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Harlequin Ichthyosis Clinical Presentation

  • Author: Julie Prendiville, MBBCh; Chief Editor: Dirk M Elston, MD  more...
Updated: Jun 03, 2016


Harlequin ichthyosis manifests at birth. Harlequin ichthyosis may or may not have been diagnosed prenatally in a high-risk family. The history should explore the following questions:

  • Are the parents consanguineous?
  • Have they had a previous child with ichthyosis?
  • Does the family have a history of severe skin disorders?
  • Do the parents or family members have a history of intrauterine or neonatal death?
  • What was the expected date of delivery?
  • Were decreased fetal movements or intrauterine growth retardation noted during the pregnancy?
  • Did the mother undergo prenatal ultrasonography?
  • Were prenatal procedures (eg, amniocentesis, chorionic villus sampling) performed?


The following findings may be noted on physical examination in the newborn period:

  • Skin: Severely thickened skin with large, shiny plates of hyperkeratotic scale is present at birth. Deep, erythematous fissures separate the scales.
  • Eyes: Severe ectropion is present. The free edges of the upper and lower eyelids are everted, leaving the conjunctivae and cornea at risk for desiccation and trauma.
  • Ears: The ears are flattened with absent retroauricular folds. The pinnae may be small and rudimentary or absent. The external auditory canal may be obstructed by scale.
  • Lips: Severe traction on the lips causes eclabium and a fixed, open mouth. This may result in feeding difficulties.
  • Nose: Nasal hypoplasia and eroded nasal alae may occur. The nares can be obstructed.
  • Extremities: The limbs are encased in the thick, hyperkeratotic skin, resulting in flexion contractures of the arms, the legs, and the digits. Limb mobility is poor to absent. Circumferential constriction of a limb or digit can occur, leading to distal swelling, ischemic necrosis and autoamputation. Hypoplasia of the fingers, toes, and fingernails is reported. Polydactyly is described.
  • Temperature dysregulation: Thickened skin prevents normal sweat gland function and heat loss. The infant is heat intolerant and can become hyperthermic.
  • Respiratory status: Restriction of chest-wall expansion can result in respiratory distress, hypoventilation, and respiratory failure.
  • Hydration status: Dehydration from excess water loss can cause tachycardia and poor urine output.
  • Central nervous system: Metabolic abnormalities can cause seizures. CNS depression can be a sign of sepsis or hypoxia. Hyperkeratosis may restrict spontaneous movements, making neurologic assessment difficult.


Genetic factors

Mutations in ABCA12, a gene that encodes adenosine triphosphate (ATP)-binding cassette transporter (ABC), subfamily A, member 12, in chromosome region 2q35, underlie this disorder.[6, 7] Patients with harlequin ichthyosis usually have functional null mutations in the ABCA12 gene. The mutations may be homozygous or compound heterozygous.[3] Missense mutations in ABCA12 result in milder autosomal recessive congenital ichthyosis phenotypes such as lamellar ichthyosis and congenital ichthyosiform erythroderma.[1, 7, 8]

The ABC superfamily of genes encodes proteins that transport a number of substrates across cell membranes.[8] ABCA12 encodes a transmembrane protein that mediates lipid transport.

This ABCA12 -mediated lipid-transfer system is essential to the transfer of lipids from the cytosol of the corneocyte into lamellar granules. Lamellar granules are intracellular granules that originate from the Golgi apparatus of keratinocytes in the stratum corneum. These granules are responsible for secreting lipids that maintain the skin barrier at the interface between the granular cell layer and the cornified layer in the upper epidermis. The extruded lipids are arranged into lamellae in the intercellular space with the help of concomitantly released hydrolytic enzymes. The lamellae form the skin's hydrophobic sphingolipid seal.

In harlequin ichthyosis, the ABCA12 -mediated transfer of lipid to lamellar granules is defective. The lamellar granules themselves are morphologically abnormal or absent. Normal extrusion of lipid from these granules into the extracellular space cannot occur, and lipid lamellae are not formed. This defective lipid "mortar" between corneocyte "bricks" results in aberrant skin permeability and lack of normal corneocyte desquamation.[9, 10, 11]

In vitro studies have demonstrated normalization of lipid transport when the wild-type ABCA12 gene is transferred to keratinocytes of patients with harlequin ichthyosis.[12]

One patient with a de novo deletion of chromosome arm 18q has been reported.[13]

Histopathologic, ultrastructural, and biochemical factors

Histopathologic, ultrastructural, and biochemical studies have identified several characteristic abnormalities in the skin of patients with harlequin ichthyosis.

