.
various skin conditions are known to follow. They do
Hence, lesions which occur in blood vessels are likely
not follow neural, vascular, or lymphatic structures
to have a linear pattern. These include the following:
and are distinct from dermatomes as well as Langer’s
a. Thrombophlebitis refers to blood vessel
lines.[1] These were first described by Alfred Blaschko
inflammation along with thrombus formation.
in 1901. The most widely accepted basis for these
lines is genotypic mosaicism, i.e., presence of more Two types are recognised - superficial and deep.
Superficial thrombophlebitis is visible and presents
with erythema and tenderness in the skin along the
Department of Dermatology, Bangalore Medical College and
distribution of the affected blood vessel.[12] Mondor’s
Research Institute, Bangalore, India disease is a type of superficial thrombophlebitis
which affects the breast and sometimes the penis,
Address for correspondence:
Dr. Dipali D. Malvankar, Department of Skin, STD and Leprosy, which presents with a linear and tender cord- like
# 52, OPD Block, Victoria Hospital, Bangalore-560 002, India. thickening of the affected vein.[13,14]
E-mail: [email protected]
b. Varicose veins present with dilated and tortuous
veins commonly occurring in the lower limbs due
to insufficient closure of valves causing backflow
Access this article online
from deep to superficial veins.[15] Veins being
Quick Response Code: Website:
linearly arranged, these lesions show a linear
www.ijdvl.com
distribution.
DOI:
c. Intravenous drug induced hyperpigmentation
10.4103/0378-6323.86499
presents with linear hyperpigmented streaks along
PMID:
the course of veins. It commonly occurs in case of
*****
intravenous drugs given for malignancies[16] [Figure 4].

How to cite this article: Malvankar DD, Sacchidanand S, Mallikarjun M, Nataraj HV. Linear lesions in dermatology. Indian J Dermatol
Venereol Leprol 2011;77:722-6.
Received: May, 2011. Accepted: June, 2011. Source of Support: Nil. Conflict of Interest: None declared.

722 Indian Journal of Dermatology, Venereology, and Leprology | November-December 2011 | Vol 77 | Issue 6
Malvankar, et al. Linear lesions in dermatology

Table 1: Causes of linear lesions

Blaschko’s lines Macules and patches of incontinentia pigmenti, hypomelanosis of Ito, linear and whorled nevoid hypermelanosis,
nevus depigmentosus, linear fixed drug eruption
Papules and plaques of morphea, Goltz syndrome, lichen striatus, Adult Blaschkitis, Darier’s disease, linear
verrucous epidermal nevus, inflammatory linear verrucous epidermal nevus, linear psoriasis, linear lichen planus,
linear lichen nitidus, linear porokeratosis, linear chronic graft versus host disease, linear Hailey-Hailey disease.
Vesicles of incontinentia pigmenti
Blood vessels Thrombophlebitis, Varicose veins, intra venous drug induced hyperpigmentation, polyarteritis nodosa.
Lymphatics Acute lymphangitis, infection with Mycobacterium marinum, Sporothrix schenckii, Leishmania braziliensis,
Nocardia brasiliensis, Mycobacterium chelonae, Francisella tularensis and Staphylococcus aureus.
Dermatomal Herpes zoster, linear vascular malformations, Segmental vitiligo
Koebner phenomenon Psoriasis, lichen planus, vitiligo. Occasionally in Darier’s disease, lichen sclerosus et atrophicus, Hailey Hailey
disease, lichen nitidus.
Auto inoculation Warts, molluscum contagiosum
Due to external factors Paederus dermatitis, Berloque dermatitis, phytophotodermatitis, dermatitis artefacta
Infestations Cutaneous larva migrans, burrows of scabies

Figure 1: Case of linear verrucous epidermal nevus showing Figure 2: Case of incontinentia pigmenti with multiple linear and
multiple linear verrucous papules since birth with superimposed whorled papulo-vesicular lesions and streaks of hyperpigmentation
warts in the proximal part

Figure 4: Case of gastric carcinoma on treatment with

Figure 3: Case of linear porokeratosis presenting with multiple 5-fluorouracil having linear streaks of hyperpigmentation along
asymptomatic plaques on the lower limb the vein of injection

