The clinical spectrum of mid-dermal elastolysis and the role of UV light in its pathogenesis

A Case Report on Mid-Dermal Elastolysis: A Distinctive Presentation on the Neck

Mid-dermal elastolysis (MDE) is a very rare and acquired skin condition. MDE has a variety of clinical manifestations that can be presented with a reticular erythematous patch with telangiectasis, perifollicular popular protrusions, or finely wrinkled skin. A biopsy is always necessary to rule out other potential elastic fiber disorders. In this case study, a 33-year-old female with an odd MDE presentation in her neck area is examined. No contributing factors, apart from exposure to sunlight, could be gleaned from the patient's history. The patient didn't benefit from the application of various types of topical agents or any other therapies to lessen the size and advancement of the lesion. In this distinct case, we discuss clinical and histological findings and the treatment plan offered, as well as include a concise review of specific past literature.

Mid-dermal elastolysis: A female-centric disease; case report and updated review of the literature

Background

Mid-dermal elastolysis (MDE) is a rare, yet well-defined clinical and histopathologic entity manifested by fine wrinkling of the skin and mid-dermal loss of elastic fibers. This disease predominantly affects young to middle-aged Caucasian females and although it has no reported systemic features, it is psychologically bothersome and can be of great cosmetic concern.

Methods

We report a case of a healthy 45 year-old female with widespread mid-dermal elastolysis. A literature search using the search terms “mid-dermal elastolysis,” “mid dermal elastolysis,” “middermal elastolysis,” and “elastophagocytosis” was conducted on Pubmed, using articles published from January 2008 until November 2014 to accompany Gambichler’s comprehensive 1977 to 2009 review of mid-dermal elastolysis. The references of relevant papers were reviewed and further cases included as appropriate.

Results

We review the clinical features and histological, ultrastructural, and immunohistochemical findings of MDE, as well as differential diagnoses. There are 13 new publications of MDE since 2008. The novel findings since Gambichler’s review are discussed and pathomechanisms revisited. Interestingly, given the striking female predominance of MDE, there is no known hormonal role in its etiology.

Evolution of granuloma annulare to mid-dermal elastolysis: report of a case and review of the literature

A 55-year-old healthy Caucasian female, on no medication, was seen by a dermatologist because of a patchy, slightly indurated and violaceous eruption involving her neck and trunk. The clinical impression was of granuloma annulare (GA). Over a period of several months the violaceous lesions became atrophic with loss of colour and eventual wrinkling of lesional skin. Sequential skin biopsies were obtained, which revealed a spectrum of changes. Those from early violaceous lesional zones displayed perivascular lymphocytic infiltrates and interstitial granulomatous inflammation, characteristic of interstitial GA. Samples from atrophic lesional areas appeared normal on routine sections but an Orcein-Giemsa (OG) stain, prompted by the clinical history of atrophy, revealed absence of elastic fibers in the mid-reticular dermis. The combined clinicopathologic findings pointed to development of mid-dermal elastolysis (MDE) at involutional sites of GA. Owing to consideration of a cutaneous T-cell lymphoma in the differential diagnosis, genotyping in search of T-cell monoclonality was performed and yielded a negative result. Our case supports the existing but scant evidence in the literature that the rare, enigmatic condition termed MDE is an end-result of inflammatory destruction of dermal elastic fibers. GA is one form of dermatitis capable of culminating in this entity, but others have also been implicated.

Histopathology of pseudoxanthoma elasticum and related disorders: histological hallmarks and diagnostic clues

Among ectopic mineralization disorders, pseudoxanthoma elasticum (PXE)-a rare genodermatosis associated with ocular and cardiovascular manifestations-is considered a paradigm disease. The symptoms of PXE are the result of mineralization and fragmentation of elastic fibers, the exact pathophysiology of which is incompletely understood. Though molecular analysis of the causal gene, ABCC6, has a high mutation uptake, a skin biopsy has until now been considered the golden standard to confirm the clinical diagnosis. Although the histological hallmarks of PXE are rather specific, several other diseases-particularly those affecting the skin-can present with clinical and/or histological characteristics identical to or highly resemblant of PXE. In this paper, we will summarize the histopathological features of PXE together with those of disorders that are most frequently considered in the differential diagnosis of PXE.

