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This disorder is characterized by a reduction and loss of subcutaneous fat and collagen of the hands and feet, above all. It can be defined it as a mild, nonprogressive, congenital form of premature skin senility due to the disappearance of the fatty tissue directly under the skin.
More precisely, skin lesions deal with large, fixed, geographic and symmetrical fine scaly recessive erythematous plaques distributed over the dorsal side of distal extremities. Skin lesions can be associated with osteoarticular alterations.
Other outcomes and observations may include abnormally small hands and feet with unusually prominent veins on the upper trunk (chest), short stature, and, sometimes, abnormally small jaw (micrognathia). Most of the cases analyzed show atrophy of the skin at the tip of the nose, which gives a sculptural appearance.The nails may be dystrophic or thick, but, most of the time, they are normal.
In the skin histopathology, there is atrophy of the dermis and subcutaneum. The collagen fibers are loose and dispersed, and the elastic fibers are always fragmented.
However, the epidermis is not affected.
Although some patients present clinical features similar to those of progeria and metageria, they do not usually show generalized atherosclerosis. Therefore, they do not usually have premature myocardic or coronary disease.
Acrogeria (also known as Gottron's syndrome) is a cutaneous condition characterized by premature aging, more especially in the form of unusually fragile, thin skin on the hands and feet (distal extremities). The prefix "acro" stems from the Greek "akros" which alludes to "extremity, tip" while the suffix "geria" comes from the Greek "gerôn" which means "elder".
This is one of the classic congenital premature aging syndromes, occurring early in life, among which are: pangeria (Werner's syndrome), progeria (Hutchinson–Gilford's syndrome) and acrogeria (Gottron's syndrome) and was characterized in 1940. Onset is in early childhood, it progresses over the next few years and then remains stable over time with morphology, colour and site remaining constant. A bruising tendency has been observed.
It is believed that Gottron syndrome may affect more females than males. Approximately forty cases have been reported in the medical literature, since the discovery of the disorder.
As of 2017 there are 13 types of Ehlers-Danlos syndromes, with a significant overlap in features.
Hypermobile EDS - characterized primarily by joint hypermobility affecting both large and small joints, which may lead to recurrent joint dislocations and subluxations (partial dislocation). In general, people with this type have soft, smooth and velvety skin with easy bruising and chronic pain of the muscles and/or bones.
Classical EDS - associated with extremely elastic (stretchy), smooth skin that is fragile and bruises easily; wide, atrophic scars (flat or depressed scars); and joint hypermobility. Molluscoid pseudotumors (calcified hematomas over pressure points such as the elbow) and spheroids (fat-containing cysts on forearms and shins) are also frequently seen. Hypotonia and delayed motor development may occur.
Vascular EDS - characterized by thin, translucent skin that is extremely fragile and bruises easily. Arteries and certain organs such as the intestines and uterus are also fragile and prone to rupture. People with this type typically have short stature; thin scalp hair; and characteristic facial features including large eyes, a thin nose, and lobeless ears. Joint hypermobility is present, but generally confined to the small joints (fingers, toes). Other common features include club foot; tendon and/or muscle rupture; acrogeria (premature aging of the skin of the hands and feet); early onset varicose veins; pneumothorax (collapse of a lung); recession of the gums; and a decreased amount of fat under the skin.
Kyphoscoliosis EDS - associated with severe hypotonia at birth, delayed motor development, progressive scoliosis (present from birth), and scleral fragility. Affected people may also have easy bruising; fragile arteries that are prone to rupture; unusually small corneas; and osteopenia (low bone density). Other common features include a "marfanoid habitus" which is characterized by long, slender fingers (arachnodactyly); unusually long limbs; and a sunken chest (pectus excavatum) or protruding chest (pectus carinatum).
Arthrochalasia EDS - characterized by severe joint hypermobility and congenital hip dislocation. Other common features include fragile, elastic skin with easy bruising; hypotonia; kyphoscoliosis (kyphosis and scoliosis); and mild osteopenia.
Dermatosparaxis EDS - associated with extremely fragile skin leading to severe bruising and scarring; saggy, redundant skin, especially on the face; and hernias.
Brittle Cornea Syndrome (BCS) characterized by thin cornea, early onset progressive keratoglobus; and blue sclerae.