Indian Journal of Dermatology, Venereology, and Leprology | November-December 2011 | Vol 77 | Issue 6 723
Malvankar, et al. Linear lesions in dermatology

d. Polyarteritis nodosa is a necrotising inflammation sporotrichosis and hence is also called sporotrichoid
of blood vessels which presents with nodules distribution [Figure 5]. The differential diagnosis
and ulcers mainly on the lower limbs along the for this includes infection with Mycobacterium
distribution of blood vessels. marinum, Sporothrix schenckii, Leishmania
braziliensis, Nocardia species, Mycobacterium
LYMPHATICS chelonae, Francisella tularensis, and Staphylococcus
aureus.[18-21]
The following conditions follow lymphatics:
a. Lymphangitis is the inflammation of lymph vessels. DERMATOMES
Acute lymphangitis is streptococcal infection of
lymphatics of subcutaneous tissue presenting A dermatome is a linear area of skin supplied by a
with erythematous linear streaks from the site of single spinal nerve. The following conditions follow
infection to the draining lymph nodes.[17] It also dermatomes:
occurs in early stages of filariasis. a. Herpes zoster presents with multiple erythematous
b. Nodular lymphangitis is a clinical presentation in vesicles with burning sensation along the
which erythematous papules and nodules occur distribution of a particular spinal nerve.
along the course of lymphatics.[18] This occurs mainly b. Vascular malformations like capillary malformations
in chronic suppurative inflammatory disorders of are sometimes are distributed along a dermatomal
the skin in which causative organisms spread via segment[22] [Figure 6].
lymphatics. This distribution commonly occurs in c. Vitiligo is an acquired disorder which presents with

Figure 5: Case of sporotrichosis showing linear distribution of Figure 6: Case of segmental vascular malformation affecting the
nodular lesions over the upper limb upper limb

Figure 7: Case of extensive verruca plana showing pseudo Figure 8: Case of paederus dermatitis showing multiple
koebnerisation with linear lesions papulovesicular lesions arranged linearly over the face

724 Indian Journal of Dermatology, Venereology, and Leprology | November-December 2011 | Vol 77 | Issue 6
Malvankar, et al. Linear lesions in dermatology

