Pseudoxanthoma elasticum papillary dermal elastolysis: a case report

Papillary dermal elastolysis histopathology mimicking folliculotropic mycosis fungoides

Papillary dermal elastolysis is a rare acquired disease of the elastic tissue that mainly affects elderly women with a clinical presentation of small firm papules in the neck, the supraclavicular areas and the upper back. Histopathologically, it is characteristic to find a complete or almost complete absence of elastic fibers in the papillary dermis with stains such as orcein or Verhoeff-Van Gieson. We present the case of an adult female patient presenting a clinical picture of years of evolution of elastic skin-colored papules on her neck, occasionally pruritic. Two biopsies were performed. In one of them an inflammatory infiltrate affecting the hair follicles was observed, and she was diagnosed with mycosis fungoides. The other biopsy showed a total absence of elastic fibers in the papillary dermis and was diagnosed as elastolysis of the papillary dermis. In early stages of papillary dermal elastolysis, a perivascular and periadnexal lymphocytic inflammatory infiltrate has been described, as is the case described above. It is important for dermatopathologist to know this atypical but possible presentation, as it may require a differential diagnosis with other entities such as follicular mycosis fungoides.

The anti-wrinkles properties of sodium acetylated hyaluronate

BACKGROUND

Intrinsic aging promotes wrinkles formation by an imbalance between matrix synthesis/degradation in favor of degradation. This is accelerated by the exposome leading to overproduction of protease and fewer remodeling.

OBJECTIVE

Protecting the integrity of extracellular matrix appears as the most efficient anti-aging solution. We developed a grafted HA specifically designed to get anti-aging property due to a specific molecular weight and acetylation degree.

METHODS

A transcriptomic analysis was performed on fibroblasts, followed by a measurement of MMP secretion and subsequent effect on collagen degradation. MMP expression in skin explants concerned by chronobiological and extrinsic aging was analyzed by immunostaining. A clinical study was conducted on volunteers presenting wrinkles on face to evaluate flash reduction of wrinkles after 6 h of application by profilometry and anti-aging efficacy after 2 months by VISIA^® CR2.3.

RESULTS

Transcriptomic analysis evidenced an inhibition of MMP gene expression with acetylated HA, confirmed by an inhibition of MMPs release by fibroblasts, and a protection of type I collagen against degradation. We confirmed the reduction of MMPs in mature skin and in skin explants exposed to UV and urban dust. We demonstrated during clinical studies the flash reduction effect of acetylated HA on crow's feet wrinkles and a filling of nasogenian areas 6 h after application, and a wrinkles number reduction on nasogenian area up to 2 months of application.

CONCLUSION

We developed a new grafted HA owing protective properties against ECM degradation induced by chronobiological and extrinsic aging, leading to a significant and efficient anti-wrinkles effect.

Elastic fibers: formation, function, and fate during aging and disease

Elastic fibers are extracellular components of higher vertebrates and confer elasticity and resilience to numerous tissues and organs such as large blood vessels, lungs, and skin. Their formation and maturation take place in a complex multistage process called elastogenesis. It requires interactions between very different proteins but also other molecules and leads to the deposition and crosslinking of elastin's precursor on a scaffold of fibrillin-rich microfibrils. Mature fibers are exceptionally resistant to most influences and, under healthy conditions, retain their biomechanical function over the life of the organism. However, due to their longevity, they accumulate damages during aging. These are caused by proteolytic degradation, formation of advanced glycation end products, calcification, oxidative damage, aspartic acid racemization, lipid accumulation, carbamylation, and mechanical fatigue. The resulting changes can lead to diminution or complete loss of elastic fiber function and ultimately affect morbidity and mortality. Particularly, the production of elastokines has been clearly shown to influence several life-threatening diseases. Moreover, the structure, distribution, and abundance of elastic fibers are directly or indirectly influenced by a variety of inherited pathological conditions, which mainly affect organs and tissues such as skin, lungs, or the cardiovascular system. A distinction can be made between microfibril-related inherited diseases that are the result of mutations in diverse microfibril genes and indirectly affect elastogenesis, and elastinopathies that are linked to changes in the elastin gene. This review gives an overview on the formation, structure, and function of elastic fibers and their fate over the human lifespan in health and disease.

Mannose-6-phosphate complex and improvement in biomechanical properties of the skin

BACKGROUND

The dermis is composed of a tangle of macromolecules that provides the skin its biomechanical properties. During chronological aging, fibroblasts lose their ability to synthesize collagen and an accumulation of matrix metalloproteinases leads to an increase in collagen degradation. As a result, there is a decline in the biomechanical properties of the skin. Skin aging is accelerated by external factors such as UV radiation and pollution, which induce accumulation of oxidants, and so of oxidized proteins in the skin.

AIMS

Atomic force microscopy (AFM) has emerged as an alternative method for studying the biomechanical properties of skin cells and tissues.

METHODS/RESULTS

Thus, we identified mannose-6-phosphate complex as a new powerful molecule capable of reversing the visible signs of aging by reorganizing the collagen network of the dermis and by improving the skin biomechanical properties. This effect was correlated with clinical studies that showed a marked antiaging effect through a reduction in the number of crow's feet and in the depth and size of neck wrinkles.

