Congenital fascial dystrophy: the stiff skin syndrome

Congenital fascial dystrophy is an uncommon disorder that may mimic scleroderma. The skin is bound down and feels "wood hard" on palpation of the trunk and extremities. Sclerodactyly, telangiectases, and nail fold changes are not present. Unlike scleroderma, the onset is at birth. Flexion contractures result and other associated abnormalities may include developmental delay and mild hirsutism. We report a typical case to illustrate the clinical and pathologic findings of patients with this disorder.

[Hypomelanosis guttata idiopathica]

A 37-year-old white female with dark complexion presented with progressive hypopigmented macules on the face and upper trunk. She was in good health and her family history was unremarkable. Histologic examination of the hypopigmented patches revealed reduced melanin within the basal layers of the epidermis. Using immunohistochemical and ultrastructural studies, the number of melanocytes appeared normal but signs of degeneration were evident and dendrites were shortened. The diagnosis of idiopathic guttate hypomelanosis was established. The clinical picture, etiology and treatment of this relatively common but often unrecognized skin disease is discussed.

Relationship between levels of soluble interleukin-2 receptors and the types and activity of vitiligo

Levels of serum-soluble interleukin-2 receptors (serum sIL-2R) are thought to indicate the activation of immunocompetent cells, mainly lymphocytes. Elevated levels of serum sIL-2R have been observed in various infectious and autoimmune diseases and also after organ transplantation. It has been hypothesized that autoimmune mechanisms are involved in the pathogenesis of vitiligo. Therefore, we studied serum sIL-2R levels in relation to disease types and activity of vitiligo. We used sera separated from venous blood samples from 12 patients with dermatomally distributed type B vitiligo, 17 patients with non-dermatomally distributed type A vitiligo during the active stage, 9 patients with type A vitiligo during the inactive stage, and 12 normal control subjects. Serum sIL-2R levels were similar in type B vitiligo patients and the controls but were significantly elevated in patients with active type A vitiligo compared with controls and inactive type A vitiligo patients. It is suggested that the immune system is activated in patients with type A vitiligo during the active stage and that autoimmune mechanisms may play a role only in type A vitiligo.

Vitiligo: the psychosocial effects

Vitiligo is a disfiguring skin disease that affects 1% of the general population. It is important for medical-surgical nurses to understand the psychologic impact and nursing implications of this disfiguring skin disease.

[Vitiligo]

Vitiligo is a disorder in which, owing to disappearance of melanocytes in the skin, sharply delimited, symmetrically arranged white patches develop. The condition occurs in 1-2% of the population, mostly between the ages of 10 and 30 years, and as often in males as in females. The course is usually progressive with periods of stability. A number of autoimmune diseases and dermatoses coincide with vitiligo. The cause of vitiligo is unknown. Hereditary factors, autoimmunization, neurological disorders and autodestruction have been hypothesized. Repigmentation therapy consists of photo(chemo)therapy use of corticosteroids, and transplantation of pigment cells. For patients in whom this fails and with more than 80% cutaneous involvement, total depigmentation therapy could be considered.

Vitiligo

Vitiligo involves a progressive loss of melanocytes from the epidermis and hair follicles. Milky-white patches appear resulting in cosmetic disfiguration that is most apparent in dark-skinned individuals. The disease is further classified according to distribution pattern and extent of depigmentation. The presence of several clinical subtypes may reflect the diversity in causative factors. To select appropriate therapeutic measures it is important to distinguish vitiligo from other disorders that affect melanocyte function. Although vitiligo has a characteristic clinical appearance and histological features, the presence of early or atypical lesions often requires the exclusion of other disorders such as postinflammatory hypopigmentation and piebaldism. Multiple hypotheses have been put forward to explain vitiligo. An inherited tendency to develop depigmentation may involve the inherent aberrancies that have been observed in nonlesional vitiligo melanocytes in vivo as well as in vitro. These abnormalities potentially render vitiliginous melanocytes more vulnerable to assaults from extracellular factors. Such factors include keratinocyte physiology, extracellular matrix composition, humoral and cellular immunity, and environmental agents. Therapies aimed at repopulation of lesional skin include phototherapy, application of topical corticosteroids, and transplantation of skin or skin cells. Moreover, micropigmentation or camouflage can be used to restore a pigmented appearance to lesional skin. In patients in which vitiligo affects extensive areas of the body, depigmentation may be the treatment of choice. In all, this acquired pigmentary disorder can be treated in a variety of ways and should not be regarded as an untreatable affliction.