Elastólise pós-inflamatória e cutis laxa (doença de James Marshall): estudo de casos

FUNDAMENTOS: Elastólise pós-inflamatória e cutis laxa são doenças raras, porém só o Estado de Minas Gerais responde por quase um terço dos casos relatados em todo o mundo. Também são escassos os trabalhos com seguimento dos pacientes. OBJETIVOS: Relatar nove casos observados no período de 1981 a 2004, confrontando seus achados com os 20 casos da literatura. MÉTODOS: Foram analisadas variáveis epidemiológicas, clínicas, histopatológicas e terapêuticas. RESULTADOS: Foram observados o predomínio na raça negra (8:1), no sexo feminino (4:1) e nos trópicos (9:1); idade de início até os quatro anos (93%); deficiência de alfa 1-antitripsina (7%); aortite (7%); dermatoses relacionadas (62%); aspecto facial envelhecido (97%), fase atrófica estável na infância após período variável de meses a anos com lesões inflamatórias (97%). A histopatologia das lesões recentes mostrou infiltrado mais intenso e perda elástica menor do que nas lesões tardias. A cirurgia de reconstrução deu bons resultados na fase atrófica, enquanto o ácido retinóico tópico a 0,05% não foi efetivo. CONCLUSÕES: A elastólise pós-inflamatória e cutis laxa na fase aguda correlacionaram-se com diversas dermatoses inflamatórias, que promoveram elastólise (62%). A abordagem adequada dessas doenças pode diminuir a extensão do quadro atrófico final, que tem como boa opção terapêutica a cirurgia reconstrutora. Sugere-se pesquisar a deficiência de alfa 1-antitripsina.

Acquired disorders of elastic tissue: Part II. decreased elastic tissue

Elastic fibers in the extracellular matrix are integral components of dermal connective tissue. The resilience and elasticity required for normal structure and function of the skin are attributable to the network of elastic tissue. Advances in our understanding of elastic tissue physiology provide a foundation for studying the pathogenesis of elastic tissue disorders. Many acquired disorders are nevertheless poorly understood owing to the paucity of reported cases. Several acquired disorders in which loss of dermal elastic tissue produces prominent clinical and histopathologic features have recently been described, including middermal elastolysis, papular elastorrhexis, and pseudoxanthoma-like papillary dermal elastolysis, which must be differentiated from more well-known disorders such as anetoderma, acquired cutis laxa, and acrokeratoelastoidosis. Learning objective At the conclusion of this learning activity, participants should have an understanding of the similarities and differences between acquired disorders of elastic tissue that are characterized by a loss of elastic tissue.

Mid-dermal elastolysis preceded by acute neutrophilic dermatosis

BACKGROUND

Mid-dermal elastolysis is a rare idiopathic elastic tissue disorder that is characterized by localized patches of finely wrinkled skin and a "band-like" loss of elastic tissue in the mid-reticular dermis. Lesions may be preceded by erythema and/or urticaria, and histological examination of inflamed lesional skin may demonstrate lymphohistiocytic dermal infiltration.

CASE REPORT

We report a case of mid-dermal elastolysis in a 31-year-old woman who developed multiple erythematous and urticarial plaques on the arms and trunk. Histologic examination of a representative lesion revealed a neutrophilic infiltrate and a normal pattern of elastic tissue. Several months later, the erythema and urticaria was noted to have resolved, leaving soft, pendulous plaques with overlying finely wrinkled skin. A follow-up biopsy at this time showed minimal lymphocytic inflammation but almost complete absence of elastic tissue in the mid-reticular dermis.

CONCLUSIONS

To our knowledge, acute neutrophilic dermatosis resulting in mid-dermal elastolysis has not been previously described. This observation lends support to an emerging theory that the pathogenesis of mid-dermal elastolysis may be inflammatory.

Mid-dermal elastolysis: a clinical, histologic, and immunohistochemical study of 11 patients

BACKGROUND

Mid-dermal elastolysis is a rare entity defined by the selective loss of elastic tissue in the mid dermis. Many cases appear induced or aggravated by ultraviolet (UV) light exposure. Pathogenesis is still uncertain.

OBJECTIVE

Our purpose was to report on the clinical and histologic features of 11 patients with mid-dermal elastolysis. Moreover, we analyzed by immunohistochemistry leukocyte subsets and expression of metalloproteinase (MMP) with the potential to degrade elastic tissue in 7 cases.

RESULTS

All patients were women with a mean age of 31.4 years. Disease duration ranged from 4 months to 17 years. Affected areas included the trunk, neck, and upper aspect of limbs. Two patients also had Hashimoto's thyroiditis and uterine carcinoma, respectively, whereas 1 patient had undergone silicone mammoplasty. In all patients, disease onset was associated with intense UV light exposure. Moderate leukocyte infiltration in the dermis was observed mostly in recent lesions and was composed of CD3(+) T cells and some CD68(+) macrophages with a normal number of factor XIIIa(+) dermal dendritic cells. Elastin, but not fibrillin-1 immunoreactivity disappeared from the mid dermis. MMP-9 was detected in epidermal keratinocytes and in the cytoplasm of large, angulated, multinucleated cells located in lesional dermis. These cells were negative for leukocyte, dendritic cell, macrophage, and T-cell markers and were absent in old lesions. Staining for MMP-7 and MMP-12 did not differ from control skin.

