Anetoderma: Background, Pathophysiology, Epidemiology

Sections

Anetoderma

Overview

Background

Anetoderma (anetos, Greek for slack) is a benign condition with focal loss of dermal elastic tissue, resulting in localized areas of flaccid or herniated saclike skin. The condition has been reported under various names, including macular atrophy, anetoderma maculosa, and atrophia maculosa cutis. Primary lesions consist of localized areas of flaccid skin, which can be macular, papular, or depressed.

Historically, idiopathic lesions were classified based on a clinically inflammatory (Jadassohn-Pellizzari) or noninflammatory (Schweninger-Buzzi) onset. However, both types of lesions may be found in the same individual, and they are histologically similar. Currently, anetoderma is classified as either primary anetoderma, which is an idiopathic occurrence of atrophic lesions in areas of skin that appear normal prior to the onset of atrophy, or secondary anetoderma, which is preceded by an inflammatory, autoimmune, infectious, or neoplastic process. Both types may be associated with systemic diseases. A familial form that manifests as primary anetoderma has also been described.^[1]

Pathophysiology

The exact cause of anetoderma is unknown. Possible explanations for the loss of elastic tissue include defective elastin synthesis, uncontrolled production of elastolytic enzymes, loss of elastolytic enzyme inhibitors, elastophagocytosis, or degeneration of elastic fibers secondary to local ischemia induced by microthromboses in dermal vessels.^[2]Some investigators have proposed a possible common epitope between elastic fibers and phospholipids as an explanation for an autoimmune-mediated process.^[2]

Elastolytic enzymes such as matrix metalloproteinases (MMPs) may be directly responsible for elastin degradation in anetoderma. Alternatively, they may act indirectly by modulating other inflammatory events, such as proteolytic activation of latent cytokines, which, in turn, may regulate the activity of other undiscovered elastolytic enzymes. Known elastolytic enzyme inhibitors include serine proteinase inhibitors (serpins) and tissue inhibitors of metalloproteinase (TIMPs).

An imbalance in levels of MMPs and TIMPs altering the rate of elastin turnover has been suggested as one explanation of the pathophysiology of anetoderma. Specifically, MMP-2 and MMP-9 have been suggested as possible culprits at the origin of elastic fiber destruction in anetoderma.^[3]

Furthermore, a 2016 study involving nine patients with idiopathic anetoderma found that the dermal expression of fibulin-4 (which binds tropoelastin and is involved in various aspects of elastic fiber development) was significantly decreased in anetoderma when compared with healthy controls. These findings suggest that in addition to elastolytic overactivity, altered reassembly of elastic fibers may also play a significant role in the pathogenesis anetoderma.^[4]

Frequency

The exact incidence of anetoderma is unknown, but secondary anetoderma is probably more common than the primary form. Familial anetoderma is uncommon, with only 12 families reported in the literature.^{[5, 6, 7, 8]}Inheritance may be autosomal dominant, autosomal recessive, or undefined.

Sex

Primary anetoderma occurs slightly more frequently in women than in men.

Age

Primary anetoderma usually presents between the second and fourth decades of life, although patients of all ages have been reported to develop anetoderma.^{[9, 10, 11]}

Prognosis

Once developed, the lesions do not change over time.