Classical-like EDS (clEDS) characterized by skin hyperextensibility with velvety skin texture and absence of atrophic scarring, generalized joint hypermobility (GJH) with or without recurrent dislocations (most often shoulder and ankle), and easily bruised skin or spontaneous ecchymoses (discolorations of the skin resulting from bleeding underneath).
Spondylodysplastic EDS (spEDS) characterized by short stature (progressive in childhood), muscle hypotonia (ranging from severe congenital, to mild later-onset), and bowing of limbs.
Musculocontractural EDS (mcEDS) characterized by congenital multiple contractures, characteristically adduction-flexion contractures and/or talipes equinovarus (clubfoot), characteristic craniofacial features, which are evident at birth or in early infancy, and skin features such as skin hyperextensibility, easy bruisability, skin fragility with atrophic scars, increased palmar wrinkling.
Myopathic EDS (mEDS) characterized by congenital muscle hypotonia, and/or muscle atrophy, that improves with age, Proximal joint contractures (joints of the knee, hip and elbow); and hypermobility of distal joints (joints of the ankles, wrists, feet and hands).
Periodontal EDS (pEDS) characterized by severe and intractable periodontitis of early onset (childhood or adolescence), lack of attached gingiva, pretibial plaques; and family history of a first-degree relative who meets clinical criteria.
Cardiac-valvular EDS (cvEDS) characterized by severe progressive cardiac-valvular problems (aortic valve, mitral valve), skin problems (hyperextensibility, atrophic scars, thin skin, easy bruising) and joint hypermobility (generalized or restricted to small joints).
There are several disorders that share some characteristics with Ehlers–Danlos syndrome. For example, in cutis laxa the skin is loose, hanging, and wrinkled. In EDS, the skin can be pulled away from the body but is elastic and returns to normal when let go. In Marfan syndrome, the joints are very mobile and similar cardiovascular complications occur. People with EDS tend to have a "Marfanoid" appearance (e.g., tall, skinny, long arms and legs, "spidery" fingers). However, physical appearance and features in several types of Ehlers–Danlos syndrome also have characteristics including short stature, large eyes, and the appearance of a small mouth and chin, due to a small palate. The palate can have a high arch, causing dental crowding. Blood vessels can sometimes be easily seen through translucent skin, especially on the chest. The genetic connective tissue disorder, Loeys-Dietz Syndrome, also has symptoms that overlap with EDS.
In the past, Menkes disease, a copper metabolism disorder, was thought to be a form of Ehlers–Danlos syndrome. It is not uncommon for patients to be misdiagnosed with fibromyalgia, bleeding disorders or other disorders that can mimic EDS symptoms before a correct diagnosis is made. Because of these similar disorders and complications that can arise from an un-monitored case of EDS, a correct diagnosis is very important. Pseudoxanthoma elasticum (PXE) is worth consideration in diagnosing a patient.
Many conditions affect the human integumentary system—the organ system covering the entire surface of the body and composed of skin, hair, nails, and related muscle and glands. The major function of this system is as a barrier against the external environment. The skin weighs an average of four kilograms, covers an area of two square meters, and is made of three distinct layers: the epidermis, dermis, and subcutaneous tissue. The two main types of human skin are: glabrous skin, the hairless skin on the palms and soles (also referred to as the "palmoplantar" surfaces), and hair-bearing skin. Within the latter type, the hairs occur in structures called pilosebaceous units, each with hair follicle, sebaceous gland, and associated arrector pili muscle. In the embryo, the epidermis, hair, and glands form from the ectoderm, which is chemically influenced by the underlying mesoderm that forms the dermis and subcutaneous tissues.
The epidermis is the most superficial layer of skin, a squamous epithelium with several strata: the stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum basale. Nourishment is provided to these layers by diffusion from the dermis, since the epidermis is without direct blood supply. The epidermis contains four cell types: keratinocytes, melanocytes, Langerhans cells, and Merkel cells. Of these, keratinocytes are the major component, constituting roughly 95 percent of the epidermis. This stratified squamous epithelium is maintained by cell division within the stratum basale, in which differentiating cells slowly displace outwards through the stratum spinosum to the stratum corneum, where cells are continually shed from the surface. In normal skin, the rate of production equals the rate of loss; about two weeks are needed for a cell to migrate from the basal cell layer to the top of the granular cell layer, and an additional two weeks to cross the stratum corneum.
