Flashcards in Dx of the Connctive Tissues Dan Deck (114):
What is follicular atrophoderma?
Dimple-like ice pick depressions at follicular orifices from birth or early life backs of the hands and feet and cheeks and sometimes in the elbow region can be isolated or part of syndrome syndrome
1. Palmoplantar hyperkeratosis, follicular keratosis, or palmoplantar hyperhidrosis
2. Bazex syndrome (Bazex-Dupre-Christol)
3. Conradi hunerman syndrome
What is Spontaneous atrophic scarring of the cheeks?
Probably AD disease
spontaneous scarring of cheeks in childhood
No trauma/acne/inflammation prior
asymptomatic/ slight itch
What is vermiculate atrophoderma?
childhood onset, progressive
inflamed follicular plugs on cheeks leading to cribriform/worm-eaten (vermiculate) atrophy
Part of keratosis pilaris atrophicans syndrome or Rombo syndrome
What are the DDs for scarring of the cheeks in kids?
Spontaneous atrophic scarring of the cheeks
Lipid proteinosisEPP (porphyria)
Hyper IgE syndrome (Job syndrome) – pitted scarring on face
Hydroa vacciniforme (inflammation with sun exposure before scarring)
Varicella scars, juvenille acne scars
What is congenital Cutis laxa?
Lax pendulous skin w/ loss of elastic tissue in dermis
AD (presents later):
ELN(elastin) or FBLN5 (fibulin5)
AR (more common but more severe) - 3 types;
FBLN4 or 5 (type 1) or loss of functional mutations proton ATPase (type 2)
De Barsey syndrome (type 3)
Occipital Horn syndrome - rare X-linked type
What are the types of Keratosis Pilaris atrophicans?
Keratosis pilaris atrophicans faciei (bearded face)
Erythromelanosis follicularis faciei et colli (face and neck)
Ulerythema ophryogenes (eyebrows)
Keratosis follicularis spinulosa decalvans (scalp)
Atrophoderma vermiculata (cheeks)
What is Conradi Hunerman Happle syndrome?
what is the gene and inheritence?
CDPX2 gene XLD, affects females
(Conrad Doesnt Play Xylophone 2)
Short stature + scoliosis
Dysmorphic face – frontal bossing and macrocephaly
Chondrodysplasia punctata – resolves by 2-5 years
What is Bazex-Dupre-Christol syndrome?
Follicular atrophoderma-BCC syndrome
BCCs - esp on face
Atrophoderma - follicular, of extremeties
Zero sweat - hypohidrosis above neck
Empty follicles - scalp hypotrichosis in males
X-linked dominant (males + females affected)
What are features of Atrophoderma of Pasini and Pierini?
Brown/blue depressed round/oval patches usually on the back
Can be chest/ arms/ abdomen; spares acral sites
'Cliff drop' 1-8mm from normal skin
NO erythema/lilac edge, NO induration
Linear variant; Linear atrophoderma of Moulin
Slowly extend in size and number for 10yrs then stabilize and persist
Benign condition, asymptomatic
mooted assoc w/ Lyme borreliosis
What is Rx of Atrophoderma of Pasini and Pierini?
No proven treatment but PUVA has helped
some people Rx with penicillin/ tetracycline given Borrelia association
HCQ or Q-switched laser have had positive case reports
What is histo of Atrophoderma of Pasini and Pierini?
Oedematous and clumped collagen in lower dermis initially; later oedema subsides
Can be increased basal layer pigmentation
Perivascular infiltrate of macrophages and T-lymphocytes
IMF shows IgM and C3 in dermal blood vessels
Eventually epidermal atrophy
What is Acrodermatitis Chronica Atrophicans?
Late manifestation of Lyme borreliosis
Insidious onset of painless dull red nodules or plaques on the extremities (acro=acral), which slowly extend centrifugally leaving areas of central wrinkled atrophy and can be dyspigmentation or scale
May be pain, itch, numbness, hyperaesthesia
Due to Borrelia afzelii - N and C Europe, Italy and the Iberian Peninsula (rare in UK and USA)
Panatrophy means thinning of the dermis and epidermis
Means atrophy of dermis + SC fat +/- deeper structures (muscle and bone)
may be due to neurological defect of sympathetic nervous system
NB In cutaneous and panatrophy there may or may not be epidermal atrophy
- Gower or Sclerotic
- Parry-Romberg's syndrome
What are causes of Generalised cutaneous atrophy?
What are causes of Localised cutaneous atrophy?
