Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Authors’ Reply
BRIDGING THE GAP
BRIEF COMMUNICATION
BRIEF REPORT
Case Report
Case Reports
Case Series
CME
CME ARTICLE
CME articles - Practice points
COMMENTARY
CONFERENCE REPORT
CONTROVERSY
Correspondence
Correspondences
CUTANEOUS PATHOLOGY
DRUG REVIEW
E-CHAT
Editorial
EDITORIAL COMMENTARY
ERRATUM
ETHICAL HOTLINE
ETHICS
Field: Evolution of dermatologic surgergy
FOCUS
FROM THE ARCHIVES OF INDIAN JOURNAL OF DERMATO SURGERY
From the Editor's Desk
FROM THE LITERATURE
GUEST EDITORIAL
Guidelines
Images in Clinical Practice
Images in Dermatosurgery
INNOVATION
Innovations
INVITED COMMENTARY
JCAS Symposium
LETTER
Letter to Editor
Letter to the Editor
LETTERS
Message from the President
NEW HORIZON
Original Article
Practice Point
Practice Points
PRESIDENTIAL SPEECH
QUIZ
RESEARCH ARTICLE
Resident’s Page
Review
Review Article
Review Articles
SHORT COMMUNICATION
Spot the Diagnosis [Quiz]
STUDY
SURGICAL PEARL
SYMPOSIUM
Symposium—Lasers
Symposium: Hair in Dermatology
Symposium: Lasers Review Article
View Point
VIEWPOINT
VIEWPOINTS
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Authors’ Reply
BRIDGING THE GAP
BRIEF COMMUNICATION
BRIEF REPORT
Case Report
Case Reports
Case Series
CME
CME ARTICLE
CME articles - Practice points
COMMENTARY
CONFERENCE REPORT
CONTROVERSY
Correspondence
Correspondences
CUTANEOUS PATHOLOGY
DRUG REVIEW
E-CHAT
Editorial
EDITORIAL COMMENTARY
ERRATUM
ETHICAL HOTLINE
ETHICS
Field: Evolution of dermatologic surgergy
FOCUS
FROM THE ARCHIVES OF INDIAN JOURNAL OF DERMATO SURGERY
From the Editor's Desk
FROM THE LITERATURE
GUEST EDITORIAL
Guidelines
Images in Clinical Practice
Images in Dermatosurgery
INNOVATION
Innovations
INVITED COMMENTARY
JCAS Symposium
LETTER
Letter to Editor
Letter to the Editor
LETTERS
Message from the President
NEW HORIZON
Original Article
Practice Point
Practice Points
PRESIDENTIAL SPEECH
QUIZ
RESEARCH ARTICLE
Resident’s Page
Review
Review Article
Review Articles
SHORT COMMUNICATION
Spot the Diagnosis [Quiz]
STUDY
SURGICAL PEARL
SYMPOSIUM
Symposium—Lasers
Symposium: Hair in Dermatology
Symposium: Lasers Review Article
View Point
VIEWPOINT
VIEWPOINTS
View/Download PDF

Translate this page into:

LETTERS
6 (
3
); 171-172
doi:
10.4103/0974-2077.118441

Benign Subcutaneous Emphysema Following Punch Skin Biopsy

Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, Dilshad Garden, Delhi, India. E-mail:
Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.

Sir,

A 45-year-old woman, clinically diagnosed as a case of disseminated discoid lupus erythematosus was admitted in dermatology in-patients. A punch biopsy was performed from the lesion present over the dorsum of the right hand. About 18 h later, she complained of a diffuse swelling involving the back of the right hand that extended rapidly to involve the entire forearm until elbow joint in next 5-6 h. It was associated with mild discomfort and no systemic symptoms. Examination revealed a diffuse swelling involving the dorsum of the right hand around a loosely sutured punch biopsy wound and the forearm. A diffuse crackling (crepitus) was palpated over the swelling. There was no evidence of accompanying foul smelling discharge, other local signs of inflammation, discoloration, bulla formation or necrosis. Radiograph of the hand and forearm revealed the presence of gas in a linear fashion in the subcutaneous tissue [Figure 1]; however, there was no gas in the deeper tissues. Ultrasound also confirmed the same findings. Pus culture for aerobic as well as anaerobic organisms was sterile. Thus, a diagnosis of benign subcutaneous emphysema (SE) was made. We removed the suture and decided to keep patient on conservative management. Next day onwards, the swelling started decreasing and resolved completely by the 4th day.