CONCLUSION

Onset of mid-dermal elastolysis appears strongly associated with UV exposure, which may induce fibroblast-like cells to express MMP-9 that in turn could be involved in the degradation of elastic fibers.

Colocalization of granuloma annulare and mid-dermal elastolysis

Mid-dermal elastolysis is an elastic tissue disorder of unknown causation. Various elastic tissue abnormalities have been described in granuloma annulare. To our knowledge, we report the first case illustrating the clinical and histologic colocalization of granuloma annulare and mid-dermal elastolysis.

Basal cell carcinoma in young women: an evaluation of the association of tanning bed use and smoking

Basal cell carcinomas (BCCs) typically occur in middle-aged to elderly patients but less commonly in younger ones. In our experience, most BCCs seen in patients younger than 40 years are found in women. We evaluated 30 women with biopsy-proven BCC and 30 control patients matched for sex, age, and skin type to determine potential risk factors for this population. Tanning bed visits, pack-years of cigarette smoking, recreational sun exposure, number of blistering sunburns, and use of sunscreens were determined for both groups. Among patients with a BCC, the histologic type of tumor, site of involvement, method of treatment, follow-up period, incidence of recurrence, and presence of actinic keratoses were also evaluated. Patients with a BCC had a statistically greater number of pack years of smoking (P =.045), and a greater percentage of these women had experienced blistering sunburns (P =.028). Although women with a BCC had, on average, almost twice as many tanning salon visits (152.2 vs 83.1), this was not statistically significant. Sunscreen use and amount of recreational ultraviolet light exposure were essentially equal between the two groups. Young women with a BCC are more likely to have a past or current history of cigarette smoking and blistering sunburns. Repeated exposure to tanning beds may also be a contributory factor.

Mid-dermal elastophagocytosis presenting as a persistent reticulate erythema

Two men are presented with a widespread persistent reticulate erythema concentrated within the chronically sun-damaged skin on their trunk. A fine papular element was present in one case and both lacked annular lesions. One patient was human immunodeficiency virus positive. Multiple skin biopsies showed an interstitial infiltrate of histiocytes containing multiple elastic fibres in the upper dermis. There was scant perivascular lymphocytic inflammation but no evident necrobiosis or palisaded granulomas seen typically with granuloma annulare. Elastic stains showed focal mid-dermal elastolysis. Diffuse reticulate erythema in sun-damaged skin may be a clinical marker for elastophagocytosis. This presentation differs from that previously described with actinic granuloma, diffuse granuloma annulare or the inflammatory phase of mid-dermal elastolysis and expands the clinical spectrum of this phenomenon.

Wrinkling due to mid-dermal elastolysis: two cases and literature review

BACKGROUND

Mid-dermal elastolysis is an acquired disorder of elastic tissue clinically characterized by diffuse fine wrinkling, most often of the trunk and arms. Histologically, a clear band of elastolysis is present in the mid-dermis.

OBJECTIVE

Although examples of diffuse elastolysis are well known, only a small number of patients with mid-dermal elastolysis have been reported to date. We present two patients with clinical and histological evidence of mid-dermal elastolysis, review the literature, and summarize the salient features of some common disorders of elastic tissue.

METHODS

The first patient presented with fine wrinkles and papules over the upper arms, upper chest, and axillae, and demonstrated increased laxity of the eyelids. The second patient had striking wrinkles extending in a band-like pattern on her arms, upper chest, back, and abdomen. Neither one of our patients had a previous history of skin inflammation, urticaria, or any other underlying diseases related to their skin changes. Skin biopsies were taken from lesional and perilesional skin of both patients, and were stained with hematoxylin and eosin, and with elastic tissue stain. In addition, a tissue sample from Patient 1 was fixed for electron-microscopy.

RESULTS

Hematoxylin and eosin stains did not demonstrate specific changes or diagnostic patterns. However, elastic tissue stains revealed a band-like loss of elastic tissue in the mid-dermis. Elastic tissue in the remaining superficial and deep dermis stained normally. Electron-microscopy was consistent with these findings and revealed significant loss of elastic tissue limited to the mid-dermis.

CONCLUSION

We have presented two cases of mid-dermal elastolysis and reviewed the literature. To date, the pathophysiology of mid-dermal elastolysis had not been elucidated and no definitive therapy exists.

Mid-dermal elastolysis in an adolescent subsequent to lesions resembling granuloma annulare

First described by Shelley and Wood in 1977, mid-dermal elastolysis (MDE) is a rare acquired disorder in which there is a bandlike absence of elastic tissue limited to the mid-dermis. In their patient, MDE developed in an area previously involved with recurrent episodes of urticaria. We describe a 15-year-old white girl with well-circumscribed, minimally palpable yellow-white plaques and wrinkling diagnosed histologically as MDE in areas clinically diagnosed 5 years previously as granuloma annulare. As in the first described patient, five years elapsed between clearance of the original skin lesions and the clinical appearance of MDE. To our knowledge, we report the first adolescent case of MDE localized to previous sites of lesions clinically consistent with granuloma annulare and propose that MDE represents an abnormal end-stage reaction to multiple processes.

