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Skin Involvement in Dupuytren's Disease
Ryckie George Wade, MBBS, MClinEd; Laszlo Igali, MD, FRCPath; Andrea Figus, MD, PhD, FEBOPRAS
Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom

Introduction: Whether the palmar skin has a role in the development, propagation or recurrence of Dupuytren's disease remains unclear. Clinical assessment for skin involvement is difficult and its correlation with histology uncertain. Our study prospectively compared the histological characteristics of the palmar skin with clinical features of Dupuytren's disease and functional outcomes.

Methods: Over three years, we prospectively biopsied the palmar skin of all consecutive patients undergoing single digit fasciectomy (for primary Dupuytren's disease without clinically involved skin) or dermofasciectomy (for clinically involved skin as determined by the senior author or recurrent disease). We biopsied skin overlying a cord or nodule. Histological analysis was undertaken by an experienced dermatopathologist. Hand function was assessed by an independent Hand Therapist. Participants were grouped as fasciectomy or dermofasciectomy for between-group analyses.

Results: Overall, 103 patients were included in the study. We found dermal fibromatosis in 22 of 44 (50%) patients undergoing fasciectomy and 41 of 59 patients (69.5%) undergoing dermofasciectomy (p=0.041). Dermal fibromatosis was associated with greater pre-operative angular deformity (cumulative flexion contracture 63.5 vs. 117.5 degrees, p<0.001). Dermofasciectomy conferred greater improvement in post-operative range of movement (49.5 vs. 90 degrees, p<0.001). There were no differences in the rate of complications between groups. There were no total graft losses. The presence of skin involvement was strongly associated with palmar nodules and occupations involving manual labour. Clinical assessment of the skin was unreliable (sensitivity 72.2% and specificity 63.6%).

Conclusion: This is the first study to show that dermal fibromatosis exists in the absence of clinical features of skin involvement, which may be an important piece of the puzzle in understanding the otherwise unpredictable nature of this disease. Skin involvement by Dupuytren's fibromatosis may have a greater role in the development and propagation of Dupuytren's disease than previously thought. Figure 1. A flow diagram of patient attrition.

Figure 2. An H&E stained section of skin from a patient who underwent primary dermofasciectomy for clinically involved skin at increasing magnification. Upper panel: dermal fibromatosis distorting the normal achitecture and adnexae. Middle panel: Dermal fibromatosis reaching the mid-reticular dermis. Lower panel: The active area of Dupuytren's disease.

Figure 3. Upper row: Pre-operative photographs of a 68 year-old right-handed man with primary Dupuytren's disease involving the skin and PIPJ 57 degree flexion contracture. Lower row: 1-year post primary dermofasciectomy and full thickness skin grafting.

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