The two main abnormalities involve lamellar granules and the structural proteins of the cell cytoskeleton. The relationship between mutations in the gene ABCA12 and abnormal lamellar granules is well documented. The pathophysiology of the other abnormalities documented below has yet to be elucidated.

Abnormal lamellar granule structure and function

The pivotal role of lamellar granules in maintaining a normal skin barrier is described in the Genetic factors bullet points at the beginning of this section.

All patients with harlequin ichthyosis have absent or defective lamellar granules and no extracellular lipid lamellae. Cultured epidermal keratinocytes from patients that carry ABCA12 mutations have demonstrated disturbed intracytoplasmic glucosylceramide transport.[8, 12] The lipid abnormality is believed to allow excessive transepidermal water loss. Lack of released lamellar granule enzymes prevents desquamation, resulting in a severe retention hyperkeratosis.

Abnormal conversion of profilaggrin to filaggrin

Profilaggrin is a phosphorylated polyprotein residing in keratohyalin granules in keratinocytes in the granular cell layer. During the evolution to the corneal layer, profilaggrin converts to filaggrin by means of dephosphorylation. Filaggrin allows dense packing of keratin filaments. Its subsequent breakdown into amino acids occurs prior to desquamation of the stratum corneum.

Some patients have a persistence of profilaggrin and an absence of filaggrin in the stratum corneum. A defect in protein phosphatase activity and subsequent lack of conversion of profilaggrin to filaggrin is hypothesized.[8]

Abnormal expression of keratin

Disturbed keratinocyte differentiation during fetal development is believed to play an important role in the pathogenesis of the harlequin ichthyosis phenotype at birth.[8] In utero studies have shown that expression of markers of late keratinocyte differentiation is highly dysregulated, suggesting a role for ABCA12 in keratinocyte differentiation.[14] Expression of the proteases kallikrein 5 and cathepsin D, which are required for normal desquamation, was found to be dramatically reduced.[14]

Keratin filament density is low in most patients. Expression of certain keratins is abnormal in some patients and normal in others. How this altered expression of structural proteins influences desquamation is uncertain.

Abnormal keratohyalin granules

Keratohyalin granules are identified by antifilaggrin antibodies and can be abnormal in some patients with harlequin ichthyosis. They can be large and stellate, small and rounded, or absent.

Contributor Information and Disclosures

Julie Prendiville, MBBCh Clinical Professor in Pediatrics, University of British Columbia Faculty of Medicine; Head, Division of Pediatric Dermatology, British Columbia's Children's Hospital, Canada

Julie Prendiville, MBBCh is a member of the following medical societies: American Academy of Dermatology, Royal College of Physicians and Surgeons of Canada, Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven R Feldman, MD, PhD Professor, Departments of Dermatology, Pathology and Public Health Sciences, and Molecular Medicine and Translational Science, Wake Forest Baptist Health; Director, Center for Dermatology Research, Director of Industry Relations, Department of Dermatology, Wake Forest University School of Medicine

Steven R Feldman, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, North Carolina Medical Society, Society for Investigative Dermatology

Disclosure: Received honoraria from Amgen for consulting; Received honoraria from Abbvie for consulting; Received honoraria from Galderma for speaking and teaching; Received consulting fee from Lilly for consulting; Received ownership interest from for management position; Received ownership interest from Causa Reseasrch for management position; Received grant/research funds from Janssen for consulting; Received honoraria from Pfizer for speaking and teaching; Received consulting fee from No.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Arash Taheri, MD Research Fellow, Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

Wen Lyn Ho, MBBCh, BAO(HON), MRCPI Clinical Fellow in Pediatric Dermatology, British Columbia Children’s Hospital, Canada

Wen Lyn Ho, MBBCh, BAO(HON), MRCPI is a member of the following medical societies: Royal College of Physicians of Ireland, British Association of Dermatologists, Irish Association of Dermatologists

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Sheila Au, MD, to the development and writing of this article.

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Harlequin ichthyosis. Courtesy of Dr Bernice Krafchik.
Harlequin ichthyosis. Courtesy of Jason K Rivers, MD, FRCPC, and Dr Lawler.
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