Poikiloderma - congenital and acquired causes
Atrophic scars - Varicella, LE, TB, deep fungal, Syphylis, ILCS, XRT
Anetoderma-primary or secondary
Acrodermatitis chronica atrophicans
Atrophoderma of Pasini and Pierini
What is Panatrophy of Gower?
V rare condtion
Affects women in teens-30s
No preceding inflammatory sclerotic process
Irreg shape, develops in few wks then stays unchanged
What is Sclerotic panatrophy?
sclerotic change precedes development of panatrophy
Linear band develop along limb or surround limb or trunk
stop progression after few mths
Progressive Hemifacial Atrophy (Parry-Romberg’s syndrome) is the same as en coup de sabre
In Parry-Romberg there is little/no sclerosis of skin and skin is not bound down although it is atrophic
En coup de sabre usuallly limited to forehed and adjacent scalp and is limited to the skin
but can have en coup de sabre as well as Parry-Romberg
Most think these 2 are on a spectrum
Progressive Hemifacial Atrophy (Parry-Romberg’s syndrome) affects F>M
3x more females
NB en coupe de sabre also affects 2-3x more females
What are the features of Progressive Hemifacial Atrophy (Parry-Romberg’s syndrome)
Starts under age 20
Hyper/hypo pigmentation in irreg patches on cheeks, forehead and lower jaw
May start w/ muscle spasms or neuralgia
progressive atrophy ensues for months
Can have hair loss
heterochromia irides in 5%
Variety of neurological signs - Horner’s most common, Epilepsy
Can be localised to 1 division of trigeminal or involve whole side of face w sharp midline demarcation. Rarely bilat, or may involve ipsilat body
MTX +/- pred
What is sclerotylosis/ Huriez syndrome?
Some People Hurry
diffuse Scleroatrophy of the hands
Hypoplastic nail changes
Increased risk of skin SCC and bowel cancer
Scleroatrophy is like sclerodactyly but no Raynauds
Nail changes include prominent lunulae, elongated cuticles, longitudinal and transverse ridging, increased longitudinal curvature and V shaped notches
Acitretin may help
What are the congenital causes of poikiloderma?
Trichothiodystrophy (photosensitive type; PIBIDS)
Mendes da Costa syndrome (erythrokeratoderma variabilis)
Hereditary acrokeratotic poikiloderma of Weary (one family described only)
Hereditary sclerosing poikiloderma of Weary
Degos –Touraine syndrome
Neutral lipid storage disease
What is Degos –Touraine syndrome?
Incontinentia pigmenti with poikiloderma and GI symptoms
What are the acquired causes of poikiloderma?
Poikiloderma of Civatte
Poikiloderma with neutropenia (syndrome)
Pre-lymphomatous poikiloderma (chronic superficial scaly dermatosis that has developed atrophy and reticulate pigmentation)
Chronic cold or heat exposure
Acrodermatitis chronica atrophicans
What is the classification of causes of elastolysis (loss of elasticity)?
- congenital cutis laxa; AD, AR (3 types), X-L
- assoc w/ inherited disease; PXE, SCARF
Variants of elastolysis/anetoderma
What are the acquired causes of Generalised elastolysis (acquired cutis laxa)?
CHiKEN SOUP With Lyme
High fever (febrile illness)
Neoplastic such as Myeloma
SLE/ Sarcoid/Syphillis/Systemic amyloid, Rheumatoid A
Oedema / Angio-oedeam
Penicillin allergy or other drug allergy/ pseudo-PXE
With - Wilson's disease
Lyme disease - Acrodermatitis chronica atrophicans
Which inherited conditions feature Generalised elastolysis? (other than congenital cutis laxa syndromes)
NB the recessve and XL variants of congenital cutis laxa feature systemic features as well as skin disease but are considered variants not separate diseases like those listed above
What are the causes of localised elastolysis?
Acrodermatitis chronica atrophicans
Granulomatous slack skin
Mid dermal elastolysis
post inflammatory elastolysis and cutis laxa
elastic tissue naevi
what is anetoderma?
Focal dermal defect of elastic tissue
Circumscribed, 1-2cm areas of flaccid skin, which may be elevated, macular or depressed
Trunk/thighs/upper armsfine, irregular, twisted elastic fibres but no elastorrhexis (fragmentation)
Can be primary or secondary
Primary - Inflammatory and non inflammatory types - Cause unknown
Secondary - Due to an underlying disease but doesn’t always develop at site of dermatosis - Assoc w/ antiphospholipid abs
what are the causes of secondary anetoderma?
