Acroangiodermatitis of amputation stump

ARTICLE

Auteur(s) : Annarosa VIRGILI, Silvana TRINCONE, Maria Rosaria ZAMPINO, Monica CORAZZA

Dipartimento di Medicina Clinica e Sperimentale-Sezione di Dermatologia, Universita’ degli Studi di Ferrara, Via Savonarola, 9 – 44100 Ferrara, Italy

Article accepted 22/4/2003

Prosthetic limb users may suffer from many dermatological problems, months or years after the post operative phase. 
Allergic and irritant contact dermatitis are common and are often caused by topical medicaments applied by the patients, or by chemical substances used in manufacturing the prosthesis [1, 2]. Among the responsible allergens, chromates may be present in leather linings of the prosthesis, while nickel is a constituent of the metallic parts (screws, plaques etc...). 
On the other hand, acrylics and epoxy resins, the principal constituents of the prosthesis, may cause allergic contact dermatitis, too. 
Bacterial (Staphylococcal and Streptococcal folliculitis) and fungal infections (Trichophyton rubrum in particular), epidermoid cystis, traumatic ulcers, blister, necrosis, hyperhydrosis, follicular and parafollicular hyperkeratoses are other benign dermatitis which have been observed [1, 2]. Malignant diseases of the stump skin, like lymphangiosarcoma or squamous cell carcinomas may affect the limb. 
Acroangiodermatitis is an unusual, benign pathology which may also mimic aggressive pathologies and requires histopathologic examination for its diagnosis. 
A case of acroangiodermatitis of the amputation stump in a female patient affected by Down’s syndrome is presented.

Case report

A 48-year-old female, affected by Down’s syndrome, had had her left lower limb amputated 4 years earlier for osteosarcoma.
The patient was wearing a suction socket prosthesis made of acrylic resin and plastics.
Three months before coming to our clinic, numerous scattered erythematous papules localized on the amputation stump were observed on the site most in contact with the prosthesis (Fig. 1).
The patient complained of mild pain. There were no systemic signs or symptoms..
Blood tests were all negative. Patch-tests were carried out with the Italian standard SIDAPA (Societa’ Italiana di Dermatologia Allergologica e Professionale) series, Plastics and glues series, Acrylic resins series; all patch tests were negative at 48 and 72 hours.
A biopsy specimen from a papule showed proliferation of blood vessels (in particular of capillaries), erythrocytes extravasation, mild dermal fibrosis. Cellular atypies, mitosis and irregular vascular slits were not observed.
The diagnosis of the acroangiodermatitis of amputation stump was therefore confirmed.
The dermatitis improved when the suction socket prosthesis was changed.

Discussion

Acroangiodermatitis, or pseudo-Kaposi’s sarcoma, is a reactive disorder clinically and histologically resembling Kaposi’s sarcoma [2-12].
It is characterized by fibroangiomatous erythematous or violaceous papules and nodules grouped on anatomic acral areas; sometimes satellite lesions are present at the periphery.
It seems to be caused by alterations of local circulation causing a reactive proliferation of small vessels. In fact it is often associated with other vascular disorders like chronic venous insufficiency (Mali’s syndrome), artero-venous shunt in hemodialysis patients, paralyzed limb, artero-venous malformations [1-12].
It may also be observed in amputation stumps, in particular in stumps fitted with a suction-socket type prosthesis.
The role of angiogenetic factors, like PGE₁ and heparin, seems to be important [8]. It is likely that the negative pressure performed by the prosthesis on the stump may represent a physical angiogenetic stimulus capable of inducing a local proliferation of small vessels.
In those who have been amputated, the physiological local tessutal modification probably causes a diminished adhesion between the stump and the prosthesis. This, in turn, induces repeated microtrauma that may be the primum movens for the proliferation of fibroblasts and small vessels and, in particulary sensitive tissue, may lead to the typical clinical manifestations of acroangiodermatitis.
This benign and reactive disease appears generally 1 to 15 years after amputation [9] and can cause important problems of differential diagnosis with other pathologies like: stasis dermatitis [10], hemangioma, lymphangioma, Kaposi’s sarcoma and lymphangiosarcoma (Stewart-Treves’ syndrome).
A histological sample could be useful. Treatment may include ablative interventions and pharmacological therapy. Dapsone at the dosage of 50 mg twice daily has been reported [11] to give good improvement over a 3 month period of therapy in a case of acroangiodermatitis associated with chronic venous insufficiency.
In the case of limb amputation, surgical revision may be considered, and a change of prosthesis advisable or even necessary.n

References

1. Lyon CC, Kulkarni J, Zimerson E, Van Ross E, Beck MH. Skin disorders in amputees. J Am Acad Dermatol 2000; 42: 501-7.

2. Noacco G, Mercier A, Le Coz CJ, Lacour JP. Dermatoses des moignons d’amputations tibiales et fémorales. Ann Dermatol Venereol 2000; 127: 317-23.

3. Kolde G, Wörheide J, Baumgartner R, Bröcker EB. Kaposi-like acroangiodermatitis in an above-knee amputation stump. Br J Dermatol 1989; 120: 575-80.

4. Badell A, Marcoval J, Graells J, Moreno A, Peyri’. Kaposi-like acroangiodermatitis induced by a suctio-socket prosthesis. Br J Dermatol 1994; 131: 915-7.

5. Goldblum OM, Kraus E, Bronner AK. Pseudo-Kaposi’s sarcoma of the hand associated with an acquired, iatrogenic arteriovenous fistula. Arch Dermatol 1985; 121: 1038-40.

6. Meynadier J, Malbos S, Guilhou JJ, Barneon G. Pseudo-angiosarcomatose de Kaposi sur membre paralytique. Dermatologica 1980; 160: 190-7.

7. Lund Kofoed M, Klemp P, Thestrup-Pedersen K. The Klippel-Trenaunay syndrome with acro-angiodermatitis (Pseudo-Kaposi’s sarcoma). Acta Derm Venereol (Stockh) 1985; 65: 75-7.

8. Troiano G, Valente G, Isoppo M, Cestari R, Nazzari G. Acroangiodermatite in moncone di amputazione. G Ital Dermatol Venereol 2000; 135: 205-7.

9. Castaño Suarez E, Zarco Olivo C, Lopez-rios F, Rodriguez-Peralto JL, Iglesias Diez L. Circulatory disorders in amputation stumps. J Am Acad Dermatol 2001; 44: 723-4.

10. Jung Uk Yi, Chang Woo Lee. Acroangiodermatitis A clinical variant of stasis dermatitis. Int J dermatol 1990; 29: 515-6.

11. Rashkovsky I, Gilead L, Schamroth J, Leibovici V. Acro-angiodermatitis: review of the letterature and report of a case. Acta Derm Venereol (Stockh) 1995; 75: 475-8.

12. Santucci B, Donati P, Cristaudo A, Cannistraci C, Picardo M. Kaposi-like acro-angiodermatitis of amputation stump caused by suction socket prosthesis. Contact Dermatitis 1992; 27: 131-2.