Autonomic Denervation Dermatitis: A Tale of Two Cases

Dear Editor,

Autonomic denervation dermatitis (ADD) is an uncommon form of eczema occurring at the surgical incision site and adjoining skin. The onset can vary from months to years after surgery. It has been reported following various surgical procedures including saphenous vein graft harvesting, total knee replacements, and femur fracture reduction. Autonomic dysregulation following inadvertent transection of the superficial dermal nerves during surgeries leads to ADD. The disease is known to have a chronic relapsing and remitting course.[1] We report the occurrence of ADD in two patients following saphenous vein graft harvesting for coronary artery bypass grafting, and fasciotomy, respectively.

Case 1: A 58-year-old man presented with itchy lesions over his right leg for two months. He has been a chronic smoker and alcoholic in the past and had undergone coronary artery bypass grafting one year back. He was on aspirin, clopidogrel, atorvastatin, and metoprolol. On examination, three ill-defined, dry, scaly, hyperpigmented plaques were noted over the medial aspect of his right leg, overlying the scar of the harvested saphenous vein [Figure 1]. A neurological examination revealed hypoesthesia in the affected area. He was diagnosed with ADD and was prescribed fluticasone propionate 0.05% cream for twice daily topical application along with emollient, resulting in resolution within two weeks.

Figure 1.

Three ill-defined, dry, scaly, hyperpigmented plaques were noted over the medial aspect of his right leg, overlying the scar of the harvested saphenous vein

Case 2: A 60-year-old, non-smoker, non-alcoholic man presented with an itchy and oozy lesion over the left leg for four months. The patient had undergone fasciotomy for necrotizing fasciitis of the left leg 10 months back. The patient did not have any other disease and was not on any medication. Cutaneous examination revealed a large, ill-defined hyperpigmented plaque with scale-crusts involving the left leg, extending to the dorsum of the left foot, along with non-pitting oedema. Two linear fasciotomy scars running across the plaque were also noted [Figure 2]. A neurological examination revealed hypoesthesia in the affected area. Doppler ultrasound revealed thickening of the soft tissues without any varicosities or perforator incompetence. The patient was diagnosed as a case of ADD and prescribed mometasone furoate 0.1% cream for twice daily application, along with emollient and oral antihistamine, resulting in improvement in signs and symptoms within three weeks.

Figure 2.

Large, ill-defined hyperpigmented plaque with scale crusts involving the left leg, extending to the dorsum of the left foot, along with non-pitting oedema and two linear fasciotomy scars running across the plaque

The terminology for eczematous eruptions at surgical sites has been inconsistent. For instance, Verma and Mody described a specific presentation following knee surgery, termed “surgery of the knee, injury to the infrapatellar branch of the saphenous nerve, traumatic eczematous dermatitis” (SKINTED). However, this is both region- and procedure-specific. Mathias’s term “posttraumatic eczema” (PTE) is broad and misleading since not all traumas cause nerve denervation. Sharquie et al. introduced “neuropathy dermatitis”, noting similar eruptions. Madke et al. proposed “autonomic denervation dermatitis” as a unifying term for eczematous dermatitis occurring at surgical sites.[2,3,4]

The cutaneous autonomic nerves have a crucial role in regulating the function of eccrine and apocrine sweat glands, as well as controlling cutaneous blood flow and vasomotor activity. These functions are essential for maintaining the integrity of the cutaneous barrier.[2] Furthermore, neurotransmitters released by these nerves, such as substance P, calcitonin-gene-related protein (CGRP), vasoactive intestinal peptide (VIP), and neurotensin, play pivotal roles in various processes of keratinocytes, including proliferation, adhesion, migration, and differentiation.[1,3] Following surgical resection, there is often an alteration in vasomotor and sudomotor function, termed “trophoneurosis”, which is known to exacerbate conditions like atopic eczema.[4] Additionally, the increased transepidermal water loss exacerbates xerosis, further complicating the condition.[4,5] The release of neuropeptides during nerve regeneration can also trigger eczematous eruptions.[2]

In the majority of cases, patients exhibit eczematous eruptions confined to the lower extremities. Individuals who undergo coronary artery bypass grafting with concurrent saphenous vein graft harvesting present with eczematous reactions exclusively on the lower limb, whereas the surgical site on the anterior chest wall remains unaffected. This differential manifestation of eczematous response at various surgical sites within the same patient may be attributed to the relatively compromised blood supply to the lower extremities, which is potentially exacerbated by autonomic nerve damage.[2]

ADD may present as chronic eczema, characterized by periods of remission and relapse, with exacerbations often occurring during the winter months. It is essential to inform patients about the chronic nature of this condition. The liberal application of emollients and occlusive moisturizers is recommended to preserve the integrity of the skin barrier. Given that ADD responds to steroid treatment, patients should be advised against the prolonged use of high-potency topical corticosteroids. Continued research is necessary to fully elucidate the pathogenesis of ADD.[1,2]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the forms, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.