The dermis is the layer of skin between the epidermis and subcutaneous tissue, and comprises two sections, the papillary dermis and the reticular dermis. The superficial papillary dermis with the overlying rete ridges of the epidermis, between which the two layers interact through the basement membrane zone. Structural components of the dermis are collagen, elastic fibers, and ground substance. Within these components are the pilosebaceous units, arrector pili muscles, and the eccrine and apocrine glands. The dermis contains two vascular networks that run parallel to the skin surface—one superficial and one deep plexus—which are connected by vertical communicating vessels. The function of blood vessels within the dermis is fourfold: to supply nutrition, to regulate temperature, to modulate inflammation, and to participate in wound healing.
The subcutaneous tissue is a layer of fat between the dermis and underlying fascia. This tissue may be further divided into two components, the actual fatty layer, or panniculus adiposus, and a deeper vestigial layer of muscle, the panniculus carnosus. The main cellular component of this tissue is the adipocyte, or fat cell. The structure of this tissue is composed of septal (i.e. linear strands) and lobular compartments, which differ in microscopic appearance. Functionally, the subcutaneous fat insulates the body, absorbs trauma, and serves as a reserve energy source.
Conditions of the human integumentary system constitute a broad spectrum of diseases, also known as dermatoses, as well as many nonpathologic states (like, in certain circumstances, melanonychia and racquet nails). While only a small number of skin diseases account for most visits to the physician, thousands of skin conditions have been described. Classification of these conditions often presents many nosological challenges, since underlying etiologies and pathogenetics are often not known. Therefore, most current textbooks present a classification based on location (for example, conditions of the mucous membrane), morphology (chronic blistering conditions), etiology (skin conditions resulting from physical factors), and so on. Clinically, the diagnosis of any particular skin condition is made by gathering pertinent information regarding the presenting skin lesion(s), including the location (such as arms, head, legs), symptoms (pruritus, pain), duration (acute or chronic), arrangement (solitary, generalized, annular, linear), morphology (macules, papules, vesicles), and color (red, blue, brown, black, white, yellow). Diagnosis of many conditions often also requires a skin biopsy which yields histologic information that can be correlated with the clinical presentation and any laboratory data.
Palmoplantar keratodermas are a diverse group of hereditary and acquired keratodermas in which there is hyperkeratosis of the skin of the palms and soles.
- Acrokeratoelastoidosis of Costa (keratoelastoidosis marginalis)
- Aquagenic keratoderma (acquired aquagenic palmoplantar keratoderma, aquagenic syringeal acrokeratoderma, aquagenic wrinkling of the palms, transient reactive papulotranslucent acrokeratoderma)
- Bart–Pumphrey syndrome (palmoplantar keratoderma with knuckle pads and leukonychia and deafness)
- Camisa disease
- Carvajal syndrome (striate palmoplantar keratoderma with woolly hair and cardiomyopathy, striate palmoplantar keratoderma with woolly hair and left ventricular dilated cardiomyopathy)
- Corneodermatoosseous syndrome (CDO syndrome)
- Diffuse epidermolytic palmoplantar keratoderma (palmoplantar keratoderma cum degeneratione granulosa Vörner, Vörner's epidermolytic palmoplantar keratoderma, Vörner keratoderma)
- Diffuse nonepidermolytic palmoplantar keratoderma (diffuse orthohyperkeratotic keratoderma, hereditary palmoplantar keratoderma, keratosis extremitatum progrediens, keratosis palmoplantaris diffusa circumscripta, tylosis, Unna–Thost disease, Unna–Thost keratoderma)
- Erythrokeratodermia variabilis (erythrokeratodermia figurata variabilis, keratosis extremitatum progrediens, keratosis palmoplantaris transgrediens et progrediens, Mendes da Costa syndrome, Mendes da Costa type erythrokeratodermia, progressive symmetric erythrokeratoderma)
