Mid-dermal elastolysis with prothrombotic abnormalities: two cases

[Mid-dermal elastolysis after insertion of a pacemaker]

BACKGROUND

Mid-dermal elastolysis (MDE) is a rare acquired disease of elastic tissue histologically characterized by focal loss of elastic fibres within the mid-dermis. While the mechanisms leading to MDE remain unknown, increased degradation of elastic fibres may be involved. Many factors potentially triggering such degradation have been suggested.

PATIENTS AND METHODS

A 58-year-old man consulted for an asymptomatic reticulated eruption that began in the area of a pacemaker implanted six weeks earlier. The eruption consisted of erythematous polycyclic and coalescing macules with a wrinkled centre. Histopathology with orcein staining revealed focal loss of elastic fibres in the superficial reticular dermis only. Hypersensitivity reaction to any components of the pacemaker was ruled out by means of allergy exploration. Laboratory investigations including autoimmunological and haematological factors were unremarkable. A diagnosis was made of a reticular variant of MDE following insertion of a pacemaker.

DISCUSSION

We report the second case of MDE following the insertion of a pacemaker, which could have triggered an inflammatory response directed specifically towards the elastic fibres.

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.

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.