Familial reactive perforating collagenosis and intolerance to cold

Acquired Reactive Perforating Collagenosis: A Case Report

Reactive perforating collagenosis (RPC) is a rare form of dermatosis. It forms with perforating folliculitis, Kyrle's disease, and serpiginous perforating elastosis, which is a group of perforating dermatosis. RPC can be hereditary with autosomal dominant transmission or it can be acquired, which is usually observed in diabetics with chronic renal failure. Here we report a new observation in a 72-year-old woman treated by phototherapy with a favorable outcome

Acquired reactive perforating dermatosis

Acquired reactive perforating dermatosis is characterized by umbilicated erythematous papules and plaques with firmly adherent crusts. Histopathological examination shows a typical cup-shaped ulceration in the epidermis containing cellular debris and collagen. There is transepidermal elimination of degenerated material with basophilic collagen bundles. The etiology and pathogenesis of acquired reactive perforating dermatosis are unclear. Metabolic disorders and malignancies are associated with this dermatosis. Associated pruritus is regarded as a key pathogenic factor. Constant scratching may cause a repetitive trauma to the skin. This pathogenesis may involve a genetic predisposition. The trauma may lead to degeneration of the collagen bundles. Treatment of acquired reactive perforating dermatosis follows a multimodal approach. Apart from the treating any underlying disease, treatment of pruritus is a major goal. Systemic steroids and retinoids, as well as UVB phototherapy are well-established treatment options. Some patients may also benefit from oral allopurinol.

[Reactive perforating collagenosis]

BACKGROUND

Reactive perforating collagenosis (RPC) belongs to the group of perforating dermatoses, which comprises elastosis perforans serpiginosa, RPC, perforating folliculitis and Kyrle's disease. RPC was initially described as a distinctive form of transepithelial elimination of altered collagen related to superficial trauma. Two types are distinguished: a hereditary type (MIM 216700), which is rare and begins during early childhood, and a second type, called acquired RPC, which is more frequent, appears in adults and is associated with other diseases, diabetes mellitus, renal insufficiency, solid tumors, lymphomas and AIDS. We report the case of a young man whose illness began during infancy, militating in favor of a diagnosis of a hereditary form of RPC. The description of similar lesions in the patient's brother confirmed our diagnosis.

PATIENTS AND METHODS

A 26-year-old man, the child of consanguinous parents, presented crusted papular lesions on his hands. The cutaneous lesions, located on the external side of the limbs, had been present since childhood, with flares during winter. Histologic analysis showed a cup-shaped depression in the epidermis containing keratinous material with extruded degenerated collagen towards the cutaneous surface. Treatment with topic retinoids did not result in any real resolution of the disease. The patient reported the presence of similar lesions in his brother, which was consistent with our diagnosis.

DISCUSSION

The pathogenesis of hereditary RPC is still unknown, even if superficial trauma is suspected as the cause of RPC. In contrast, in diabetes, acquired RPC pathogenesis has recently been related to advanced glycation end-products of collagen.

Acquired reactive perforating collagenosis: current status

Acquired reactive perforating collagenosis is a unique perforating dermatosis, characterized clinically by umbilicated hyperkeratotic papules or nodules and histologically by a focal hyperkeratosis in direct contact with transepidermal perforating dermal collagen. Several inflammatory or malignant systemic diseases may coexist with acquired reactive perforating collagenosis. The possible biochemical or immunological mechanisms of the systemic diseases, potentially responsible for the development and appearance of acquired reactive perforating collagenosis, are still under investigation. Several topical treatments, ultraviolet B phototherapy and allopurinol p.o. administration may be effective.

Familial reactive perforating collagenosis

Background:

Reactive perforating collagenosis (RPC) is one of the rare forms of transepidermal elimination in which genetically altered collagen is extruded from the epidermis. This disease usually starts in early childhood as asymptomatic umbilicated papules on extremities, and the lesions become more conspicuous with age.

Aims:

The objective of our study was to determine the clinico-pathological features of RPC and the response to various treatment modalities.

Methods:

Ten patients of RPC, belonging to five different families, were studied clinically. Various laboratory investigations were carried out and diagnosis was made by histopathology of the lesions. Patients were given various topical and oral treatments.

Results:

RPC is familial in most cases without any definite inheritance pattern. It begins in childhood and the lesions are usually recurrent and become profuse and large with age. Systemic diseases have no role in the onset of lesions.

