SURGICAL TRAUMA AS A TRIGGER FOR PSORIASIS AND THE KOEBNER PHENOMENON: SCARRING AND COMPLICATIONS AFTER RECONSTRUCTIVE AND AESTHETIC PLASTIC SURGERY
Keywords:
psoriasis; guttate psoriasis; Koebner phenomenon; plastic surgery; wound healing; surgical site infection; reconstructionAbstract
DOI: https://doi.org/10.46296/yc.v10i19.0938
Abstract
Background: Cutaneous trauma may induce psoriatic lesions on previously unaffected skin (Koebner phenomenon). In plastic surgery, this process may mimic infection, involve scars, flaps, grafts, or donor sites, and prompt unnecessary procedures. Objective: To synthesize evidence on postsurgical psoriasis, Koebnerization, wound healing, and infection, emphasizing reconstructive and aesthetic procedures. Methods: A PRISMA 2020 systematic review was conducted. Primary studies were searched through July 27, 2026, in PubMed/MEDLINE, PubMed Central, Europe PMC, publisher websites, and reference lists. Plastic/cutaneous surgery reports and comparative studies of postoperative complications in psoriasis were eligible. Risk of bias was assessed using JBI and ROBINS-I. Adjusted odds ratios for postoperative infection were pooled using REML random effects with Hartung–Knapp adjustment. Results: Fifteen studies were included: eight publications directly related to grafts, flaps, breast reconstruction, tissue expansion, hair transplantation, or surgical scars, and seven comparative studies in arthroplasty or spine surgery. Direct evidence was dominated by isolated cases; seven publications described postsurgical Koebnerization and one prospective series evaluated seven hair transplantation procedures. No study isolated guttate psoriasis. Five studies contributed to the infection meta-analysis; the pooled estimate was OR 2.88 (95% CI 0.89–9.34; I² 86.9%). The conventional unadjusted confidence interval was 1.38–5.98. Overall certainty was very low because of observational designs, indirectness, inconsistency, and imprecision. Conclusions: Surgical trauma can precipitate psoriasis along scars, grafts, flaps, and donor sites, but its incidence in plastic surgery is unknown. Psoriasis may be associated with greater postoperative infection risk, although the estimate is heterogeneous and indirect. Prospective plastic-surgery cohorts should document psoriasis subtype, activity, treatment, Koebnerization, wound healing, and aesthetic outcomes.
Keywords: psoriasis; guttate psoriasis; Koebner phenomenon; plastic surgery; wound healing; surgical site infection; reconstruction.
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Ji YZ, Liu SR. Koebner phenomenon leading to the formation of new psoriatic lesions: evidences and mechanisms. Biosci Rep. 2019;39(12):BSR20193266. doi:10.1042/BSR20193266.
Sagi L, Trau H. The Koebner phenomenon. Clin Dermatol. 2011;29(2):231-236. doi:10.1016/j.clindermatol.2010.09.014.
Eyre RW, Krueger GG. Response to injury of skin involved and uninvolved with psoriasis, and its relation to disease activity: Koebner and “reverse” Koebner reactions. Br J Dermatol. 1982;106(2):153-159.
Saleh D, Tanner LS. Guttate psoriasis. In: StatPearls. StatPearls Publishing; 2026.
Leung AKC, Barankin B, Lam JM, Leong KF, Hon KL. Guttate psoriasis: an updated review. Drugs Context. 2023;12:2023-5-1.
Wolf R, Perluk H, Krakowski A. Primary eruption of psoriasis in a donor site of a split-skin graft. J Am Acad Dermatol. 1989;21(4 Pt 1):814. doi:10.1016/S0190-9622(89)80289-0.
Behranwala KA, Gui GPH. The Koebner phenomenon in a myocutaneous flap following immediate breast reconstruction. Br J Plast Surg. 2002;55(3):267-268. doi:10.1054/bjps.2002.3807.
Alolabi N, White CP, Dal Cin A. The Koebner phenomenon and breast reconstruction: psoriasis eruption along the surgical incision. Can J Plast Surg. 2011;19(4):143-144. doi:10.1177/229255031101900411.
Vaggu AK, Panchaprateep R, Caroli S, Amonpattana K, Pathomvanich O, Pathomvanich D. Should hair transplantation be performed in psoriasis? Hair Transplant Forum Int. 2012;22(4):124-126. doi:10.33589/22.4.0124.
Ganguly AK, Laghimsetty S, Bhagyalakshmi N. Koebner phenomenon triggered by external dacryocystorhinostomy scar in a patient with psoriasis: a case report and literature review. Ophthalmic Plast Reconstr Surg. 2018;34(2):e52-e53. doi:10.1097/IOP.0000000000001016.