depigmented macules and patches. Sometimes, linear streaks along the area of contact with the
this disorder follows dermatomal segments when irritant.[31]
it presents with linear macules and patches and is d. Dermatitits artefacta: Dermatitis artefacta (factitious
called as dermatomal, segmental, zosteriform or dermatitis) refers to self-inflicted skin injuries
pseudosegmentalis type of vitiligo.[23] Segmental made consciously to elicit sympathy, escape
vitiligo has an early onset, rapid progression and responsibility, or collect disability insurance. The
no specific precipitating factors.[24] In one study, lesions are common on areas which are easily
the most commonly involved dermatome was the accessible and commonly arranged in a linear
trigeminal and only a few patients had an associated pattern.[32]
autoimmune disease.[24]
INFESTATIONS
KOEBNER’S PHENOMENON
a. Cutaneous larva migrans is a skin infestation
Koebner’s phenomenon was first described by clinically characterized by erythematous linear
Heinrich Koebner,[25] and refers to the development serpiginous lesions caused by nematode larvae.[33]
of isomorphic lesions at the sites of trauma in case of b. The burrows made by the scabies mite in the skin
cutaneous disorders.[26] Scratching being a common are also commonly linear.
cause of cutaneous trauma, leads to linear lesions along
the line of scratching. True Koebner’s phenomenon CONCLUSION
occurs in psoriasis, lichen planus and vitiligo and is
also occasionally seen in other conditions[26] [Table 1]. The importance of linear lesions in dermatology cannot
be over emphasized. Linear lesions act as diagnostic
AUTO INOCULATION clues in many disorders. They also help in elucidating
the pathogenesis as they give a clue to the pathway of
This is also termed as pseudo Koebner’s phenomenon. It spread of the disease. Koebner phenomenon indicates
occurs in infectious disorders like due to implantation the presence of active disease and helps to decide the
of infectious agent in the skin during trauma leading line of management.
to development of isomorphic linear lesions like in
Koebner’s phenomenon. Examples include warts and REFERENCES
molluscum contagiosum[26] [Figure 7].
1. Jackson R. The lines of Blaschko: A review and reconsideration:
Observations of the cause of certain unusual linear conditions
EXTERNAL FACTORS of the skin. Br J Dermatol 1976;95:349-60.
2. Tagra S, Talwar AK, Walia RS. Lines of Blaschko. Indian J
a. Paederus dermatitis (dermatitis linearis,[27] or Dermatol Venereol Leprol 2005;71:57-9.
3. Moss C. Mosaicism and linear lesions. In: Bolognia JL, Jorizzo
blister beetle dermatitis[28]) commonly occurs in JL, Rapini RP, editors. Dermatology. 2nd ed. Spain: Mosby
tropical and subtropical regions. It is a peculiar Elsevier; 2008. p. 841-5.
irritant contact dermatitis characterized by sudden 4. Bolognia JL, Orlow SJ, Glick SA. Lines of Blaschko. J Am Acad
Dermatol 1994;31:157-90.
onset linear erythematous and bullous lesions and 5. Moss C, Larkins S, Stacey M, Blight A, Farndon PA, Davison
burning on exposed areas of the body.[28] It occurs EV. Epidermal mosaicism and Blaschko’s lines. J Med Genet
when beetles of the genus Paederus (also called 1993;30:752-5.
6. Rieger E, Kofler R, Borkenstein M, Schwingshandl J, Soyer
rove beetles) are crushed on the skin, releasing the HP, Kerl H. Melanotic macules following Blaschko’s lines in
vesicant pederin, which causes irritant dermatitis[29] McCune-Albright syndrome. Br J Dermatol 1994;130:215-20.
[Figure 8]. 7. Choi SW, Yang JE, Park HJ, Kim CW. A case of extragenital lichen
sclerosus following Blaschko’s lines. J Am Acad Dermatol
b. Berloque dermatitis occurs when perfumes
2000;43:903-4.
containing bergamot oil are applied followed by 8. Sommer S, Wilkinson SM, Merchant WJ. Eosinophilic cellulitis
exposure to sunlight. It presents with erythema and following the lines of Blaschko. Clin Exp Dermatol 1999;24:
hyperpigmentation along the pattern formed by the 449-51.
9. Duran-McKinster C, Moises C, Rodriguez-Jurado R, Tamayo-
trickle of droplets, which is usually linear.[30] Sanchez L, Orozco-Covarrubias L, Ruiz-Maldonado R.
c. Phytophotodermatits (meadow dermatitis, Streptococcal exanthem in a blaschkolinear pattern: Clinical
strimmer dermatitis, weed wacker dermatitis)[30] evidence for genetic mosaicism in hypomelanosis of ito. Pediatr
Dermatol 2002;19:423-5.
occurs due to furocoumarins in plants which cause 10. Duran-McKinster C, Rivera-Franco A, Tamayo L, De La Luz
a phototoxic reaction. It commonly presents with Orozco-Covarrubias M, Ruiz-Maldonado R. Bart Syndrome:

Indian Journal of Dermatology, Venereology, and Leprology | November-December 2011 | Vol 77 | Issue 6 725
Malvankar, et al. Linear lesions in dermatology