- Focal acral hyperkeratosis (acrokeratoelastoidosis lichenoides, degenerative collagenous plaques of the hand)
- Focal palmoplantar and gingival keratosis
- Focal palmoplantar keratoderma with oral mucosal hyperkeratosis (focal epidermolytic palmoplantar keratoderma, hereditary painful callosities, hereditary painful callosity syndrome, keratosis follicularis, keratosis palmoplantaris nummularis, nummular epidermolytic palmoplantar keratoderma)
- Haim–Munk syndrome (palmoplantar keratoderma with periodontitis and arachnodactyly and acro-osteolysis)
- Hidrotic ectodermal dysplasia (alopecia congenita with keratosis palmoplantaris, Clouston syndrome, Clouston's hidrotic ectodermal dysplasia, Fischer–Jacobsen–Clouston syndrome, keratosis palmaris with drumstick fingers, palmoplantar keratoderma and clubbing)
- Howel–Evans syndrome (familial keratoderma with carcinoma of the esophagus, focal non-epidermolytic palmoplantar keratoderma with carcinoma of the esophagus, palmoplantar ectodermal dysplasia type III, palmoplantar keratoderma associated with esophageal cancer, tylosis, tylosis–esophageal carcinoma)
- Hystrix-like ichthyosis–deafness syndrome (HID syndrome)
- Keratoderma climactericum (acquired plantar keratoderma, climacteric keratoderma, Haxthausen's disease)
- Keratosis punctata palmaris et plantaris (Buschke–Fischer–Brauer disease, Davis Colley disease, keratoderma disseminatum palmaris et plantaris, keratosis papulosa, keratoderma punctatum, keratodermia punctata, keratoma hereditarium dissipatum palmare et plantare, palmar and plantar seed dermatoses, palmar keratoses, papulotranslucent acrokeratoderma, punctate keratoderma, punctate keratoses of the palms and soles, maculosa disseminata)
- Keratitis–ichthyosis–deafness syndrome (erythrokeratodermia progressiva Burns, ichthyosiform erythroderma with corneal involvement and deafness, KID syndrome)
- Mal de Meleda (acral keratoderma, Gamborg–Nielsen keratoderma, mutilating palmoplantar keratoderma of the Gamborg–Nielsen type, palmoplantar ectodermal dysplasia type VIII, palmoplantar keratoderma of the Norrbotten type)
- Naxos syndrome (diffuse non-epidermolytic palmoplantar keratoderma with woolly hair and cardiomyopathy, diffuse palmoplantar keratoderma with woolly hair and arrythmogenic right ventricular cardiomyopathy of Naxos, Naxos disease)
- Olmsted syndrome (mutilating palmoplantar keratoderma with periorificial keratotic plaques, mutilating palmoplantar keratoderma with periorificial plaques, polykeratosis of Touraine)
- Pachyonychia congenita type I (Jadassohn–Lewandowsky syndrome)
- Pachyonychia congenita type II (Jackson–Lawler pachyonychia congenita, Jackson–Sertoli syndrome)
- Palmoplantar keratoderma and spastic paraplegia (Charcot–Marie–Tooth disease with palmoplantar keratoderma and nail dystrophy)
- Palmoplantar keratoderma of Sybert (Greither palmoplantar keratoderma, Greither syndrome, keratosis extremitatum hereditaria progrediens, keratosis palmoplantaris transgrediens et progrediens, Sybert keratoderma, transgrediens and progrediens palmoplantar keratoderma)
- Papillon–Lefèvre syndrome (palmoplantar keratoderma with periodontitis)
- Porokeratosis plantaris discreta
- Punctate palmoplantar keratoderma
- Schöpf–Schulz–Passarge syndrome (eyelid cysts with palmoplantar keratoderma and hypodontia and hypotrichosis)
- Scleroatrophic syndrome of Huriez (Huriez syndrome, palmoplantar keratoderma with scleroatrophy, palmoplantar keratoderma with sclerodactyly, scleroatrophic and keratotic dermatosis of the limbs, sclerotylosis)
- Striate palmoplantar keratoderma (acral keratoderma, Brünauer–Fuhs–Siemens type of palmoplantar keratoderma, focal non-epidermolytic palmoplantar keratoderma, keratosis palmoplantaris varians, palmoplantar keratoderma areata, palmoplantar keratoderma striata, Wachter keratoderma, Wachters palmoplantar keratoderma)
- Spiny keratoderma (porokeratosis punctata palmaris et plantaris, punctate keratoderma, punctate porokeratosis of the palms and soles)
- Tyrosinemia type II (oculocutaneous tyrosinemia, Richner–Hanhart syndrome)
- Vohwinkel syndrome (keratoderma hereditaria mutilans, keratoma hereditaria mutilans, mutilating keratoderma of Vohwinkel, mutilating palmoplantar keratoderma)