Pityriasis versicolor + staph, VZV, TB, Lyme Dx(ACA)
DLE, SLE, CCLE(profundus/discoid) with C2 def, aPLS
Dermatofibroma, neurofibroma, involuted IH
Leprosy, Lymphoma, MF
Electrode attachment + other perinatal injuries
Sarcoidosis, Syphilis - occurs with secondary, latent, congenital or tertiary syphilis.
What are the features of primary anetoderma?
What is the Rx?
Crops of 0.5-1cm erythematous macules develop on trunk, thighs and upper arms, occasionally elsewhere
Macules enlarge for short time then flatten and wrinkle
can be grey, white or blue in colour
5->100 lesionsmay develop new lesions for years
Lesions may coalesce resembling cutis laxa
Examining finger can sink into distinct pit w/ sharp borders w/ buldge reappearing when pressure is released
Cannot treat medically when established
try to slow progression with Penicillin and ε(epsilon)-amino caproic acid or colchicine
What is Blepharochalasis?
Laxity of eyelid from defect in elastic tissue, cause unknown
Usually sporadic, can be AD
Develops at puberty
What is Mid-Dermal Elastolysis?
Widespread wrinkling of the crinkle type involving the entire skin surface of young to middle aged women, usually middle aged Caucasian
discrete perifollicular papules
Selective band like loss of elastic fibres in mid dermis on van Gieson stain
Normal elastic fibres in rest of dermis
Preservation of elastic tissue around hair follicles - gives perifollicular papules
Triggers may include - UVR, AI-CTD, pregnancy, OCP, insect bites and Lyme Borreliosis
No effective Rx
What are the features of PXE?
What is the gene and inheritence?
ARABCC6 gene on Chr 16
Calcium accumulates in elastic fibres of skin + tissues
skin changes often present in childhood
CHICS (skin looks like chicken skin)
Comets, Angioid streaks + peau d'orange of eyes
Haemorrhage (upper GI bleed)
Ischaemic heart disease
Claudication (PVD) >age 30
Squeaky valves; MR/AR/ aortic dissection
May get reticulate pigmentation on abdo
Usually arises before 30. Occasionally old age. Persists indefinitely
Changes similar to skin occur on all mucosal surfaces
Exaggerated horizontal or oblique mental crease pathognomonic finding
Eye changes due to calcification of Bruch’s membrane of retina
Bleeding - GI, intracranial
What are the histopath features of PXE?
clumped, degenerate elastin fibres in mid-reticular dermis as seen on EVG stain
calcium deposits (von kossa stain)
What is the work-up and management of PXE?
Can send for genetic testing for ABCC6 mutation
FBC, film, iron studies
Calcium, phosphate, Vit D
Fasting lipids and BSL for CV risk
Refer to ophth for fundoscopy
Refer cardiology for coronary angiogram
o Echoo Doppler legs vessels
o CT head if neurology
o FOBs, urine for blood
There are complex diagnostic criteria -
Major are clinical skin or histo criteria, eye criteria and genetic/FHx crieria
2 or more major criteria from different categries is enough for diagnosis
Not much Rx for skin - low calcium diet may help; plastic surgery for most disfiguring
Main management is appropriate referrals for monitoring and care - eye, cardiol, obstetric etc
UVA causes more solar elastosis than UVB
UVB more important
What is Digital Papular Calcific Elastosis (DPCE)?
collagenous and elastotic marginal plaques of hands
Acquired papular eruption w/ keratoderma + changes in dermal connective tissue
More often dominant hand
Affects radial aspect of index finger, 1st web space + ulnar aspect of thumb
can get SCC
What are the 3 histopathological zones of actinic granuloma?
External to annular lesion is solar elastosis
Thickened annulus w/ histiocytic and giant cell infiltrate
Central zone w/ little/no elastotic tissue remaining
what is the Rx of actinic granuloma?
ILCS and tretinoin
Isotretinoin/Acitretin has worked
What are the features of AR cutis laxa?
Characteristic facies “hound dog” – broad nose, sagging cheeks and large ears
premature aged appearance
vocal cord laxity (deep voice)
Risk of death with pulmonary emphysema
Herniae, diverticulae, osteoporosis, arotic aneurysm, dental caries
What is Ascher's syndrome?
blepharochalaxis + progressive enlargement of the upper lip due to hypertrophy and inflammation of the labial salivary glands
May be excessive salivation
What are the features of Marfan's syndrome?
