Atrophies of Connective Tissue

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Atrophies of Connective Tissue

This chapter focuses primarily on entities in which there is a reduction in collagen and/or elastic tissue within the dermis. They vary from very common skin disorders such as striae to cutaneous manifestations of rare genetic syndromes. Loss of subcutaneous fat, i.e. lipoatrophy, is covered in Chapter 84, while acrodermatitis chronica atrophicans is covered in Chapter 61 and Ehlers–Danlos syndrome and cutis laxa are covered in Chapter 80.

Striae (Distensae)

• Linear atrophic lesions that reflect dermal damage (‘breaks’) at sites of mechanical stress due to stretching of the skin, hence the popular term ‘stretch marks’; most commonly observed in adolescents undergoing growth spurts or weight gain and on the abdomen in up to 75% of pregnant women.

• Striae are multiple, symmetric, and arranged along the lines of cleavage, with the typical sites of involvement and characteristic patterns shown in Fig. 82.1; early lesions may be red-purple in color (striae rubra) but with time, most striae become skin-colored to white with fine wrinkling (striae alba) (Fig. 82.2).

Fig. 82.1 Common anatomic sites of striae and linear focal elastosis.

Fig. 82.2 Striae. A Linear erythematous lesions on the abdomen (striae rubra). B Multiple linear atrophic streaks of striae alba in a teenager. C Large axillary striae in a patient receiving chronic, high-dose systemic corticosteroids. B, Courtesy, Kalman Watsky, MD.

• Additional causes include hypercortisolism (e.g. Cushing’s syndrome), application of potent topical CS (especially in areas of occlusion such as major body folds), and heredity; in weightlifters, mechanical stress and muscle enlargement can lead to striae.

• DDx: linear focal elastosis, in particular when lesions are present on the lower mid-back.

• Rx: difficult and striae often become less noticeable over a period of years; possible modest improvement with topical tretinoin 0.1% cream; lasers (e.g. pulsed dye for striae rubra, 308 nm excimer for striae alba) reportedly lead to improvement.

Pizogenic Pedal Papules (Piezogenic Papules)

• Herniations of fat in the heel region where there is reduced dermal connective tissue; the skin-colored papules appear with the pressure of weight-bearing and disappear when the leg is raised (Fig. 82.3A); occasionally occur on the wrist.

Fig. 82.3 Pizogenic pedal papules. A Skin-colored to yellowish outpouchings on the heel represent herniation of subcutaneous fat through the plantar fascia and they are sometimes painful. B Soft nodules on the medial and plantar surface of the foot in an infant. B, Courtesy, Julie V. Schaffer, MD.

• In an infantile variant, larger nodules occur on the medial aspect of the heel and their appearance does not require weight-bearing (Fig. 82.3B).

Anetoderma

• Well-circumscribed, skin-colored, flaccid lesions that result from a marked focal decrease in elastic tissue within the dermis (Fig. 82.4).

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