1
|
Zhao Q, Chu Z, Li L, Feng C, Zhou H, Hu J, Zhao L, Che D, Zhang X, Peng B, Han Y, Geng S. New clinical classification of stiff skin syndrome. Arch Dermatol Res 2024; 316:333. [PMID: 38844593 DOI: 10.1007/s00403-024-03090-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 11/29/2023] [Accepted: 04/26/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Stiff skin syndrome (SSS) is a rare disease characterized by thickened, indurated skin and limited joint movement. Multiple diverse phenotypes have been reported, and the correlation of severity with the clinical heterogeneity and histopathological findings of SSS needs to be refined. OBJECTIVE To define subtypes based on clinical features and predict the prognosis of a new SSS classification. METHODS Eighty-three patients with SSS were retrospectively reviewed for clinicopathological manifestations and routine laboratory workup, including 59 cases obtained from a PubMed search between 1971 and 2022 and 24 cases diagnosed in our department between 2003 and 2022. RESULTS Among the 83 patients, 27.7, 41, and 31.3% had classic widespread, generalized segmental, and localized SSS, respectively. Joint immobility was present in 100, 71, and 20% of classic, generalized, and localized cases, respectively. Histopathologic findings were common among the 3 groups, and based on that, we further found a difference in the distribution of proliferative collagen. 54.5% of classic and 50% of generalized cases occurred throughout the dermis or the subcutis, whereas 76% of localized cases were mainly involved in the reticular dermis or subcutis. In patients with incipient localized SSS, 42% (21/50) developed generalized SSS, and only 6% (3/50) progressed to classic SSS, whereas more than half of the incipient generalized SSS cases (60.6%, 20/33) developed classic SSS. LIMITATIONS This retrospective study was limited to previously published cases with limited data. CONCLUSIONS We propose a distinct clinical classification characterized by lesion distribution, including classic widespread, generalized segmental, and localized SSS, associated with disease severity and prognosis.
Collapse
Affiliation(s)
- Qiang Zhao
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Zhaowei Chu
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Li Li
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Cheng Feng
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Hongmei Zhou
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Jiahui Hu
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Lihong Zhao
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Delu Che
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Xinyue Zhang
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Bin Peng
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Yichen Han
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China
| | - Songmei Geng
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Shaanxi, 710049, People's Republic of China.
| |
Collapse
|
2
|
Lin Z, Pei Y, Tang X, Rong L, Chen L, Jiang X. Classification and rising medication therapy in stiff skin syndrome: A case report and literature review. Dermatol Ther 2022; 35:e15633. [PMID: 35686816 DOI: 10.1111/dth.15633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/30/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022]
Abstract
Stiff skin syndrome (SSS) is a rare disorder characterized by skin induration and limited joint mobility in the absence of visceral, musculoskeletal, vascular, or immunologic abnormalities. Distinctive subsets of SSS could be distinguished by various manifestation and mechanism, which accounts for the high heterogeneity in SSS cases. Although rehabilitation training remains the mainstay of management, rising medications has drawn awareness in recent years, owing to the potential efficacy. Nevertheless, experience was limited, especially in widespread SSS. We report on a 5-year-old girl with widespread SSS, whose lesion stopped progressing after combination therapy by mycophenolic acid (MPA) and losartan (LST) in addition to rehabilitation exercise. Despite limited experience, a combined therapy of MPA and LST seems to be effective in retarding progression of widespread SSS.
Collapse
Affiliation(s)
- Zhilang Lin
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yuxin Pei
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xuhua Tang
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Liping Rong
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lizhi Chen
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaoyun Jiang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| |
Collapse
|
3
|
Foti R, De Pasquale R, Dal Bosco Y, Visalli E, Amato G, Gangemi P, Foti R, Ramondetta A. Clinical and Histopathological Features of Scleroderma-like Disorders: An Update. Medicina (B Aires) 2021; 57:medicina57111275. [PMID: 34833493 PMCID: PMC8625286 DOI: 10.3390/medicina57111275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 11/25/2022] Open
Abstract
Scleroderma-like disorders include a set of entities involving cutis, subcutis and, sometimes, even muscular tissue, caused by several pathogenetic mechanisms responsible for different clinical–pathological pictures. The absence of antinuclear antibodies (ANA), Raynaud’s phenomenon and capillaroscopic anomalies constitutes an important element of differential diagnosis with systemic sclerosis. When scleroderma can be excluded, on the basis of the main body sites, clinical evolution, any associated pathological conditions and specific histological features, it is possible to make a correct diagnosis.