AD mutation in fibrillin-1 gene (FBN1)
30% new mutations
Mitral valve prolapsed, Myopia
Aortic Regurge, Aneurysm, Dissection
Fibrillin gene, Chr Fifteen + PH(marPHan)- Pectus excavatum, High arched palate
Negative Nitroprusside test (differentiates from homocystinuria), neural deafness (6%)
Subluxated lens (Upward or up + lateral dislocation of Lens)
Skin features - HESP
Elastosis perforans serpiginosa
what is the management of a Marfans pt?
refer to cardio and ophthal
Pregnancy unadvisable due to 50% risk of transmission and acceleration of CV disease and vascular rupture during pregnancy
Little skin Rx needed
What are the features of Ehlers Danlos syndrome - protein affected, genes, systemic features?
Heterogeneous group of defects in connective tissue
Collagen mutations or proteins which interact with collagens
Causes defective collagen network
Elastic fibres are normal so skin is hyperextensible but has normal recoil
- types 1-4 account for 60% of cases
>40% are types 1 or 2 - collagen 5 mutations
Most common types are AD
Key features are;
Soft, Hyperextensible skin
scarring and poor wound healing
dental abnormalities common
no mental problems
Molluscoid pseudotumours are typical of type 4 EDS
Type 1 mainly
blue grey spongy tumours of connective tissue occuring at pressure points
fibrous capsule containing fat and mucoid material which can be calcified
What are the features of EDS types 1 and 2?
what are the genes and inheritence?
AD - Classical types of EDS
allelic variants – different subunits of same gene affected
Type 1 - Gravis = A1 region of collagen 5 (COL5A1)
Type 2 - Mitis = A2 region of collagen 5 (COL5A2)
account for 43% of EDS, Type II is milder
soft velvety, hyperextensible skin
Wide atrophic scars; cig paper scars/sutures tear
No striae in pregnancy
piezogenic pedal papules
Molluscoid pseudotumours, spheroids
Facies - widely spaced eyes, wide nasal bridge, epicanthic folds, can be blue sclera
Can have redundant palms/soles like a glove
Later life get redundant skin folds esp blepharochalasis
Poor muscle tone
What are spheroids?
small firm s/c nodules w/ calcification on X-ray on shins/forearms in one third of EDS pts
What are the features of EDS type 3?
what are the genes and inheritence?
AD, some are collagen 3 mutations, some tenascin-X
accounts for 10% of cases, most benign
Smooth, velvety skin
Only min scarring
Joint hypermobility +++
Some get dysautonomia – syncope, palpitations, fatigue
What are the features of EDS type 4?
what are the genes and inheritence?
AD mutation in Collagen 3 (COL3A1)
accounts for 6% of cases, rare, severe form
Thin, translucent skin that show underlying vessels
easy bruising (misdiagnosis child abuse)
Scars and pseudotumours
No/minimal Joint hypermobility or skin hyperextensibility
often born prem and have short stature
Arterial aneurysms - dissection and rupture
visceral rupture (bowel + uterus)
Acrogeric type - premature aging w/ thin peaked nose and thin lips, hollow eyes
Ecchymotic type - easy bruising predominates
should avoid pregnancy, trauma, physical contact sports, and trumpet playing (raised ICP can trigger vascular rupture). Risk of sudden death from aortic dissection and rupture of colon and vessel perforation
What is the management of EDS?
Need to determine type as very different prognosis
Identify clinical, biochemical and molecular abnormalities
type VI may respond to Vit C – regulates collagen biosynthesis
Type IV should avoid pregnancy, trauma, physical contact sports, and trumpet playing (raised ICP can trigger vascular rupture). Risk of sudden death from aortic dissection and rupture of colon and vessel perforation
Try to manage bleeding conservatively, make surgeons aware
Sutures will tend to pull out. Need to be buttressed.
Arteriography also difficult, warn surgeons
What is the DIFFERENTIAL of elastosis perforans serpiginosa?
reactive perforating collagenosis,
What is Occipital horn syndrome?
Used to be called EDS type 9 or X-linked cutis laxa
Same gene as Menkes syndrome
Mild skin laxity and extracutaneous features
What are the features of Prolidase deficiency?
AR, rare inborn error of collagen metabolism
Deficiency of Prolidase required to make collagen
Chronic skin ulceration, mental retardation, and recurrent resp infections
Abnormal facies (no characteristic pattern)
Spongy fragile skin with pitting, scarring and ulceration.
