Letters to the Editor
Subcutaneous emphysema
mimicking angioedema
Sir,
Subcutaneous emphysema is an uncommon entity that
may be associated with an underlying pneumothorax.
Timely intervention in the form of early diagnosis and
treatment is important to avoid a fatal outcome.[1,2] It may
mimic angioedema, a common and often a relatively benign
disorder thereby leading to inappropriate management. [3]
We report a case of a 65‑year‑old man who was referred
to the dermatology outpatient department for evaluation of
progressively increasing facial swelling of two days duration
associated with difficulty in breathing. There was no preceding
history of drug intake. There was no history of any food allergy,
drug allergy, or similar such episodes in the past. He was
a chronic smoker and a known case of chronic obstructive
pulmonary disease (COPD). He developed acute respiratory
distress three days ago and was subsequently diagnosed as
a case of angioedema by a dermatologist and was prescribed
tablet prednisolone 40 mg daily and tablet hydroxyzine
25 mg thrice daily with no symptomatic improvement over
the next two days. Physical examination revealed the
presence of a diffuse facial swelling predominantly involving
periorbital region and both cheeks extending down to the
supraclavicular region and upper chest. However, there was
distinct sparing of the lips, which prompted us to look for other
clues and to consider other differentials. Crepitus could be
elicited on palpation of the swollen areas., Chest radiograph
(posteroanterior view), showed presence of opaque striations/
shadows in the scapular region suggesting subcutaneous
emphysema without any evidence of pneumothorax [Figure 1].
Therefore, a final diagnosis of subcutaneous emphysema,
resulting probably from the rupture of an apical lung bulla
in a patient with pre‑existing COPD was made. The patient
was referred to medical emergency where he was treated
with anxiolytics, bronchodilators, and administered ventilation
with 100% oxygen leading to remarkable improvement in
respiratory distress and satisfactory reduction in facial swelling
over next three days.
Subcutaneous emphysema results from entrapment of air
into the subcutaneous tissues.[1,2] It can result from various
causes including blunt or penetrating trauma to the chest or
neck, following gastrointestinal perforation (corrosives burns
of the esophagus, Boerhaave’s syndrome, gas gangrene),
diving injuries, endoscopy, tracheostomy, cryosurgery, dental
surgery, or skin biopsy.[1‑7] While reviewing the literature we
came across only four reports of subcutaneous emphysema
© 2016 Indian Dermatology Online Journal | Published by Wolters Kluwer - Medknow
mimicking angioedema[3‑5,7] where subcutaneous emphysema
resulted from dental surgery in majority.[3,4] Subcutaneous
emphysema may occur spontaneously as a result of
increased pressure in the lungs due to rupture of alveoli, as
might have happened in our patient. Subsequent to an injury
or otherwise, air from the mediastinum and retroperitoneal
spaces travels along the fascial planes to reach the
subcutaneous region where it gets trapped, resulting in
subcutaneous emphysema. Spontaneous subcutaneous
emphysema may have varied clinical presentations
depending on the cause, but is often associated with sudden
onset dramatic swelling of the neck associated with chest
pain, wheezing, dyspnea, and dysphagia. [2,7] Similarity
of most of these symptoms to angioedema can lead to
a misdiagnoses by the dermatologists. History of COPD
along with characteristic sparing of lips and presence of
crepitus on palpation prompted us to diagnose subcutaneous
emphysema in our patient. Imaging techniques such as
radiographs of the chest and neck regions have been used
to visualize air in the subcutaneous spaces. Radiolucent
striations in the subcutaneous tissues are seen in
radiographs, whereas computed topography shows air
as dark pockets along with the entry point of the air. [2,7]
Subcutaneous emphysema usually has a benign course.
Mild‑to‑moderate cases of subcutaneous emphysema may
be dealt with by treatment of the predisposing factors, bed
rest, anxiolytics, supplemental oxygen, and reassurance.
Severe cases might require chest tube or insertion of catheter
and positive pressure ventilation.[1,2] This report highlights
the fact that subcutaneous emphysema is an uncommon
but an important cause of facial swelling with respiratory
distress that is likely to be misdiagnosed as angioedema, a
commonly encountered dermatological condition.
Figure 1: Chest radiograph posteroanterior view showing radiolucent
shadows in scapular and subcutaneous region of upper chest
55
 Letters to the Editor

Financial support and sponsorship 2005;141:1437‑40.