Lateral view radiograph of the hand showing soft tissue swelling involving the dorsum of hand with radiolucent shadow of entrapped subcutaneous air (arrow)
Figure 1
Lateral view radiograph of the hand showing soft tissue swelling involving the dorsum of hand with radiolucent shadow of entrapped subcutaneous air (arrow)

The word emphysema arises from ancient Greek language and means “to blow in.”[1] SE is an entity rarely encountered in dermatology literature.[23]SE is a condition, in which air or other gases penetrate the skin and sub mucosa resulting in soft-tissue distension. Surgical emphysema may either be traumatic, iatrogenic or spontaneous. A sudden and dramatic swelling appears on the cutaneous surface due to leakage of air into the skin and subcutaneous tissue. The acute onset and a distinct crackling sound (crepitus) upon palpation, characterise this entity.[3] Large amount of free air entering and spreading along the deep fascia and subcutaneous tissue along the path of least resistance due to a ball-valve mechanism has been proposed as a possible mechanism in such cases of SE following skin biopsy.[4]

SE may be a benign or a potentially lethal condition. The most serious cause of SE is gas gangrene, which has a history of preceding trauma and causes extensive destruction of tissue. It presents with a sudden onset swelling with foul smell and systemic signs and symptoms. Culture from tissue material and blood culture is positive for Clostridium species. It shows no spontaneous recovery and is a potentially fatal condition without treatment.

Benign, non-infectious SE is a post-traumatic condition. Trauma may be due to: (1) iatrogenic manoeuvres performed in emergency and intensive care settings, such as positive pressure ventilation or endotracheal intubation; (2) perforation of the pulmonary or digestive tracts;[5](3) blast and air-gun injuries; (4) dental extraction; and (5) dermatologic conditions.[4] SE has also followed cases of irrigation of wounds with hydrogen peroxide or as a result of cryotherapy.[6] Benign SE resolves spontaneously as in the present report and treatment involves management of the underlying cause, if persistent.

Sudden appearance of swelling following a simple office procedure such as punch biopsy, may be an alarming sign to a resident, but proper examination and investigations may help to ascertain the diagnosis of benign SE; a self-limiting entity.

REFERENCES

  1. , , , , . Subcutaneous air emphysema – A rare condition (four case reports) J Oral Med. 1984;39:47-50.
    [Google Scholar]
  2. , . Subcutaneous emphysema: A rarity in dermatology. J Eur Acad Dermatol Venereol. 2007;21:248-9.
    [Google Scholar]
  3. , , , , , . Dermatologie und Venerologie. (5th ed). Berline-Heidelberg-NewYork: Springer-Verlag; .
    [Google Scholar]
  4. , , , , . Letter: Benign subcutaneous emphysema after a skin biopsy. Dermatol Surg. 2008;34:1141-2.
    [Google Scholar]
  5. , . The thorax. In: , , , eds. Bailey and Love's Short Practice of Surgery (25th ed). London: Hodder Arnold; . p. :879.
    [Google Scholar]
  6. , , , . Subcutaneous emphysema resulting from liquid nitrogen spray. J Am Acad Dermatol. 2006;55:S95-6.
    [Google Scholar]

    Fulltext Views
    160

    PDF downloads
    127
    View/Download PDF
    Download Citations
    BibTeX
    RIS
    Show Sections