Conclusion:

Oral and topical retinoids in combination with emollients is the best treatment option.

Feline perforating dermatitis resembling human reactive perforating collagenosis: clinicopathological findings and outcome in four cases

The clinicopathological findings of perforating dermatitis in two young and two adult cats are described. In all cases, the lesions were characterized by single or multiple papules and plaques, 0.5-3.0 cm in diameter, each containing a central, firm, exophytic, cone-shaped, yellow-orange keratotic plug, tightly adherent to the underlying skin. Removal of the protruding material was associated with bleeding and left the ulcerated surface exposed. In one case, the lesions showed a linear configuration and identical lesions occurred on the suture sites following biopsy. Histopathologically, the diagnosis was straightforward because of the presence of vertically orientated collagen bundles extruded from ulcerated, concave-shaped invaginations of the skin. In two cases, vitamin C administration failed to resolve the disease. In two cases, methyl-prednisolone acetate was used to manage relapsing episodes and vitamin C helped to reduce glucocorticoid requirements. In one case, treatment with methyl-prednisolone acetate only appeared to be curative. The fourth case was lost to follow-up immediately after the diagnosis.

Familial reactive perforating collagenosis: a clinical, histopathological study of 10 cases

OBJECTIVE

To study the clinical and histopathological features of familial reactive perforating collagenosis (RPC).

MATERIAL AND METHODS

Ten patients, including affected siblings in three, took part in the study. Parental consanguinity was present in one. Histopathological study was performed in all patients.

RESULTS

The eruptions appeared mainly during infancy or early childhood as papules showing a central plug, which subsided within 10 weeks. Areas commonly affected were the face, extremities and trunk. Rare sites were the scalp, ears and buttocks. One pregnant woman, in whom RPC had first manifested around puberty, had relatively widespread lesions. In those with seasonal variation, recurrences were seen a little more frequently in summer than in winter owing to the longer duration of the former. Histopathology confirmed the diagnosis with follicular involvement in four cases. In two patients whose backs were also affected, the lesions went unnoticed, as they were small and inconspicuous. In addition, the brother of a girl with RPC who claimed to be free of the dermatosis, had facial scars suggestive of RPC in the past.

CONCLUSIONS

Familial RPC can remain quiescent for a long period and the inherited defect not only shows extreme variability in expression but also demonstrates that lesions can be few and localized so as to escape notice in individuals and family members presenting with this benign, uncommon and self-subsiding dermatosis. In all patients topical retinoic acid was helpful in early regression. Sunscreens may mitigate the severity of RPC in those whose lesions are precipitated in summer but this needs further evaluation.

Acquired reactive perforating collagenosis: four patients with a giant variant treated with allopurinol

Reactive perforating collagenosis (RPC) is one of the four essential acquired perforating dermatoses. The condition is characterized by the transepidermal elimination of altered collagen. This paper describes four patients with a giant variant of RPC which has not previously been documented. Three of the patients had associated diabetes mellitus and one had chronic renal failure secondary to fetal scarring. Three of the four patients had a significant improvement in their lesions and symptoms following treatment with allopurinol.

Koebnerization of reactive perforating collagenosis induced by laser hair removal

Laser hair removal, due to demonstrated efficacy and safety, has become a commonly performed office procedure. We report an unusual occurrence after laser hair removal with the 800 nm diode laser that previously has never been described. After laser hair removal treatment to the ventral surface of the ears, a patient developed lesions of previously diagnosed reactive perforating collagenosis. Interestingly, the lesions appeared on the dorsal surface of the ears. Perhaps the koebner phenomenon was invoked as the laser energy penetrated to the untreated dorsal surface, which was not protected by epidermal contact cooling.

Acquired reactive perforating collagenosis associated with diabetes mellitus: eight cases that meet Faver's criteria

Reactive perforating collagenosis (RPC) is characterized by umbilicated papules with a central adherent keratotic plug. Histologically, this condition shows transepidermal elimination of altered dermal collagen bundles into a cup-shaped epidermal depression. The present paper describes eight patients with associated diabetes mellitus who meet the diagnostic criteria for the acquired form of RPC (ARPC). Although half of these patients underwent dialysis, the lesions did not tend to develop after dialysis. Pruritus and the Koebner phenomenon were common, and histologically a microvasculopathy was noted in the dermis of all patients. We speculate that this disease is triggered by a cutaneous response to superficial trauma. Furthermore, this response acts synergistically with vasculopathy in the dermis, primarily in the case of diabetes mellitus. A secondary sign of ARPC may be degenerated collagen fibres as a result of transepidermal elimination.