Nil.
Conflicts of interest
There are no conflicts of interest.
Amit Kumar Dhawan, Archana Singal,
Kavita Bisherwal, Deepika Pandhi
Department of Dermatology and STD, University College of
Medical Sciences and Guru Teg Bahadur Hospital
(UCMS and GTB) Hospital, Delhi, India
Address for correspondence:
Dr. Amit Kumar Dhawan,
House No. 436, 2nd Floor
Indra Vihar, Delhi ‑ 110 009, India.
E‑mail: amitkumardhawan@gmail.com
4. Haitz KA, Patel AJ, Baughman RD. Periorbital subcutaneous
emphysema mistaken for unilateral angioedema during dental crown
preparation. JAMA Dermatol 2014;150:907‑9.
5. Jensen P, Johansen UB, Thyssen JP. Cryotherapy caused widespread
subcutaneous emphysema mimicking angiooedema. Acta Derm Venereol
2014;94:241.
6. Yadav P, Pandhi D, Singal A. Benign subcutaneous emphysema
following punch skin biopsy. J Cutan Aesthet Surg 2013;6:171‑2.
7. Cakmak SK, Gönül M, Gül U, Kiliç A, Demirel O. Subcutaneous
emphysema mimicking angioedema. J Dermatol 2006;33:902‑3.
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REFERENCES Quick Response Code:

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1. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal
emphysema. Pathophysiology, diagnosis, and management. Arch Intern DOI:
Med 1984;144:1447‑53. 10.4103/2229-5178.174304
2. Pan PH. Perioperative subcutaneous emphysema: Review of differential
diagnosis, complications, management, and anesthetic implications. J
Clin Anesth 1989;1:457‑9.
3. Frühauf J, Weinke R, Pilger U, Kerl H, Müllegger RR. Soft tissue Cite this article as: Dhawan AK, Singal A, Bisherwal K, Pandhi D.
cervicofacial emphysema after dental treatment: Report of 2 cases with Subcutaneous emphysema mimicking angioedema. Indian Dermatol Online
J 2016;7:55-6.
emphasis on the differential diagnosis of angioedema. Arch Dermatol

Loose anagen hair syndrome: Although LAHS is occasionally seen in adults, it is always
important to examine parents of children diagnosed

Is there any association with
atopic dermatitis?
Sir,
It was interesting to read the article by Avhad G, Ghuge P,
Jerajani H.[1] They have reported eyebrow involvement, which
is not very common in loose anagen hair syndrome (LAHS).
We appreciate the authors for differentiating LAHS from other
causes of hair loss in children.
Earlier, LAHS was believed to be a condition affecting primarily
blond hair children, but after the first report of LAHS from Egypt
in the year 2009,[2] more and more cases are being reported in
children with dark hair, but most of them in the form of isolated
case reports. The first study on LAHS from India was published
in international literature in 2013, which concluded that LAHS
is probably as common in dark‑haired children as in blondes,
but only underdiagnosed. In this study, male:female ratio was
found equal, which suggested underdiagnosis in boys.[3] Here
we would like to share our experience and views and highlight
certain points.
as having LAHS because most of the adult cases are
diagnosed retrospectively, while examining parents of
children diagnosed as having LAHS. Adult LAHS (type C),
is characterized by normal‑appearing hair with excessive
shedding of LAHS. There is predisposition for patients with
LAHS types A and B, which are common in children, to
evolve into LAHS type C with age.[4] Therefore, adult cases
remain underdiagnosed and misdiagnosed as telogen hair
loss. As we found familial occurrence as high as 50%, [1]
parents and siblings of diagnosed cases of LAHS should
always be screened.
Although in most of the cases LAHS occurs in isolation,
association with coloboma, Noonan syndrome, ectodermal
dysplasia, ectrodactyly–ectodermal dysplasia‑clefting
syndrome, trichorhinophalangeal syndrome, nail–patella
syndrome, neurofibromatosis, trichotillomania, woolly hair,
AIDS, and alopecia areata is reported.
In our previous study, we found one patient with associated
atopic dermatitis. One similar case was also found few months
back [Figures 1 and 2]. Both the patients we found were in

56 Indian Dermatology Online Journal ‑ January‑February 2016 ‑ Volume 7 ‑ Issue 1