Atrophoderma elastolytica discreta

Atrophoderma elastolytica discreta is the clinicopathologic name for a unique entity herein first described in a patient with cutaneous lesions simulating atrophoderma of Pasini and Pierini but coupled with histopathologic changes of anetoderma. The clinical and histological findings seen here have not been previously seen in the many variants of anetoderma, and, as such, they are sui generis evidence of a new entity in clinical dermatology.

Mid-dermal elastolysis: a pathological and ultrastructural study of five cases

The aim of this study was to evaluate the presence of inflammatory phenomena and elastic fiber phagocytosis in mid-dermal elastolysis. The pathological and ultrastructural features of 5 Caucasian female patients (ranging from 26 to 40 years) with acquired diffuse asymptomatic areas of skin wrinkling have been reviewed. The clinical features of all cases were characteristic of this condition and only in one patient were erythematous urticaria-like, non pruriginous patches also observed. In 4 cases a history of prolonged sun bathing was present and in 3 cases there was a short history of oral contraception. The pathological study confirmed the typical absence of elastic fibers in the midreticular dermis. In two cases elastic fibers were still detectable in the periadnexal dermis. Hematoxylin and eosin sections showed a mild perivascular infiltrate in two cases, while in three patients histiocytes were scattered among collagen bundles. Multinucleated giant cells containing fragmented elastic fibers were detectable in one patient. Ultrastructural analysis revealed large mononuclear cells with phagocytic aspects toward elastic fibers in all cases.

Indoor tanning: risks, benefits, and future trends

The indoor tanning industry is a $1 billion-a-year business in the United States, and use of these high-intensity UVA tanning devices continues to grow. Many members of the medical community are concerned about the safety of these largely unregulated devices, but tanning salon operators state such concerns are unfounded and unproved. A comprehensive review of current knowledge of the operation and effects of indoor tanning is presented. The effects of UV radiation (especially UVA) on experimental animals and human beings are examined. Both acute and chronic effects are delineated from experimental sources as well as from epidemiologic studies and clinical observations. Existing safety regulations are described. Information on operator knowledge and compliance with existing safety regulations is reviewed.

Mid-dermal elastolysis: an ultrastructural and biochemical study

Mid-dermal elastolysis (MDE) is a particular elastic tissue disorder in which selective loss of elastic fibres occurs in the mid-dermis. It is clinically characterized by the appearance of fine wrinkling of the epidermis and perifollicular protrusion which gives the skin an aged appearance. It is sometimes associated with an inflammatory event such as urticaria while other cases are regarded as idiopathic. The pathogenesis of MDE is still obscure. Some authors have underlined the role of macrophage activation and others have imputed UV radiation. We report here a typical case of MDE arising after several attacks of solar urticaria. Electron microscopic and biochemical studies were carried out. Ultrastructural examination showed active elastophagocytosis by macrophages and mast cells, often degranulated, near phagocytosing cells. Biochemical studies demonstrated that fibroblasts derived from lesional skin of the MDE patient produced high levels of elastase and cathepsin G compared with fibroblasts from a healthy sex- and age-matched control. Phagocytosis of morphologically normal elastic tissue is a noticeable characteristic feature of MDE. In our case mast-cell activation and the abnormal synthesis and/or release of fibroblast elastolytic enzymes seemed to play a role in the pathogenesis of the MDE.

Pseudoxanthoma elasticum-like papillary dermal elastolysis: a report of two cases

We report 2 women, aged 83 and 63 years, who presented with multiple asymptomatic, slowly progressive, coalescing, skin-colored papules affecting the sides of the neck and lower abdomen. Incisional biopsies obtained from both patients revealed elastolysis in the papillary dermis. These 2 cases represent pseudoxanthoma elasticum-like papillary dermal elastolysis, a recently described entity, the etiology of which remains unclear.

Ultrastructural evaluation of mid-dermal elastolysis

Mid-dermal elastolysis is a well-defined clinical and histopathologic entity manifested by fine wrinkling of the skin and a mid-dermal loss of elastic fibers. Ultrastructural and histologic studies were performed in an attempt to better define the cause of the elastolytic process. Biopsy specimens from the lesions of 3 patients with mid-dermal elastolysis were studied at light and electron microscopic levels. Ultrastructural evidence of normal elastic fiber engulfment by activated macrophages was observed; however, some fields also demonstrated envelopment of abnormally degenerated elastic tissue. Although there are many potential causes of this degeneration, photodistribution of the lesions suggests that ultraviolet damage is a primary inciting factor.