Familial reactive perforating collagenosis: a case report

Reactive perforating collagenosis is characterised by trans-epidermal elimination of collagen and is hypothesized to be both autosomally dominant and recessive. We report a family in which two brothers and a sister had lesions of reactive perforating collagenosis.

Reactive perforating collagenosis and acquired perforating dermatosis: presentation of two cases

Two rare cases of patients suffering from diabetes mellitus and skin lesions with histological transepidermal elimination are presented. The clinical and histological findings confirmed the diagnoses of reactive perforating collagenosis and acquired perforating dermatosis. The relationship between the two entities and their pathogenesis are discussed.

The pathogenesis of the transepithelial elimination of the collagen bundles in acquired reactive perforating collagenosis. A light and electron microscopical study

Two cases of acquired reactive perforating collagenosis with poorly controlled diabetes mellitus were studied by histochemistry and by electron microscopy. In excoriated wound the necrotic mass on the bottom of the ulcer contained the collagen bundles which were continuous with the collagen bundles in the reticular layer. In the developing stage, the epidermis regenerated between the necrotic mass and the reticular dermis, and the collagen bundles in the reticular dermis were in continuity with those in the necrotic mass through the epithelial tunnels. The collagen in the epidermal channels did not degenerate ultrastructurally. In the mature lesion, collagen bundles being eliminated through the epidermis were surrounded by the fibroblasts at the basal cell layer. Collagen fibers were seen in the cytoplasm of these fibroblasts. From these findings, the mechanisms of the formation of the eruption in acquired reactive perforating collagenosis might be as follow: 1) In the developing stage, the regeneration of epidermis progresses between the necrotic mass and the reticular dermis, and among the collagen bundles. As a result, the collagen bundles remain in the channels of the epidermis. And then, 2) the regenerated epidermis makes the thick horny layer. As a result, the necrotic masses are lifted up and the collagen bundles are pulled up from the dermis through the epidermal channels.

Reactive perforating collagenosis--transepidermal elimination of type IV collagen

Reactive perforating collagenosis (RPC) is a rare skin disorder characterized by reddish papules with a central keratotic plug which appear mainly on the extensor aspects of the limbs. An idiopathic or classical variant has been delineated from an acquired one which occurs in diabetes mellitus and renal failure. Histopathological examination of the lesions shows transepidermal elimination of abnormally staining bundles of collagen. To clarify the origin of this collagenous material we performed an immunohistochemical study including biopsies of two patients with RPC, one classical and one acquired. Staining reactivity to antibodies against type IV collagen was observed, thus providing evidence that the collagen eliminated in RPC may be derived from the basement membrane zone.

Acquired reactive perforating collagenosis. Report of six cases and review of the literature

BACKGROUND

Reactive perforating collagenosis (RPC) is characterized by transepithelial elimination of altered collagen. Two types have been recognized: the childhood form and the adult form.

OBJECTIVE

Our purpose was to review the associated disorders, evaluate the possible causes, and set criteria for the diagnosis of the disease.

METHODS

The clinical and pathologic findings of six patients with the adult form of RPC are reviewed. The literature on this subject is compared with our findings.

RESULTS

Pruritus was reported in all cases. Treatment of pruritus cleared the lesions in many patients. This is the first report of an association between RPC and hyperparathyroidism, hypothyroidism, liver disorders, and neurodermatitis.

CONCLUSION

Various disorders can be associated with the adult form of RPC. Pruritus is the common factor among all types. Control of itching might be helpful for clearing the lesions. We propose the following diagnostic criteria for acquired RPC: (1) histopathologic findings of elimination of necrotic basophilic collagen tissue into a cup-shaped epidermal depression, (2) clinical presentation of umbilicated papules or nodules with a central adherent keratotic plug, and (3) onset of skin lesions after the age of 18 years.

Perforating dermatoses: a review and report of four cases

Perforating dermatoses, an often overlooked entity comprised of Kyrle's disease, perforating folliculitis, reactive perforating collagenosis, elastosis perforans serpiginosa, and acquired perforating dermatosis, are succinctly described, focusing attention on their clinical features, histopathology, treatment, and pathogenesis. The literature on these facets has been extensively reviewed. In addition, three fresh cases of Kyrle's and one of perforating folliculitis have been incorporated to illustrate these conditions.