Collapse
Affiliation(s)
- Rosario Foti
- Division of Reumathology, A.O.U. “Policlinico-San Marco”, 95123 Catania, Italy; (R.F.); (Y.D.B.); (E.V.); (G.A.)
| | - Rocco De Pasquale
- U.O. Dermatologia, Ospedale San Marco, 95123 Catania, Italy; (R.D.P.); (R.F.)
| | - Ylenia Dal Bosco
- Division of Reumathology, A.O.U. “Policlinico-San Marco”, 95123 Catania, Italy; (R.F.); (Y.D.B.); (E.V.); (G.A.)
| | - Elisa Visalli
- Division of Reumathology, A.O.U. “Policlinico-San Marco”, 95123 Catania, Italy; (R.F.); (Y.D.B.); (E.V.); (G.A.)
| | - Giorgio Amato
- Division of Reumathology, A.O.U. “Policlinico-San Marco”, 95123 Catania, Italy; (R.F.); (Y.D.B.); (E.V.); (G.A.)
| | - Pietro Gangemi
- U.O. Anatomia Patologica, Ospedale San Marco, 95123 Catania, Italy;
| | - Riccardo Foti
- U.O. Dermatologia, Ospedale San Marco, 95123 Catania, Italy; (R.D.P.); (R.F.)
| | - Alice Ramondetta
- U.O. Dermatologia, Ospedale San Marco, 95123 Catania, Italy; (R.D.P.); (R.F.)
- Correspondence: ; Tel.: +39-095-479-4298
| |
Collapse
|
4
|
Cerejeira D, Bonito F, António AM, Cunha H. Segmental stiff skin syndrome (SSS): Clinical case and a brief review. Australas J Dermatol 2021; 62:380-382. [PMID: 33769553 DOI: 10.1111/ajd.13589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/11/2021] [Accepted: 02/14/2021] [Indexed: 01/25/2023]
Abstract
Stiff skin syndrome (SSS) is a rare, scleroderma-like condition that is commonly characterised by stony hard skin and limited joint mobility, in the absence of visceral involvement or immunologic abnormalities. Depending on the distribution of the disease, this disorder can be further categorised into classic (widespread) SSS or its newly described segmental variant. Additional features of this syndrome may include hypertrichosis, lipodystrophy, dysmetria and scoliosis. In this report, we present the case of a patient with segmental SSS and we briefly review the current literature about the topic.
Collapse
Affiliation(s)
- Diogo Cerejeira
- Dermatology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Frederico Bonito
- Dermatology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | - Henriqueta Cunha
- Dermatology Department, Hospital Garcia de Orta, Almada, Portugal
| |
Collapse
|
5
|
Wang T, Yang Y, Dong Q, Zhu H, Liu Y. Acromicric dysplasia with stiff skin syndrome-like severe cutaneous presentation in an 8-year-old boy with a missense FBN1 mutation: Case report and literature review. Mol Genet Genomic Med 2020; 8:e1282. [PMID: 32406602 PMCID: PMC7336748 DOI: 10.1002/mgg3.1282] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 03/31/2020] [Accepted: 04/04/2020] [Indexed: 12/17/2022] Open
Abstract
Background Acromicric dysplasia is a rare heritable short‐stature syndrome with joint stiffness and varying degrees of cutaneous hardness. Stiff skin syndrome is a rare connective tissue disorder characterized by diffusely thick and hard skin from the time of birth. Heterozygous point mutations in the FBN1 have been proposed as the predominant cause of both diseases. Methods By performing skin biopsy, X‐ray imaging, electrocardiography, as well as whole‐genome sequencing and Sanger sequencing, we diagnosed an 8‐year‐old Chinese boy as acromicric dysplasia with severe skin stiffness caused by a heterogeneous mutation in the FBN1. Results The patient presented with skin tightness, wrist and ankle stiffness, short stature and limbs, several deformed joints in the extremities, cone‐shaped epiphyses, and distinct facial features. He also had a patent foramen ovale and frequent respiratory infections. Skin biopsy showed thickened dermis and excessive collagen aggregation. Alcian blue staining indicated dermal mucopolysaccharide deposition. Mutation analysis revealed a heterozygous missense mutation, c.5243G>A (p.Cys1748Tyr), in exon 42 of the FBN1. Conclusion This is a report about acromicric dysplasia with stiff skin syndrome‐like severe cutaneous presentation caused by a single hotspot mutation, further revealing the gene pleiotropy of FBN1.
