Letters to the Editor

Reported histological examinations have shown an Subcutaneous emphysema: a rarity

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2005 totothe
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increase of type I collagen, with normal or decreased elastic

fibres and no increase in dermal fibroblast.5 In addition,
in dermatology
production of collagenase was reduced by approximately Editor
80% in the cultures of lesional fibroblast compared to A 72-year-old woman was admitted to the hospital for
controls.5 malaria and chronic obstructive pulmonary disease. She
Conservative (high-potency topical or intralesional subsequently developed septicaemia and acute respiratory
steroids, keratolytic agents, protective padding at the sites distress syndrome during her stay and had to be shifted to
of trauma) and surgical treatments for the management of the intensive care unit (ICU) where she underwent
collagenomas have been proposed.8 Nevertheless, occa- tracheostomy and was put on a ventilator. A high airway
sionally the nodules are self-limited.8 In conclusion, we pressure of 35–40 mm of H2O was maintained presumably
report a case of a karate practitioner with a plantar colla- due to the underlying chronic obstructive pulmonary
genoma and we suggest that chronic minor trauma on the disease. Drugs given included inhaled salbutamol and
sole could be considered as an aetiological factor of plantar ipratropium bromide, intravenous hydrocortisone followed
collagenomas. However, further studies are necessary to by oral prednisolone, meropenam, activated protein C,
clarify this hypothesis. vaccuronium, midazolam and constant IV fluids. About
5 days after being on the ventilator she developed a big
M Rodríguez-Martín,* M Sáez-Rodríguez, A Carnerero- swelling on both forearms. Dermatologic opinion was
Rodríguez, R Cabrera de Paz, M Sidro-Sarto, N Pérez- sought.
Robayna, M García-Bustínduy, F Rodríguez-García, On examination, she had two huge swellings on ventral
R Sánchez, L Díaz-Flores,† A Noda-Cabrera aspects of both forearms. (fig. 1) The swellings appeared
†Departments of Dermatology and Pathology, Hospital
Universitario de Canarias, University of La Laguna, 38320 – La
Laguna, Tenerife, Spain, *Corresponding author,
tel. +34 22 678494; fax +34 22 319293;
E-mail: [email protected]

References
1 Choi JC, Lee MW, Chang SE et al. Isolated plantar
collagenoma. Br J Dermatol 2002; 146: 164–165.
2 Boente M, Primc N, Asial R, Winik B. Familial cutaneous
collagenoma: a clinicopathologic study of two new cases.
Pediatr Dermatol 2004; 21: 33–38.
3 Togawa Y, Nohira G, Shinkai H, Utani A. Collagenoma in
Down syndrome. Br J Dermatol 2003; 148: 596–597.
4 Menta M, Nico S, Neuza Y, Valente S, Abreu-Machado K.
Isolated plantar collagenoma. Acta Derm Venereol (Stock) 2003;
83: 144.
5 Uitto J, Bauer EA, Santa Cruz DJ, Holtmann B, Eisen AZ.
Decreased collagenase production by regional fibroblast
cultured from skin of a patient with connective tissue
nevi of the collagen type. J Invest Dermatol 1982;
78: 136–140.
6 Botella-Estrada R, Alegre V, Sanmartín O, Ros C, Aliaga A.
Isolated plantar cerebriform collagenoma. Arch Dermatol
1991; 127: 1589–1590.
7 Martínez W, Arnal F, Capdevila A, Almagro M. Isolated
plantar cerebriform collagenoma. Pediatr Dermatol 1994; 11:
84–85.
8 Cohen P, Eliezri Y, Silvers D. Athlete’s nodules: treatment by
surgical excision. Sports Medical 1990; 10: 198–203.

DOI: 10.1111/j.1468-3083.2006.01805.x fig. 1 Close-up of subcutaneous emphysema.