Also photosensitivity, telangiectasia, purpura, premature greying and lymphoedema
Also splenomegaly, recurrent infections and obesity
What is SCARF syndrome?
Cutis laxa, Craniostenosis,
What is Pachydermoperiostosis?
Rare AD disease
increased production of α1-procollagen
Digital clubbing, cylindrical thickening of legs/forearms (due to tissue thickening)
Hypohidrosis, seborrhoea, sebaceous gland hyperplasia, folliculitis results in thick, furrowed redundant skin on face and forehead/scalp (cutis verticis gyrata)(‘pachyderma’ = skin like pachyderms; elephant/rhino)
symmetrical irregular periosteal ossification at distal ends of long bones on Xrays
Can also get carpal and tarsal tunnel syndrome, chronic leg ulceration, and archilles tendon calcification
What are the associations of Cutis Verticus Gyrata?
Occurs in males mostly, onset at puberty
esp common in aboriginals
benign form without associations called 'essential type'
Can be assoc w/ neurologic and/or ophthalmologic abnormalities
Can be secondary phenomenon due to;
What are the DDs of Cutis Verticus Gyrata?
Leonine facies - many causes
Extensive congential cerebriform melanocytic naevus on scalp
Dissecting cellulitis of scalp
What are the diagnostic criteria for relapsing polychondritis?
3 or more of these features required to make diagnosis;
Chondritis of ear, nose, throat(resp tract), Occular, vestibulocochelar, Arthritis;
1. recurrent chondritis of the pinna
2. chondritis of the nasal cartilage
3. chondritis of the larynx, trachea or respiratory tract
4. ocular inflammation
5. cochlear or vestibular lesions
6. non-erosive arthritis
What are the associations of relapsing polychondritis?
- RA, SLE, DM, Sjogren’s, Still’s, Ank spond, Crohn’s, Hashimotos thyroiditis, vasculitis, thymoma, psoriasis, glomerulonephritis
- HepC- HIV
- myelodysplasia, myeloma, lymohoma, leukaemia
- Carcinoma of bladder, breast, pancreas, lung, colon
What are the skin complications of relapsing polychondritis?
Cutaneous and systemic vasculitis
oral and complex apthae
papules, sterile pustules
Skin features of associated disease
What are the systemic complications of relapsing polychondritis?
Respiratory tract and/or costochondral joints (cough, hoarseness, choking, dyspnoea, wheeze, tender palpation of anterior neck)
Larynx involvement may need tracheostomy
Cardiovascular (aortic valvular inflammation (10%), AAA, myocarditis, pericarditis, MI)
sudden valve rupture
Neurological (headaches, nerve palsies, hemiplegia)
Joint pain (non-erosive arthritis)
serous otitis media, Hearing loss (cochlear or vestibular lesions)
What are the lab findings of relapsing polychondritis?
Areas of damaged cartilage (loses basophilic staining) separated by lymphocytic infiltrate with neuts and plasma cell
Later, separated by granulation tissueo
Perichondrial fibrosis in older lesions
Can have +ve ANA, RF, cANCA↑ urinary excretion of acid mucopolyscacharides during each relapse (classical feature)
Xrays – joint cartilage destruction without changes in adjacent bone
urine secretion of acid mucopolyscacharides is reduced during attacks of relapsing polychondritis?
Increased - classical feature
What is the significance of sparing of the earlobe in attacks of relapsing polychondritis?
Helps to differentiate from infection (celuliits)
What is the treatment of relapsing polychondritis?
Diagnose and Rx early to prevent deformity and complications
Pred 30 mg reducing for relapses – slow wean as settles
Indocid/dapsone/ Colchicine have been use for acute flares also
IV cyclophosphamide for renal disease
Many other immunosupressants 2nd line
Must assess for associations and complications and investigate and refer as necessary
What is MAGIC syndrome?
Mouth and Genital Ulcers with Inflamed Cartilage
Combination Behcet’s + relapsing polychondritis
Striae are more common in Ehlers-Danlos syndrome
typically no striae even in pregnancy
Striae are more common in Marfans syndrome syndrome
What is Linear atrophoderma of Moulin?
V rara Linear blaschkoid atrophoderma May be variant of Atrophoderma of Pasini and Pierini
- Pigmented bands of atrophy on trunk and limbs in Blaschko’s lines
- starts in adolesence
- No prior inflammation
- No subsequent scleroderma
- self limiting
- Normal or thickened collagen bundles on histo
What are the causes of panatrophy?
