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

Acquired Reactive Perforating Collagenosis in a Patient with Lung Fibrosis

Reactive perforating collagenosis (RPC) is a rare disorder characterized by the transepidermal elimination of altered collagen. The inherited form of RPC begins in early childhood, but acquired reactive perforating collagenosis (ARPC) begins in adult life. ARPC is associated with diabetes mellitus, renal disease, and malignancy. ARPC with lung fibrosis has not previously been reported in the literature, and the relationship between ARPC and lung fibrosis has not been studied. The etiological relationship between the two disorders appears to be uncertain. Although their association in this case could be due to chance, it may be due to the transforming growth factor beta abnormalities seen in both diseases. In this report, we describe a case of ARPC with lung fibrosis and propose an etiological association between the two diseases.

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.

Acquired perforating dermatosis: clinicopathological features in twenty-two cases

BACKGROUND

The term of acquired perforating dermatosis (APD) comprises the perforating dermatoses occurring in adult patients. Clinical and histological features of the disease are not uniform, and may resemble any of the four classic perforating disorders: elastosis perforans serpiginosa, reactive perforating collagenosis, perforating folliculitis or Kyrle's disease. Chronic renal failure and/or diabetes mellitus usually accompany this skin disease.

OBJECTIVE

The aim of this study was to delineate the clinical and histopathological features of acquired perforating dermatosis and to investigate the potential relationship between this disease and associated conditions.

METHODS

Twenty-two patients with acquired perforating dermatosis were enrolled in this study. Clinical findings of acquired perforating dermatosis and the spectrum of associated diseases were investigated. Haematoxylin and eosin sections were re-examined, and immunohistochemical stainings (elastic van Gieson and Masson trichrome stains) and periodic acid-Schiff stain were also used for histopathological evaluation.

RESULTS

Different clinical types of lesions resembling reactive perforating collagenosis, perforating folliculitis or Kyrle's disease were observed. Histopathological features were consistent with any of the four types of perforating dermatoses. Most of the patients (86.4%) had at least one systemic disease. Chronic renal failure (72.7%) and diabetes mellitus (50%) were the most commonly associated conditions. Most of the patients with diabetes mellitus (90.9%) had chronic renal failure due to diabetic nephropathy. All of the patients with chronic renal failure were on dialysis treatment. The other associated conditions were hepatitis (27.3%), anti-HCV Ab-positivity (13.6%), hypothyroidism (9.1%) and tuberculosis lymphadenitis (4.5%). Of the 22 patients, 13.6% were otherwise healthy, and 9.1% were renal transplant recipients.

CONCLUSION

Clinicopathological findings of our study indicate that the cases with APD represent the broad spectrum of perforating disorders rather than the variants of the same disease. Although APD is frequently associated with diabetes mellitus and chronic renal failure, this skin disorder may also develop in patients with other systemic disorders, and in those without any medical problems. This skin disease is probably linked to dialysis treatment in patients with chronic renal failure due to diabetes mellitus or other causes.

Perforating disorder caused by salt-water application and its experimental induction

BACKGROUND

Perforating disorders are uncommon diseases characterized by transepidermal elimination histopathologically and include reactive perforating collagenosis, elastosis perforans serpiginosa, Kyrle's disease and perforating folliculitis. In addition, perforating disorders can develop in patients with diabetes mellitus, renal failure and even by accidental exposure of calcium salts.

METHODS

We report two cases of perforating disorder caused by chemical burn with commercially available salt-water application for self-treatment of chronic dermatitis or pruritus.

RESULTS

The commercially used salt water for making bean curd was analyzed and it consisted of calcium and other salts without harmful heavy metals. We induced a similar phenomenon by experimental application of commercial salt water on guinea pigs.

CONCLUSION

Bean curd is used as a food commonly in the Far-East, allowing a greater chance of exposure to salt water accidentally or occupationally. Bean curd is becoming more popular even in Western countries. To confirm causation, we induced a similar phenomenon in guinea pigs by experimental application of commercial salt water.

Reactive perforating collagenosis: a condition that may be underdiagnosed

Reactive perforating collagenosis is a perforating disorder developing in adults, usually in association with diabetes mellitus or renal failure. We present three cases diagnosed at the Royal Prince Alfred Hospital in a 5 month period. All three patients had long-standing diabetes mellitus, hypertension, hypercholesterolaemia and ischaemic heart disease. Each patient presented with generalized pruritus and a papular eruption across the trunk and limbs. More than one biopsy or multiple levels were needed before the diagnostic histological features were seen. The first patient responded to 0.5% phenol with 10% glycerine in sorbolene cream. The second patient did not respond to topical betamethasone diproprionate 0.5 mg/g cream and antihistamines (hydroxyzine 25 mg nocte) and required narrow-band ultraviolet (UV) B. The third patient, having failed to respond to topical betamethasone diproprionate 0.5 mg/g cream and wet dressings, antihistamines (hydroxyzine 25 mg tds and doxepin 50 mg nocte) and UVB required acitretin 25 mg orally per day. Because reactive perforating collagenosis responds to treatment, we believe this condition should be considered in patients with diabetes mellitus or renal failure presenting with pruritus and that biopsy of intact lesions may need multiple levels to help establish the diagnosis.