Collapse
Affiliation(s)
- Tao Wang
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuyan Yang
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qi Dong
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuehua Liu
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
6
|
Myers KL, Mir A, Schaffer JV, Meehan SA, Orlow SJ, Brinster NK. Segmental stiff skin syndrome (SSS): A distinct clinical entity. J Am Acad Dermatol 2016; 75:163-8. [DOI: 10.1016/j.jaad.2016.01.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/12/2016] [Accepted: 01/26/2016] [Indexed: 11/17/2022]
|
7
|
Chamney S, Cartmill B, Earley O, McConnell V, Willoughby CE. The ocular phenotype of stiff-skin syndrome. Eye (Lond) 2015; 30:156-9. [PMID: 26471116 DOI: 10.1038/eye.2015.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 05/08/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Stiff skin syndrome (SSS; MIM#184900) is a rare autosomal dominantly inherited Mendelian disorder characterised by thickened and stone-hard indurations of the skin, mild hypertrichosis, and limitation of joint mobility with flexion contractures. It is autosomal dominant with high penetrance and results from mutations in the fibrillin 1 (FBN1; MIM*134797) gene. Here we present the associated ocular phenotype in a two generation nonconsanguineous Northern Irish family.METHODS The affected patients underwent complete ophthalmic and orthoptic assessment and genetic testing.RESULTS All three patients had ophthalmoplegia of varying degrees. Direct sequencing of the FBN1 gene detected a heterozygous pathogenic mutation (c.4710G>C; p.Trp1570Cys) in all affected patients.CONCLUSIONS This is the first report of ophthalmoplegia in association with SSS.
Collapse
Affiliation(s)
- S Chamney
- Department of Ophthalmology, Royal Victoria Hospital, Belfast, UK
| | - B Cartmill
- Department of Ophthalmology, Royal Victoria Hospital, Belfast, UK
| | - O Earley
- Department of Ophthalmology, Mater Hospital, Belfast, UK
| | - V McConnell
- Northern Ireland Regional Genetics Department, Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, UK
| | - C E Willoughby
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| |
Collapse
|
8
|
McCalmont TH, Gilliam AE. A subcutaneous lattice-like array of thick collagen is a clue to the diagnosis of stiff skin syndrome. J Cutan Pathol 2012; 39:2-4, 1. [PMID: 22211327 DOI: 10.1111/j.1600-0560.2011.01845_2.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Timothy H McCalmont
- Departments of Pathology and Dermatology, University of California, San Francisco, CA, USA.
| | | |
Collapse
|
9
|
Olivieri J, Smaldone S, Ramirez F. Fibrillin assemblies: extracellular determinants of tissue formation and fibrosis. FIBROGENESIS & TISSUE REPAIR 2010; 3:24. [PMID: 21126338 PMCID: PMC3012016 DOI: 10.1186/1755-1536-3-24] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 12/02/2010] [Indexed: 11/13/2022]
Abstract
The extracellular matrix (ECM) plays a key role in tissue formation, homeostasis and repair, mutations in ECM components have catastrophic consequences for organ function and therefore, for the fitness and survival of the organism. Collagen, fibrillin and elastin polymers represent the architectural scaffolds that impart specific mechanic properties to tissues and organs. Fibrillin assemblies (microfibrils) have the additional function of distributing, concentrating and modulating local transforming growth factor (TGF)-β and bone morphogenetic protein (BMP) signals that regulate a plethora of cellular activities, including ECM formation and remodeling. Fibrillins also contain binding sites for integrin receptors, which induce adaptive responses to changes in the extracellular microenvironment by reorganizing the cytoskeleton, controlling gene expression, and releasing and activating matrix-bound latent TGF-β complexes. Genetic evidence has indicated that fibrillin-1 and fibrillin-2 contribute differently to the organization and structural properties of non-collagenous architectural scaffolds, which in turn translate into discrete regulatory outcomes of locally released TGF-β and BMP signals. Additionally, the study of congenital dysfunctions of fibrillin-1 has yielded insights into the pathogenesis of acquired connective tissue disorders of the connective tissue, such as scleroderma. On the one hand, mutations that affect the structure or expression of fibrillin-1 perturb microfibril biogenesis, stimulate improper latent TGF-β activation, and give rise to the pleiotropic manifestations in Marfan syndrome (MFS). On the other hand, mutations located around the integrin-binding site of fibrillin-1 perturb cell matrix interactions, architectural matrix assembly and extracellular distribution of latent TGF-β complexes, and lead to the highly restricted fibrotic phenotype of Stiff Skin syndrome. Understanding the molecular similarities and differences between congenital and acquired forms of skin fibrosis may therefore provide new therapeutic tools to mitigate or even prevent disease progression in scleroderma and perhaps other fibrotic conditions.