Panatrophy of Gower - No assoc sclerotic processes
Sclerotic panatrophy - morphea/sclerotic change preceding atrophy
What are the features of congenital cutis laxa (generalised elastolysis)
AR or AD
mutations in elastin or fibulin5
Aged appearance (premature aging)
Loose redundant pendulous skin folds
Facies - Hound dog-like
Bladder and Bowel diverticulae
Emphysema (adults) or hypoplastic lungs (neonates)
Deep voice (vocal cord thickening)
Prognosis mainly depends on lung disease - usually normal life span
What are Fibromatoses?
what is the classification?
Benign proliferations of fibrous tissue, fibroblastic cells or spindle-shaped stromal cells with varying degrees of aggressive behaviour
Part way between a benign fibroma and metastasizing fibrosarcoma
Does not include reactive fibrous overgrowth or keloids
2 major groups;
Palmar (Dupuytrens), plantar, penile (peyronies) and knuckle pads
Deep fibromatoses AKA Desmoid tumours (non metastasizing fibrosarcoma) – rapidly growing tumours with a tendon-like consistency which involve muscle and aponeuroses
What are the associations of Dupuytrens contracture (Palmar fibromatosis)?
ulnar nerve damage
Drug - phenytoin
Can be inherited in AD fasion
Can be part of polyfibromatisis syndrome - 5% have Dupuytrens
What is Pachydermodactyly?
Benign fibromatosis on fingers of young males, rarely females
Symmetrical swelling of dorsal+sides of prox middle, ring and index prox phalanges
Histo - collagen extension to SC tissues, epiderm hyperplasia, dermal thickening
What are the types of Juvenille Fibromatoses?
Juvenile hyaline fibromatosis
Fibrous harmatoma of infancy
Infantile digital fibromatosis
Calcifying aponeurotic fibroma
Giant cell fibroblastoma
What is Juvenile hyaline fibromatosis?
Disorder of glycosaminoglycan synthesis
Most frequent fibromatoses in childhood
hyaline accumulation in dermis
Most commonly affected sites are head, neck and trunk
skin papules/tumours, gingival enlargement, osteolytic lesions (in 50%), jt contractures, poor musculature
Joint contractures - disabling
More severe systemic form gets internal organ involvement and early death
What is Fibrous harmatoma of infancy?
Rare tumour of children esp under 2 yrs
Probably neoplastic rather than hamartoma
Benign, fibroblastic/myofibroblastic deep dermal and subcut tumour
Asymptomatic, solitary, skin coloured plaque or nodule. Few cm diameter
Rarely pigmented or hairy
Axilla, arm or shoulder girdle
Tumour has 3 distinct pathological components;
1. Bundles of interlacing, elongated, wavy spindle cells in variable collagenous b/g.
2. Nests of more immature round cells associated with focal myxoid change
3. Mature adipose tissue
What is Infantile digital fibroma(tosis)? On what digits does it occur?
AKA Inclusion body (digital) fibromatosis
A benign fibro/myofibroblastic proliferation with round pink intracytoplasmic inclusions.
Present at birth or develops in infancy
Almost always on fingers and toes esp 3-5th digits, never on thumb or great toe.
Multiple small nodules.
Observe or excise if bothersome
what is Nodular fasciitis?
Rapidly enlarging subcutaneous nodule; can be in fascia or muscle
M=F, any age often young adults
Tender mass on UL> trunk> H&N
can be in mouth or orbit
Bundles of uniform fibroblasts and myofibroblasts which have pink cytoplasm, vesicular nuclei and a small nucleolus.
In a vascular stroma
Many mitoses but no abnormal mitoses
Stroma shows myxoid change and mucin deposition – has ‘tissue culture-like’ appearance
Often hyalinised collagen bundles which may look keloidal
May be multinucleated giant cells which resemble osteoclasts.
What are Infantile Stiff Skin Syndromes?
Group of rare syndromes w/ hard stiff skin and joint contractures starting in childhood
Winchester’s syndrome (Still’s dx w/ stiff skin + cataracts)
Congenital fascial dystrophy (AKA stiff skin syndrome)
What are the risk factors for Keloid scarring?