the congenital localized absence of skin may follow the lines of editors. Fitzpatrick’s Dermatology in General Medicine. 7th ed.
Blaschko: Report of Six Cases. Pediatr Dermatol 2000;17:179–82. New York: McGraw Hill Book; 2008. p. 1652.
11. Nagai Y, Ishikawa O, Hattori T, Ogawa T. Linear lupus 23. Dhar S, Dutta P, Malakar R. Pigmentary Disorders. In: Valia
erythematosus profundus on the scalp following the lines of RG, Valia AR, editors. IADVL Textbook of Dermatology. 3rd ed.
Blaschko. Eur J Dermatol 2003;13:294-6. Mumbai: Bhalani Publishing House; 2008. p. 753.
12. Torpy JM, Burke AE, Glass RM. JAMA patient page: 24. Hann SK, Lee HJ. Segmental vitiligo: Clinical findings in 208
Thrombophlebitis. JAMA 2006;296:468. patients. J Am Acad Dermatol 1996;35:671-4.
13. Pugh CM, DeWitty RL. Mondor’s disease. J Natl Med Assoc 25. Kuner N, Hartschuh W, Khan-Durani B. Heinrich Kobner
1996;88:359-63. and the “isomorphic phenomenon: History and review of the
14. Kumar B, Narang T, Radotra BD, Gupta S. Mondor’s disease of literature. Hautarzt 2003;54:274-8.
penis: A forgotten disease. Sex Transm Infect 2005;81:480-2. 26. Thappa DM. The isomorphic phenomenon of Koebner. Indian J
15. Nullen H, Noppeney T. Diagnosis and treatment of varicose Dermatol Venereol Leprol 2004;70:187-9.
veins, Part 1: Definition, epidemiology, etiology, classification, 27. Morsy TA, Arafa MA, Younis TA, Mahmoud IA. Studies on
clinical aspects, diagnostic and indications. Chirurq Paederus alfierii Koch (Coleoptera:Staphylinidae) with special
2010;81:1035-44.
reference to the medical importance. J Egypt Soc Parasitol
16. Alley E, Green R, Schuchter L. Cutaneous toxicities of cancer
1996;26:337-51.
therapy. Curr Opin Oncol 2002;14:212-6.
28. Singh G, Yousuf Ali S. Paederus dermatitis. Indian J Dermatol
17. Singh G, Kaur V, Singh S. Bacterial infections. In: Valia RG,
Venereol Leprol 2007;73:13-5.
Valia AR, editors. IADVL Textbook of Dermatology. 3rd ed.
29. Zargari O, Kimyai-Asadi A, Fathalikhani F, Panahi M. Paederus
Mumbai: Bhalani Publishing House; 2008. p. 232.
dermatitis in northern Iran: A report of 156 cases. Int J Dermatol
18. Giordano CN, Kalb RE, Brass C, Lin L, Helm TN. Nodular
lymphangitis: Report of a case with presentation of a diagnostic 2003;42:608-12.
paradigm. Dermatol Online J 2010;16:1. 30. Anstey AV. Disorders of skin colour. In: Burns T, Breathnach S,
19. Schneider P, Monsel G, Veziris N, Roujeau JC, Bricaire F, Cox N, Griffiths C, editors. Rook’s Textbook of Dermatology. 8th
Caumes E. Successful treatment of nodular lymphangitis due to ed. Oxford: Wiley Blackwell; 2010. p. 58.32.
Mycobacterium chelonae in two immunosuppressed patients. 31. Adams SP. Dermacase: Phytophotodermatitis. Can Fam
Dermatol Online J 2011;17:8. Physician 1998;44:503,509.
20. Kostman JR, DiNubile MJ. Nodular lymphangitis: A 32. James WD, Berger TG, Elston DM, editors. Pruritus and
distinctive but often unrecognized syndrome. Ann Intern Med neurocutaneous dermatoses. In: Andrews’ Diseases of the Skin
1993;118:883-8. Clinical Dermatology. 10th ed. Philadelphia: Saunders Elsevier;
21. Lieberman AA, Grossman ME, Bloomgarden D. Sporotrichoid 2006. p. 61.
lymphangitis due to Staphylococcus aureus in a diabetic 33. Tomović M, Skiljević D, Zivanović D, Tanasilović S, Vesić S,
patient. Clin Infect Dis 1995;21:433-4. Daković Z, et al. Two cases of probable endogenous extensive
22. Boon LM, Vikkula M. Vascular Malformations. In: Wolff K, cutaneous larva migrans in Serbia. Acta Dermatovenerol Alp
Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Panonica Adriat 2008;17:37-40.

Announcement
iPhone App
A free application to browse and search the journal’s content is now available for iPhone/iPad. The application
provides “Table of Contents” of the latest issues, which are stored on the device for future offline browsing.
Internet connection is required to access the back issues and search facility. The application is Compatible
with iPhone, iPod touch, and iPad and Requires iOS 3.1 or later. The application can be downloaded from http://
itunes.apple.com/us/app/medknow-journals/id458064375?ls=1&mt=8. For suggestions and comments do
write back to us.

726 Indian Journal of Dermatology, Venereology, and Leprology | November-December 2011 | Vol 77 | Issue 6