A new treatment for acquired reactive perforating collagenosis

Acquired reactive perforating collagenosis is reported in an insulin dependent diabetic patient with renal impairment, managed successfully with surgical debridement and split skin grafting. The literature on treatment of reactive perforating collagenosis is reviewed.

Reactive perforating collagenosis in a setting of double disaster: acquired immunodeficiency syndrome and end-stage renal disease

We report reactive perforating collagenosis in an intravenous heroin abuser with acquired immunodeficiency syndrome and end-stage renal disease. The literature on perforating disorders in patients with acquired immunodeficiency syndrome and the pathogenesis of reactive perforating collagenosis in this setting is reviewed.

Adult, acquired reactive perforating collagenosis. Report of a case including ultrastructural findings

A case of reactive perforating collagenosis in an adult male patient with chronic renal failure. Pruritic, umbilicate papules, showing extrusion of collagen fibers through the epidermis were detected histopathologically. Electron microscopy showed absence of basal membrane beneath the perforation and collagen fibers with preserved periodicity passing through widened intercellular spaces with islands of cytoplasmic material.

Reactive perforating collagenosis: light, ultrastructural and immunohistological studies

Reactive perforating collagenosis is an uncommon disorder and few accounts refer to ultrastructural features. This report includes a study by light and transmission electron microscopy of serially sectioned biopsies from early lesions in two patients. Immunohistological investigations utilizing antibodies to basement membrane, laminin, collagen and cytokeratin were also done. Collagen and elastin were demonstrated within the centre of the lesions and there was a defect in the basal lamina at the base of the lesion. The collagen, cytokeratin and the basal lamina in the lesions were antigenically similar to those in the surrounding normal skin. These results are compared with previous findings and discussed in the light of the current views on the pathogenesis of this disorder.

Reactive perforating collagenosis

Seven patients with reacting perforating collagenosis (RPC) were diagnosed from 1974 to 1982. Experimental production of lesions in two patients confirmed the contributory role of superficial trauma. The pathogenesis of RPC involves transepithelial elimination of altered collagenous bundles. This process may be observed in a wide variety of disparate skin diseases.

The perforating disorders

This article reviews the diseases that may show epidermal perforation as a histologic feature. Many of these represent examples of transepithelial elimination (TEE), a mechanism by which the skin rids itself of abnormal substances. After a review of disorders in which perforation is an occasional finding, four diseases that have been considered essential perforating disorders are discussed: elastosis perforans serpiginosa (EPS), reactive perforating collagenosis (RPC), perforating folliculitis (PF), and Kyrle 's disease (KD). A review of the literature, including recent reports of perforating diseases associated with chronic renal failure, suggests that there may be considerable clinical and histologic overlap among PF, KD, and the adult form of "perforating collagenosis." A working classification for the perforating disorders is suggested.

Perforating folliculitis and psoriasis

A 51-year-old man with a 10-year history of psoriasis presented with coexistent perforating folliculitis. Several perforating lesions were located within psoriatic plaques. This case is instructive from several viewpoints: (1) it is the second case to appear in the literature, to our knowledge, describing the coexistence of these two conditions; (2) several of the larger lesions resolved during topical therapy with retinoic acid; (3) it demonstrates the histologic difficulties encountered in attempting to classify the major perforating diseases. Possible mechanisms for the development of perforating disease in this patient are discussed, as are the reasons for its apparent response to topical therapy.

Chondrodermatitis nodularis helicis: a transepidermal perforating disorder

Chondrodermatitis nodularis helicis is a chronic disorder occurring exclusively on the ear. It is most common in the sixth decade, and two thirds of the patients are men. Although it has no single characteristic histologic feature, a diagnosis can be made with certainty with a clinical history and a combination of morphologic changes seen in the cartilage and overlying skin. The natural history and histology are similar to a group of disorders characterized by transepithelial elimination known as the perforating dermatoses.

[Dermatoses with transepithelial perforation (author's transl)]

The histologic concept of epidermal elimination of particulate matter was formulated by Pinkus in 1954. Mehregan enlarged on this by recognizing its fundamental role in a variety of skin diseases. The importance of this epidermal reaction pattern in five "perforating" dermatoses is stressed. Also, it is shown that active participation of the corium and epithelio-mesenchymal interaction are required for the iniation of this mechanism. The histological differentiation and histogenesis of the presented dermatoses are discussed.