Clinical Presentation

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Gambichler T, Reininghaus L, Skrygan M, Schulze HJ, Schaller J, Colato C, et al. Fibulin Protein Expression in Mid-dermal Elastolysis and Anetoderma: A Study of 23 Cases. Acta Derm Venereol. 2016 Jun 15. 96 (5):708-10. [Medline].
Patrizi A, Neri I, Virdi A, Misciali C, D'acunto C. Familial anetoderma: a report of two families. Eur J Dermatol. 2011 Jul 1. [Medline].
Friedman SJ, Venencie PY, Bradley RR, Winkelmann RK. Familial anetoderma. J Am Acad Dermatol. 1987 Feb. 16(2 Pt 1):341-5. [Medline].
Thomas JE, Mehregan DR, Holland J, Mehregan DA. Familial anetoderma. Int J Dermatol. 2003 Jan. 42(1):75-7. [Medline].
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Zattra, E, B. Pigozzi, et al. Anetoderma in cutaneous marginal-zone B-cell lymphoma. Clin Exp Dermatol. 2009. 34(8):945-948.
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Pezzetta S, Russo I, Brumana M, Marino F, Alaibac M. Exacerbation of a Primary Follicular Centre Cutaneous B-cell Lymphoma during Pregnancy and Resolution to Anetoderma After Delivery. Acta Derm Ve. 2016 Aug 23. 96(6):828-9. [Medline].
Lee SM, Kim YJ, Chang SE. Pinhole carbon dioxide laser treatment of secondary anetoderma associated with juvenile xanthogranuloma. Dermatol Surg. 2012 Oct. 38(10):1741-3. [Medline].
Trevisan G, Padovan C, Scaini MT, Cinco M, Floris R, Bonin S. Anetoderma associated with lyme disease: a case report. Acta Derm Venereol. 2008. 88(5):536-8. [Medline].
de Souza EM, Ayres Vallarelli AF, Cintra ML, Vetter-Kauczok CS, Brocker EB. Anetodermic pilomatricoma. J Cutan Pathol. 2008 Aug 18. [Medline].
Clement M, du Vivier A. Anetoderma secondary to syphilis. J R Soc Med. 1983 Mar. 76(3):223-4. [Medline].
Emer J, Roberts D, Sidhu H, Phelps R, Goodheart H. Generalized Anetoderma after Intravenous Penicillin Therapy for Secondary Syphilis in an HIV Patient. J Clin Aesthet Dermatol. 2013 Aug. 6(8):23-8. [Medline].
Crone AM, James MP. Acquired linear anetoderma following angular cheilitis. Br J Dermatol. 1998 May. 138(5):923-4. [Medline].
Cockayne SE, Gawkrodger DJ. Hamartomatous congenital melanocytic nevi showing secondary anetoderma-like changes. J Am Acad Dermatol. 1998 Nov. 39(5 Pt 2):843-5. [Medline].
Sheehan DJ, Madkan V, Strickling WA, Peterson CM. Atrophic dermatofibrosarcoma protuberans: a case report and reappraisal of the literature. Cutis. 2004 Oct. 74(4):237-42. [Medline].
Ozkan S, Fetil E, Izler F, Pabucçuoglu U, Yalcin N, Gunes AT. Anetoderma secondary to generalized granuloma annulare. J Am Acad Dermatol. 2000 Feb. 42(2 Pt 2):335-8. [Medline].
Kang HS, Paek JO, Lee MW, Yu HJ, Kim JS. Anetoderma developing in generalized granuloma annulare in an infant. Ann Dermatol. 2014 Apr. 26(2):283-5. [Medline].
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Shalders K, Ilchyshyn A, Walzman M. Secondary anetoderma following molluscum contagiosum infection. Acta Derm Venereol. 2003. 83(6):461-2. [Medline].
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Johnson WC. Wilson's disease and penicillamine-induced anetoderma. Arch Dermatol. 1977. 113:976.
Hirschel-Scholz S, Salomon D, Merot Y, Saurat JH. Anetodermic prurigo nodularis (with Pautrier's neuroma) responsive to arotinoid acid. J Am Acad Dermatol. 1991 Aug. 25(2 Pt 2):437-42. [Medline].
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Media Gallery

Multiple lesions of anetoderma.
Close-up view of a single lesion of anetoderma.

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Author

Anne Elizabeth Laumann, MBChB, MRCP(UK), FAAD Professor of Dermatology, Chief of General Dermatology, Director of the Collagen Vascular Disorders Clinic, Northwestern University, The Feinberg School of Medicine

Anne Elizabeth Laumann, MBChB, MRCP(UK), FAAD is a member of the following medical societies: American Academy of Dermatology, Association of Professors of Dermatology, British Association of Dermatologists, Chicago Dermatological Society, Chicago Medical Society, Illinois Dermatological Society, Illinois State Medical Society, Medical Dermatology Society, Society for Investigative Dermatology, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Victoria Godinez-Puig, MD Resident Physician, Department of Dermatology, Northwestern University, The Feinberg School of Medicine

Victoria Godinez-Puig, MD is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Julia Sanger Minocha, MD Resident Physician, Department of Medicine, Northwestern University, The Feinberg School of Medicine

Julia Sanger Minocha, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

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.

Acknowledgements

Peter Fritsch, MD Chair, Department of Dermatology and Venereology, University of Innsbruck, Austria

Peter Fritsch, MD is a member of the following medical societies: American Dermatological Association, International Society of Pediatric Dermatology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Stephen C Ho, MD is a member of the following medical societies: American Academy of Dermatology, American Contact Dermatitis Society, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Society of Cosmetic Dermatology and Aesthetic Surgery, and Colorado Medical Society

Disclosure: Nothing to disclose.

Jin Mo Park, PhD Assistant Professor, Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School

Disclosure: Nothing to disclose.

Jenny Sun, MD Research Fellow, Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School

Disclosure: Nothing to disclose.

Anetoderma

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