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.

Acquired reactive perforating collagenosis with IgA nephropathy

A 25-year-old Japanese man developed numerous discrete umbilicated papules on his face, trunk, and both forearms at the onset of IgA nephropathy. The newest lesion was a nonumbilicated skin-colored papule. On histopathologic examination, alteration of capillaries was observed in both newer and umbilicated papules. In our case, a primary cause of the reactive perforating collagenosis could be an alteration of the capillaries.

Acquired perforating dermatosis in a British dialysis population

A perforating disorder of the skin developing in association with chronic renal failure and often also diabetes, acquired perforating dermatosis (APD), affects up to 10% of patients receiving maintenance haemodialysis in North America. The prevalence of this condition in British dialysis patients has not yet been ascertained. We have undertaken a skin survey of our dialysis population (n = 80) to determine the prevalence and clinical presentation of APD, with subsequent assessment of disease management and outcome. Of 72 patients who participated in the survey, eight were found to have APD, seven of whom were also diabetic. Skin lesions had developed pre-dialysis in two patients, on commencement of dialysis in one, and after 1-3 years on dialysis in the remaining five. Patients typically presented with pruritic dome-shaped papules with central crusts arising on the trunk and extensor limb surfaces. Histological examination of biopsy specimens revealed two types of lesion, typified by either narrow or broad ulcer craters, each showing perforation of both collagen and elastic fibres. Topical/intradermal steroid or topical retinoid were effective therapies in certain of our patients. Clinical clearance was achieved after 3-12 months of treatment in five patients with improvement in the remaining two patients who received treatment. Of the four patients who were alive at 2-year review, three remained clear, while one patient continued to develop new lesions. We report an 11% prevalence of APD in our dialysis population, suggesting the disorder to be as prevalent in patients with chronic renal failure in Britain as in North America. An association of the disorder with long-standing diabetes was confirmed.

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 perforating dermatosis of diabetes mellitus and renal failure: further ultrastructural clues to its pathogenesis

An ultrastructural study of a typical case of acquired perforating dermatosis in a patient with renal failure and diabetes mellitus is reported. Crystal-like microdeposits of an electron-lucid material were detected in the upper dermis, close to the transepidermal channel. Compact macrophage conglomerations surrounded the deposits, and a strong histiocytic response was present. Mononuclear inflammatory cells of "activated" type penetrated the acanthotic epidermis provoking basement membrane dissolution and widening of interkeratinocyte spaces. Collagen fibers were seen in the keratotic plug, indicating the process of transepidermal elimination. Our observation supports the hypothesis suggesting that some kind of storage phenomenon may be at the origin of perforating skin lesions in renal failure patients.

Ultrastructural changes in acquired perforating dermatosis

We performed ultrastructural studies of skin lesions in seven adults with acquired perforating dermatosis. Three of the patients had diabetes mellitus and two were undergoing hemodialysis. Lesions in an early stage showed exocytosis of inflammatory cells and alteration of elastic fibers. Lesions in an intermediate stage featured discontinuities of the basement membrane and aggregates of electron-dense material lateral to the perforated focus, together with dermal edema, scattered macrophages, and densely aggregated collagen fibers that focally filled the papillary dermis. Later-stage lesions showed fibroblasts in the dermis and degenerated elastic fibers within transepidermal channels. In most cases there was a single large epidermal channel lined by flattened epithelial cells, and containing a variety of cellular and extracellular materials. Small "secondary" channels without abnormal keratinization were also observed within the epidermis. The findings suggest that altered keratinization is limited to the immediate vicinity of well-formed transepidermal channels, and that exocytosis of inflammatory cells and alterations of elastica are early and possibly key changes in lesion development. The unexpected discovery of hair fragments in one case suggests that curled hairs may play a role in the pathogenesis of some cases of acquired perforating dermatosis.

Acquired perforating dermatosis: comparison of an acquired perforating dermatosis and perforation as an incidental histologic finding

A 66-year-old Japanese woman with a rare acquired perforating disorder, usually called adult-type reactive perforating collagenosis, is reported. The patient had poorly controlled diabetes mellitus with retinopathy under oral diabetic medication. She was found to have multiple papules and umbilicated nodules on the trunk and four extremities when she was admitted and examined for the origin of jaundice and severe pruritus of sudden onset. In the biopsy specimen, collagen fibers were observed to be eliminated from the dermis through epidermal tunnel-like perforations. No elastic fibers were eliminated, and serial sectioning of the specimen could not prove follicular perforation. Adenocarcinoma of the biliary duct was found to be the cause of the jaundice with pruritus. Although such cases are usually classified as acquired reactive perforating collagenosis of adult onset, proposed reclassification for acquired perforating disorders is discussed. Another case which also showed perforation and transepithelial elimination of both collagen and elastic fibers as an incidental histologic finding is described. Such elimination seems to be a not uncommon step in the formation of pruriginous eruptions. Therefore, these cases should be differentiated from acquired-type characteristic perforating disorders.