CONCLUSION

Mannose-6-phosphate complex appeared to be able to protect proteins in the dermis scaffold against oxidation and degradation, allowing an improvement in the skin biomechanical properties.

Pseudoxanthoma elasticum-like papillary dermal elastolysis: A mimicker of genetic pseudoxanthoma elasticum

Pseudoxanthoma elasticum (PXE)-like papillary dermal elastolysis (PDE) is an acquired, rare, elastic tissue disorder that presents with multiple asymptomatic, nonfollicular yellowish or normochromic papules, coalescing into symmetrical cobblestone plaques, with a predilection for the neck of postmenopausal women. The condition develops slowly, in months to years, and, although clinically similar to PXE, it is devoid of any systemic implication, being only of esthetic concern. The etiology is unknown, but it is speculated that there is a multifactorial pathogenesis, with the contribution of intrinsic aging, exposure to ultraviolet radiation, abnormal elastogenesis, and genetic factors. The diagnosis is confirmed by histopathology, with special stains specific for elastic fibers revealing loss of elastic plexus in the papillary dermis and the presence of melanophages. Its prevalence is probably underestimated, which reinforces the importance of better clinical and histologic identification to distinguish it from inherited PXE and to avoid extensive systemic investigations and unnecessary medical visits for the patient.

Pseudoxanthoma elasticum and skin: Clinical manifestations, histopathology, pathomechanism, perspectives of treatment

Pseudoxantoma elasticum (PXE), also known as Groenblad-Strandberg syndrome, is a rare heritable disease with an estimated prevalence of 1:50,000 in the general population. PXE is considered a prototype of multisystem ectopic mineralization disorders and it is characterized by aberrant mineralization of soft connective tissue with degeneration of the elastic fibers, involving primarily the eyes, the cardiovascular system, and the skin. Cutaneous lesions consist of small, asymptomatic, yellowish papules or larger coalescent plaques, typically located on the neck and the flexural areas. PXE is caused by mutations in the ABCC6 (ATP-binding cassette subfamily C member 6) gene that encodes a transmembrane ATP binding efflux transporter, normally expressed in the liver and the kidney; however, the exact mechanism of ectopic mineralization remains largely unknown. The histological examination of cutaneous lesions, revealing accumulation of pleomorphic elastic structures in middermis, is essential for the definitive diagnosis of PXE, excluding PXE-like conditions. PXE is currently an intractable disease; although the cutaneous findings primarily present a cosmetic problem, they signify the risk for development of ocular and cardiovascular complications associated with considerable morbidity and mortality. The purpose of this review is to present a comprehensive overview of this rare form of hereditary connective tissue disorders, focus on the pathogenesis, the clinical manifestation, and the differential diagnosis of PXE. Emphasis is also placed on the management of cutaneous lesions and treatment perspectives of PXE.

Elastic fibres in health and disease

Elastic fibres are insoluble components of the extracellular matrix of dynamic connective tissues such as skin, arteries, lungs and ligaments. They are laid down during development, and comprise a cross-linked elastin core within a template of fibrillin-based microfibrils. Their function is to endow tissues with the property of elastic recoil, and they also regulate the bioavailability of transforming growth factor β. Severe heritable elastic fibre diseases are caused by mutations in elastic fibre components; for example, mutations in elastin cause supravalvular aortic stenosis and autosomal dominant cutis laxa, mutations in fibrillin-1 cause Marfan syndrome and Weill–Marchesani syndrome, and mutations in fibulins-4 and -5 cause autosomal recessive cutis laxa. Acquired elastic fibre defects include dermal elastosis, whereas inflammatory damage to fibres contributes to pathologies such as pulmonary emphysema and vascular disease. This review outlines the latest understanding of the composition and assembly of elastic fibres, and describes elastic fibre diseases and current therapeutic approaches.

Linear Lumbar Localized Lysis of Elastic Fibers: A Distinctive Clinical Presentation of Mid-dermal Elastolysis

BACKGROUND

The absence or loss of elastic fibers in the skin is referred to as dermal elastolysis.

PURPOSE

This paper describes a woman with a distinctive clinical presentation of mid-dermal elastolysis characterized morphologically by multiple horizontal raised bands on the lower back.

METHODS

A 20-year-old Filipino woman presented with multiple asymptomatic, flesh-colored, raised, firm, linear, cord-like bands on the lumbar area of her back. There were neither similar lesions elsewhere nor a family member with this condition.

RESULTS

Microscopic examination of the raised band showed nearly complete absence of elastic fibers in the mid dermis. In contrast, a biopsy of symmetrically located normal-appearing skin showed a uniform distribution of elastic fibers throughout the dermis. Linear lumbar localized elastolysis is a descriptive designation that accurately reflects a correlation of the clinical and pathological changes of this condition.

CONCLUSION

The clinical differential of raised horizontal cord-like bands on the lower back (without a family history of an inherited elastic fiber disorder, a prior history of trauma, or a significant change in weight or exercise habit) includes linear focal elastosis and linear lumbar localized elastolysis. Microscopic evaluation of a Verhoeff-van Gieson stained lesion specimen (which may be accompanied by a biopsy of normal-appearing skin for comparison) will readily differentiate these conditions. The former is usually characterized by increased elastic fibers, whereas the latter, as in this patient, shows a paucity or absence of elastic fibers in the mid dermis.

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.