Age (peak between puberty and 30)
Race (B>W), Afro Caribeans
Sites = ear lobes/ shin / neck/ shoulders/ upper trunk/ LL and sites that stretch
Mechanism of injury; burns, scalds
Foreign material = sutures/ endogenous hair
Scarring acne on back
Recent Roacutane + laser
Polyfibromatosis syndrome = Dupuytren’s
Other associations; acromegaly, post thyroidectomy, Dubowitz, Rubinstein-Taybi, EDS, pachydermoperiostosis Linear keloids in athletes taking anabolic steroids
Keloid scarring can be triggered by pregnancy
Spontaneous keloids - presternal region of chest, probably micotrauma. Can be seen in in syndromes; rubinstein-taybi, noonan and Dubowitz, Goeminne
What are the key features of Keloid scarring?
extends beyond the defect
does not regress spontaneously
grows in a pseudotumor fashion with distortion of lesion tends to recur after excision
Often painful and hyperaesthetic
What are the clinical and histo DDs for Keloid scarring?
What is the treatment for keloids?
Potent TCS under occlusion
20% silicone gel - for small lesions and for prevention
Adjuvant XRT after surgery is the most effective - superficial XRT or electrom beam
ILCS +/- prior LN2 cryo
Laser - PDL, others have been used too
What are the causes of premature aging appearance?
Classic inherited premature aging syndromes
Congenital progeroid syndromes
Diseases causing elastolysis (cutis laxa group) e.g. De Bersey syndrome
Fragile skin e.g. prolidase deficiency
Thickened immobile skin e.g. diabetic cheiroarthropathy
Loss of SC fat e.g. generalised lipodystrophy
Generalised cutaneous atrophy – RA, steroids
Excessive exposure to radiation (UV)
What are the 3 classicial inherited premature aging syndromes?
Progeria (Hutchinson-Gilford syndrome)
Acrogeria (Gottron syndrome)
What are congenital progeroid syndromes?
Syndromes other than classical premature aging syndromes which show some features of premature aging (not due to photosensitivity alone);
Wrinkly skin syndrome
Neonatal pseudohydrocephalic progeroid syndrome
Acrogeric Type 4 EDS
Mandibulo-acral dysplasia (MADA)
What are the photosensitivty premature aging syndromes?
What are the features of Progeria?
aka Hutchinsons-Gilford syndrome
Small stature, mid facial cyanosis, bird like facies, prominent frontal tuberosities and scalp viens. Dry, thin and wrinkled with mottled hyperpigmentation. Hair loss in first 2 years of life
CVS - atheroma
What are the features of Acrogeria?
Micrognathia; atrophy of skin on tip of nose
Atrophic with telangiectasia and mottled hyperpigmentation on extremities.
No leg ulcers, atheroma, DM, decreased life expectancy
Hair and eyes normal
What are features of Pangeria?
RecQ DNA helicase 2 gene defect (WRN gene)
Small stature - Cessation of growth at 12y
Skin of ears strophic and bound down
Skin is dry; Thick dermis, atrophic epi w/ poikiloderma
Hair shows Premature greying @ 20y
Hair loss @ 20-30
Bilateral cataract @ 20-30y, Keratopathy, Glaucoma
Nails are normal
Lower limb ulcers
Hyperkeratosis over bony prominences
Loss of SC fat
Malignancy risk ++
Life expectancy 30-40y
Die of severe atheroma
Diagnostic criteria of PXE?
Dx: 1 major from 2 systems
Probable: 2 major from same cat or 1 major + 1 minor from another category
1) Skin yellow papules/plaques neck or body,Or
bx with histo changes from affected skin
2) Eye: angioid streaks Or peau d'orange
3) Genetics: mutation of both alleles of ABCC6, Or 1st degree relative
1) eye: 1 streak shorter than 1 disk Diameter, comets in retina, 1 or more wing signs
2) Genetics: 1 allele mutation
What are the types of perforating dermatoses?
- Familial Reactive perforating collagenosis (collagen fibres perforate)
- Elastosis perforans serpiginosa (EPS) (elastic fibres perforate)
- Acquired (reactive) perforating dermatosis (collagenosis) - Kyrles disease
- Perforating folliculitis
- Transepithelial elimination (TEE) seen incidentally as part of another dermatosis
- TEE of substance secondary to an exogenous agent. E.g. Ca containing EEG paste, ILCS injections
What are the features of Kyrle’s disease?
perforating disease in adults (30yrs)
perforation of collagen fibres
acquired, and often idiopathic or assoc w/ hepatic/renal/diabetic disorders
Keratinous red/brown papules/nodules w central keratin plug
Can coalesce forming large keratotic plaque
Can be asymptomatic or intensely itchy
What are the features Acquired (reactive) perforating dermatosis?