248 JEADV 2007, 21, 247–289 © 2006 European Academy of Dermatology and Venereology
 Letters to the Editor

a gram stain, culture of that tissue material and blood

culture would be expected to yield organisms. It is also a
potentially fatal condition without treatment and shows
no spontaneous recovery.
It is interesting to note that the appearance of the swell-
ings in this patient coincided exactly with the high airway
pressures and subsided with corresponding reduction in
the airway pressure. It is proposed that the swellings could
have been due to the high intrathoracic pressure resulting
from intermittent positive pressure ventilation with sub-
sequent spread of free air through fascia and interstitial
tissue to the forearm. Treatment of this entity consists of
removal of the underlying cause, which in this case was
weaning off the ventilator.
fig. 2 Histology of the subcutaneous emphysema swelling showing pale
and vacuolated dermis.
SB Verma
18 Ami Society, Diwalipura, Vadodara 390 015, India,
multiloculated and multilobulated from outside. They tel. +91 9227106000;
were very tense but non-tender. There was notable E-mail: [email protected]
crepitus felt upon palpation of the swellings on both sides.
Biopsy of the larger swelling showed a pale highly vacu- References
olated dermis and separation of the lipocytes at a deeper
1 Braun Falco O, Plewig G, Wolff HH, Burgdorf WHC,
level. (fig. 2) The patient was taken off the ventilator
Landthaler M, eds. Dermatologie und Venerologie, 5th edn.
2–4 days after the appearance of these swellings. There
Springer–Verlag, Berline–Heidelberg–New York 2005.
was spontaneous disappearance of the lesions on both
2 Lau AC, Yam LY, So LK. Management of critically ill patients
forearms that coincided with the gradual reduction in
with severe acute respiratory syndrome (SARS). Int J Med Sci,
the airway pressure. Lesions disappeared completely once
2004; 1: 1–10.
the patient was taken off the ventilator. 3 Guldager H, Soeren N, Peder C, Soerensen M. A comparison
Based on the clinical history of the patient being on of volume control and pressure-regulated volume control
intermittent positive pressure ventilation with tracheos- ventilation in acute respiratory failure. Crit Care, 1997; 1:
tomy, her age, the nature of the swellings, a distinct crepitus 75–77.
upon palpation and the sudden disappearance of the 4 Pontoppidan H. From continuous positive-pressure breathing
swellings after discontinuing the ventilator a clinical to ventilator-induced lung injury. Anesthesiology 2004; 101:
diagnosis of subcutaneous emphysema was made. Biopsy 1015–1017.
findings were consistent with the diagnosis. No active 5 Ibrahim AE, Stanwood PL, Freund PR. Pneumothorax and
treatment was required to treat this condition except systemic air embolism during positive-pressure ventilation.
removing the source of the problem, that is, the ventilator. Anesthesiology, 1999; 90: 1479–1481.
Subcutaneous emphysema is a very rarely encountered 6 Brown DC, Holt D. Subcutaneous emphysema,
entity in dermatology.1 It is found rarely in emergency pneumothorax, pneumomediastinum, and
medicine and intensive care departments. A sudden and pneumopericardium associated with positive-pressure
dramatic swelling appears on the cutaneous surface due ventilation in a cat. J Am Vet Med Assoc, 1995; 206: 997–999.
to leakage of air into the skin and subcutis. Its acute onset 7 Hashem B, Smith JK, David WB. A 63-year-old woman with
and a distinct crackling sound, that is, crepitus, upon subcutaneous emphysema following endotracheal
palpation, characterize the resultant swelling.1 Free air intubation. Chest, 2005 July; 128: 434–438.
8 Cavuslu S, Oncul O, Gungor A, Kizilaya E, Candan H.
spreads along the deep fasciae and through interstitial
A case of recurrent subcutaneous emphysema as a
tissue following the path of least resistance. This phe-
complication of endotracheal intubation. Ear Nose Throat J,
nomenon is reported to occur in ICU settings due to the
2004; 83: 485–488.
positive pressure ventilation, which can also cause pneu-
9 Doherty KM, Tabaee A, Castillo M, Cherukupally SR.
mothorax or pneumomediastinum.2–6 Endotracheal
Neonatal tracheal rupture complicating endotracheal
intubation is another situation where it can occur.7–9 Gas
intubation: a case report and indications for conservative
gangrene, which can also exhibit crepitus, has a history of management. Int J Pediatr Otorhinolaryngol, 2005; 69: 111–116.
preceding trauma, foul smell and extensive destruction
of tissue. There are systemic signs and symptoms, too, and DOI: 10.1111/j.1468-3083.2006.01823.x

JEADV 2007, 21, 247–289 © 2006 European Academy of Dermatology and Venereology 249