Tan YL, Raflis RA, Hakim NA, Aina EN, Daphne A. Koebner’s phenomenon in psoriasis post nipple sparing mastectomy with immediate silicone implant breast reconstruction. Asian J Case Rep Surg. 2020;3(2):248-251.
Alessandri-Bonetti M, Conforti C, Amendola F, Carbonaro R, Cirami M, Vaienti L. Pustular psoriasis triggered by a subcutaneous tissue expander. Dermatol Pract Concept. 2023;13(2):e2023099. doi:10.5826/dpc.1302a99.
Persaud SR, Rodriguez-Unda NA. Koebner phenomenon psoriasis after right ankle free flap reconstruction. Arch Plast Surg. Published online March 3, 2026. doi:10.1055/a-2780-1435.
Drancourt M, Argenson JN, Tissot Dupont H, Aubaniac JM, Raoult D. Psoriasis is a risk factor for hip-prosthesis infection. Eur J Epidemiol. 1997;13(2):205-207. doi:10.1023/A:1007302330323.
Gold PA, Garbarino LJ, Anis HK, et al. Psoriasis and post-surgical infections in primary total knee arthroplasty: an analysis of 10,727 patients. J Arthroplasty. 2022;37(8):1575-1578. doi:10.1016/j.arth.2022.03.055.
Day W, Ch’en PY, Ratnasamy PP, Jeong S, Varthi AG, Grauer JN. The correlation of psoriasis and its treatment medications with lumbar discectomy postoperative infections. Spine J. 2023;23(11):1623-1629. doi:10.1016/j.spinee.2023.06.392.
Sleiman AG, Vallette N, Milto AJ, Revelt N, Scaife SL, Thuppal SV. The effect of autoimmune skin disorders on post-operative outcomes following arthroplasty. Surgeon. 2023;21(5):e292-e300. doi:10.1016/j.surge.2023.03.003.
Parel PM, Agarwal AR, Ramesh A, Harris AB, Mathew K, Best M, Srikumaran U. Increased risk of 90-day deep surgical site infection and periprosthetic joint infection following total shoulder arthroplasty in psoriasis patients. Semin Arthroplasty JSES. 2024;34(2):348-353. doi:10.1053/j.sart.2023.12.006.
Durst C, Rajaee L, Chang K, Lee A, Rajaee S. Psoriasis is a risk factor for surgical site infection after primary TKA. Clin Orthop Relat Res. 2024;482(7):1196-1200. doi:10.1097/CORR.0000000000003011.
Durbin JW, et al. Outcomes following total hip arthroplasty in patients who have cutaneous psoriasis and psoriatic arthritis. J Arthroplasty. Published online March 23, 2026. doi:10.1016/j.arth.2026.03.054.
Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71.
Joanna Briggs Institute. Critical appraisal checklist for case reports and case series. JBI Manual for Evidence Synthesis. Accessed July 27, 2026.
Sterne JAC, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919. doi:10.1136/bmj.i4919.
Bakkour W, Purssell H, Chinoy H, et al. The risk of post-operative complications in psoriasis and psoriatic arthritis patients on biologic therapy undergoing surgical procedures. J Eur Acad Dermatol Venereol. 2016;30(1):86-91. doi:10.1111/jdv.12997.
Hicken GJ, Kitaoka HB, Valente RM. Foot and ankle surgery in patients with psoriasis. Clin Orthop Relat Res. 1994;(300):201-206.
Nottrott M, et al. Wound healing in a patient with psoriasis vulgaris and femur megaprosthesis implantation. Sarcoma. 2008;2008:509242. doi:10.1155/2008/509242.
Hwang YF, Wu NY, Lee PY. Koebner phenomenon induced by failed revisional orthopedic surgery but remitted with bone union: a case report. Medicine (Baltimore). 2017;96(41):e8138. doi:10.1097/MD.0000000000008138.
Afshar A, Tabrizi A. Nail psoriasis triggered by the reconstruction of syndactyly. Arch Bone Jt Surg. 2017;5(3):193-195.
Murphy MJ, Damsky W, Vesely MD. A pruritic psoriatic plaque develops at the donor site of an autologous skin graft: Koebner phenomenon. Lancet. 2021;398(10313):1836. doi:10.1016/S0140-6736(21)02332-1.
Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ, Griffiths CEM. Psoriasis prevalence in adults in the United States. JAMA Dermatol. 2021;157(8):940-946. doi:10.1001/jamadermatol.2021.2007.
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