Largely same as Kyrles
Affects 10% of ESRF pts - consider in these pts who are very itchy
Also in diabetics and rarely liver disease or internal malignancy
Can be perforation both collagen and elastic fibres
Rx with topical C/S, ILCS, topical retinoids
PHOTOTHERAPY most useful option - can help w renal itch too
change dialysis tubing
Allopurinol has been used successfully
What are the features of Inherited reactive perforating collagenosis?
papules on prominences after superficial trauma - koebnerising
small lesions enlarge to 5mm over few weeks
keratinous umbilicated plug - bleeds if removed
can be precipitated by cold, improves in warm weather
persists into adulthood
usuallly no Rx required
what is perforating folliculitis
type of folliculitis on trunk and extremeties in young adults
papules with keratinous plug that exude necrotic material
cause unknown ??overlap with pityrosporum folliculitis
What is Elastosis perforans serpiginosa?
arcuate/serpiginous slightly erythematous flesh coloured keratotic papules on the upper trunk, face or limbs of young adults (M>F)
Genetically determined defect of elastic tissue
Extrusion of elastic fibres at sites of wear/may follow abrasion
Idiopathic or assoc w/ CTD or drug
flesh coloured, red, umbilicated papule 2-3mm with central, tightly adherent plug that bleeds if removed
nape/ sides of neck/ Upper armscan be itchyhigh risk of keloids when biopsied
What are the associations of Elastosis perforans serpiginosa?
A DERM POP
Penicillamine: produces abnormal elastin. (Disrupts desmosin cross links within elastin)
What is the histology of Elastosis perforans serpiginosa?
claw like epidermal down growths
surrounds basophilic debris, fibrin, inflammatory and granulation tissue
epidermis hyperplastic and acanthotic
plug of crusting/ HK and variable PK
aggregates of Neuts or Lymphocytes
within plugs is horny material in upper 1/3, amorphous debris in lower 2/3
Foreign body giant cell rxn underlying plug
brightly eosinophilic elastic tissue +++ in sup dermis
Van geison stain = black
What is the treatment of Elastosis perforans serpiginosa?
Currettage and cautery
TCS under occlusion not very effective
Caution w/ Electrosyrgery/ dermabrasion/ surgery - risk of keloids!! - best avoid these modalities
Retinoid for widespread EPS
aggressive rx may result in scarring, be careful
spontaneously resolve anyway
What is colloid millium?
degenerative change of elastic fibres w/ yellowish/translucent papules/plaques on light exposed skin
What are the types of colloid millium?
prior to puberty, often familial
On face, small lesions
sun-exposed areas, lesions are larger
Drug-induced type - phenol in oils or hydroquinone
What is the histology of colloid millium?
Colloidal material (usually eosinophilic) in dermal papillae
Bands collagen surrounding the colloid globules
Fibroblasts and small blood vessels preserved in colloid material
May be a Grenz zone
Overlying compact orthokeratosis
What is the treatment of colloid millium?
Can also try diathermy or cryotherapy
What is White fibrous papulosis of the neck?
Asympotatic small white fibrous papules around the neck esp to middle aged and elderly men
Bundles of thick collagen fibres in dermis
What is Papular elastorrhexis?
Rare type of connective tissue naevus
Adolescents or young adults
Multiple oval white/yellow papules on trunk or limbs
Non follicular based
Reduced dermal elastic fibres
Overlap w/ skin lesions of Buschke-Ollendorf
What are Constricting bands of the extremities (Ainhum and pseudoainhum)
Constricting band around digit/limb
Can be shallow/involving skin, or deeper involving fascia/bone - may autoamputate digit/limb
Anhinum (African means saw)
affects 5th toe in black africans
Related to underlying abnormalities in blood supply (plantar arch) precipitated by mechanical trauma like walking
May be related to infection like leprosy/Tb
Pseudo-anhimun and other constricting bands
May be congenital due to amniotic bands or acquired due to trauma, cold, neuropathy, PSS, Vohwinkels, Pachyonychia congenita, EPP, Olmsted’s
Regarding Ehlers-Danlos Syndrome, it occurs in almost 1 in 5000 persons
Regarding Ehlers-Danlos Syndrome, it is most commonly autosomal recessive
Regarding Ehlers-Danlos Syndrome, molluscoid pseudo tumours present on the flexor surfaces of joints
Regarding Ehlers-Danlos Syndrome, skin tears rather than stretching