[Elastolysis of the mid-dermis and annular elastolytic giant cell granuloma: different stages in the clinical spectrum of dermal elastolysis? Case report and review of the literature]

[Annular elastolytic giant cell granuloma]

BACKGROUND

Annular elastolytic giant cell granuloma (AEGCG) is a rare form of granulomatous dermatosis. It is characterised histologically by phagocytosis of elastic fibres by multinucleated cells. We report a favourable outcome in a case of AEGCG following PUVA therapy and treatment with synthetic antimalarials.

PATIENTS AND METHODS

A 67-year-old retired wine grower presented with highly pruritic annular lesions with raised borders on the shoulders and trunk that had been present for several months. Histological examination of a biopsy sample from the erythematous border was characteristic of AEGCG. Various topical treatments proved ineffective and systemic corticosteroids attenuated the patient's pruritus but had no effect on the skin lesions. PUVA therapy resulted in regression of lesions on the trunk, but the rash spread to the patient's arms and was covered with epidermal microcysts. PUVA therapy was discontinued and treatment with a synthetic antimalarial (hydroxychloroquine 400mg/d) was initiated, resulting in complete regression of the lesions.

DISCUSSION

AEGC was isolated in 1979 by Hanke et al. on the basis of five cases seen in females. This is a rare form of dermatosis with some 30 cases being reported in the English literature. The clinical aspect is fairly evocative, with erythematous papular lesions, either alone or in groups, with a raised border and a lighter centre tending towards atrophy. In most cases, the lesions are found predominantly in areas exposed to sunlight. The histological appearance is characteristic, with an image of giant cell elastophagic granuloma from which the name of the disease is taken. This appearance allows the disease to be differentiated from a number of other granulomatous diseases. The aetiology is unknown and treatment is empirical. Spontaneous cure can occur and consistent results have not been obtained with any treatments. In our case, PUVA was partly successful, and the synthetic antimalarials resulted in complete regression of residual lesions.

Mid-dermal elastolysis revisited

The clinical as well as histological data of 79 mid-dermal elastolysis (MDE) patients reported in the literature were evaluated. MDE is an acquired skin condition of the elastic tissue predominantly manifesting on the trunk and proximal extremities of young women. Most commonly observed skin changes include patches of well-circumscribed fine wrinkles (type I) and perifollicular papular protrusions (type II). Rarely, MDE may also occur with persistent reticular erythema and wrinkling (type III). The critical diagnostic histopathological feature of MDE is the selective loss of elastic fibres in the mid-dermis. Mild lymphohistiocytic infiltrates, elastophagocytosis of elastic fibres by macrophages, and even multinucleate giant cells are occasionally observed in MDE lesions. Immunohistological studies and cell culture experiments indicate that dysbalances in elastin turnover are associated with pathological degradative processes including increased elastolytic activity that finally lead to loss of elastic fibres in the mid-dermis. First-line differential diagnoses may include closely related conditions such as anetoderma, annular elastolytic giant cell granuloma, cutis laxa acquisita and pseudoxanthoma elasticum-like papillary dermal elastolysis. Future therapeutic approaches in MDE patients should focus on agents that are able to block increased elastase activity and induce elastin synthesis.

[Mid-dermal elastolysis]

Mid-dermal elastolysis is a rare dermatosis of still unknown etiology with a characteristic mid-dermal loss of elastic tissue on histopatholoy. Papular and plaque-like wrinkling of the skin as well as inflammatory and non-inflammatory variants have been described. We present a 39-year-old patient with extended skin wrinkling of the trunk and upper extremities after extensive UV light exposure and describe the clinical and histopathological findings. Based on our case, differential diagnoses are discussed and the literature is reviewed.

Reticular erythema with focal mid-dermal elastophagocytosis (REMDE)

SUMMARY

A 57-year-old man presented with a persistent arcuate partly reticular erythema of the upper chest. Histopathological examination revealed an upper and mid-dermal perivascular and interstitial dermatitis with macrophages which had engulfed elastic fibers. Additionally a focal dermal elastolysis was observed. The characteristic clinicopathological constellation has hitherto been reported in only 3 cases, including our case. Presumably, the disease belongs to a spectrum of clinical manifestation of mid-dermal elastolysis. It is suggested to gather future cases under the provisional diagnosis ''reticular erythema with focal mid-dermal elastophagocytosis" (REMDE) to gain more insights into this rare disease.

Annular elastolytic giant cell granuloma: sparing of a burn scar and successful treatment with chloroquine

Annular elastolytic giant cell granuloma is a rare granulomatous skin disease characterized by phagocytosis of elastic fibres by multinucleated giant cells. Lesions are either solitary or grouped in a few annular patches with elevated borders and central atrophy. Sun-exposed areas are more commonly involved than covered skin. The pathogenesis of the disease is still controversial. We report a 72-year-old fair-skinned woman with unusual clinical findings. An irregularly shaped erythematous plaque covered the entire face, and hundreds of lichenoid papules were present on both sun-exposed and covered areas which gradually evolved into annular lesions of about 0.5-1 cm in diameter. Sparing of an old burn scar and a nearly complete lack of elastic fibres in the scar site were noted, illustrating the presumed importance of dermal elastic tissue in the pathogenesis. The course of the disease is chronic. Several treatments have been tried, with variable success. In our patient, improvement was achieved with chloroquine over a period of 16 weeks.