Collapse
Affiliation(s)
- Jacopo Olivieri
- Scienze Mediche e Chirurgiche, Sezione Clinica Medica, Universita' Politecnica delle Marche, Ancona, Italy
| | - Silvia Smaldone
- Pharmacology and Systems Therapeutics, Mount Sinai School of Medicine, New York, USA
| | - Francesco Ramirez
- Pharmacology and Systems Therapeutics, Mount Sinai School of Medicine, New York, USA
| |
Collapse
|
10
|
Mlika RB, Kenani N, Badri T, Hammami H, Hichri J, Haouet S, Mokhtar I, Fenniche S. Morphea profunda in a young infant after hepatitis B vaccination. J Am Acad Dermatol 2010; 63:1111-2. [DOI: 10.1016/j.jaad.2009.02.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 02/02/2009] [Accepted: 02/02/2009] [Indexed: 10/18/2022]
|
11
|
Loeys BL, Gerber EE, Riegert-Johnson D, Iqbal S, Whiteman P, McConnell V, Chillakuri CR, Macaya D, Coucke PJ, De Paepe A, Judge DP, Wigley F, Davis EC, Mardon HJ, Handford P, Keene DR, Sakai LY, Dietz HC. Mutations in fibrillin-1 cause congenital scleroderma: stiff skin syndrome. Sci Transl Med 2010; 2:23ra20. [PMID: 20375004 PMCID: PMC2953713 DOI: 10.1126/scitranslmed.3000488] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The predisposition for scleroderma, defined as fibrosis and hardening of the skin, is poorly understood. We report that stiff skin syndrome (SSS), an autosomal dominant congenital form of scleroderma, is caused by mutations in the sole Arg-Gly-Asp sequence-encoding domain of fibrillin-1 that mediates integrin binding. Ordered polymers of fibrillin-1 (termed microfibrils) initiate elastic fiber assembly and bind to and regulate the activation of the profibrotic cytokine transforming growth factor-beta (TGFbeta). Altered cell-matrix interactions in SSS accompany excessive microfibrillar deposition, impaired elastogenesis, and increased TGFbeta concentration and signaling in the dermis. The observation of similar findings in systemic sclerosis, a more common acquired form of scleroderma, suggests broad pathogenic relevance.
Collapse
Affiliation(s)
- B L Loeys
- Institute of Genetic Medicine and Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Broadway Research Building, Room 539, 733 North Broadway, Baltimore, MD 21205, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
|
13
|
Guiducci S, Distler JHW, Milia AF, Miniati I, Rogai V, Manetti M, Falcini F, Ibba-Manneschi L, Gay S, Distler O, Matucci-Cerinic M. Stiff skin syndrome: evidence for an inflammation-independent fibrosis? Rheumatology (Oxford) 2009; 48:849-52. [PMID: 19468049 DOI: 10.1093/rheumatology/kep118] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Stiff skin syndrome (SSS) is a rare scleroderma-like syndrome of unknown aetiology. A 16-year-old boy presented with thoracic and abdominal asymmetry, and 'orange peel' cutaneous lesions, with fibrotic stone-hard indurations at the buttocks, thighs and arms leading to secondary joint contractures of the extremities. Our aim was to analyse the expression of extracellular matrix (ECM) molecules and pro-fibrotic cytokines in the dermis and epidermis of SSS. METHODS The diagnosis of SSS was confirmed by clinical and histopathological examination. Collagen type 1 alpha-2 chain (Col1A2), fibronectin-1, thrombospondin-1, TGF-beta, connective tissue growth factor (CTGF), IL-6, -1beta, ET-1, Fibroblast growth factor receptor 3 (FGFR-3) and MCP-1 expression was analysed in SSS and age- and sex-matched healthy control skin by real-time PCR. VEGF expression was also studied. RESULTS Histopathological examination showed flattened dermal papillae, a scarce presence of sub-epidermal microvessels and mild dermal fibrosis, but no inflammatory infiltrates. In the SSS dermis, the expression of IL-1beta, -6 and MCP-1 was low, whereas VEGF was intensively expressed. No differences were observed for TGF-beta, CTGF and ET-1. In contrast, col1A2, fibronectin-1 and thrombospondin-1 were overexpressed in the SSS dermis. CONCLUSION In our SSS patient, an overexpression of ECM proteins was detected, whereas no inflammatory infiltrates or up-regulation of pro-fibrotic cytokines were found. The data suggest that fibrosis in SSS might be independent from inflammation.
Collapse
Affiliation(s)
- Serena Guiducci
- Department of BioMedicine, Division of Rheumatology, DENOthe Centre, University of Florence, AOUC, Florence, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|