Recent investigations on vitiligo vulgaris

Vitiligo is a depigmenting disorder of the skin caused by destruction of melanocytes. The depigmented skin has several abnormal functions, including some autonomic nervous functions. The inflammatory response in the depigmented skin is muted. Recent genetic and epidemiologic studies indicate that vitiligo affects men and women equally. The prevalence in the population is about one in 200. Vitiligo seems to be transmitted as a polygenic trait. New data suggest that it is not associated with autoimmune endocrine disorders, but more comprehensive studies are required.

Localized vitiligo and frontoethmoidal meningoencephalocele

A child with frontoethmoidal meningoencephalocele in whom localized facial vitiligo developed after surgical correction of the encephalocele is presented. The potential role of the ocular disease accompanying the encephalocele in the development of the hypopigmentation is discussed.

Unusual skin depigmentation following eyelid cryosurgery

A 71-year-old African-American man was treated with cryosurgery of the left lower lid for trichiasis. Dramatic depigmentation of the lid skin followed, including substantial pigment loss on the untreated upper lid. Pigmentation returned to nearly normal over a 9-year period. Depigmentation of the skin following cryosurgery is a well-known complication. The clinical course of the depigmentation, however, is not well demonstrated in the literature. This case documents, with clinical photographs, the spontaneous return to nearly normal pigmentation 9 years following the cryosurgery. In addition, the extensive depigmentation seen in this patient cannot be explained by cryoinjury alone. We speculate that the depigmentation was due, in part, to segmental vitiligo initiated at the site treated with cryosurgery.

The occurrence of cutaneous nerve endings and neuropeptides in vitiligo vulgaris: a case-control study

Pioneering studies both in humans and animals have demonstrated an association between the peripheral nervous system and epidermal melanocyte destruction. The presence of certain neuropeptides and neuronal structural markers in peripheral nerve fibres was investigated in involved and uninvolved vitiligo skin and compared with normal healthy skin. A group of 18 vitiligo vulgaris patients and matched healthy volunteers participated in the investigation. The indirect immunofluorescence technique was employed. There was a tendency for a reduction in the number and intensity of low affinity (p75) nerve growth factor receptor immunoreactive (NGFr-IR) basal keratinocytes in involved vitiliginous skin (P < 0.06) compared with control skin, while the number of NGFr-IR nerve fibres was significantly increased (P < 0.01). The number of calcitonin gene-related peptide (CGRP)-IR nerve fibres in the epidermis and papillary dermis was dramatically increased in involved skin as compared with control skin (P < 0.01) and with uninvolved skin (P < 0.05). No clear difference could be found in the distribution of vasoactive intestinal polypeptide (VIP)- and neuropeptide tyrosine (NPY)-IR nerve fibres. A different structural appearance of the peripheral nervous system as well as a changed balance of neuropeptides in vitiliginous skin point to a critical role of the nervous system in the pathogenesis of vitiligo.

Occupational dermatitis in shoemakers

In an epidemiological study of occupational dermatitis in 5 different shoe factories, 246 workers were interviewed, examined and patch tested using standard and occupational patch test series. The prevalence of occupational contact dermatitis was 14.6% (36/246): 8.1% (20/246) irritant contact dermatitis (OICD) and 6.5% (16/246) allergic contact dermatitis (OACD). Among the latter, the most common occupational allergens were p-tert-butylphenol-formaldehyde resin and mercaptobenzothiazole. 6% (15/246) presented with hyperkeratosis of the fingertips, while 3.2% (8/246) reported pruritus sine materia (PSM) present only during working hours. 2 workers presented with vitiligo-like leukodermic patches on the backs of their hands and on their forearms. Some jobs were more frequently associated with skin complaints. In the assembly department, OACD was most frequent (11.4%), attributed to contact with adhesives and, to a lesser degree, with rubber and leather. OICD caused by contact with the solvents contained in adhesives and varnishes was most frequent in the assembly and trimming departments (17.1% and 15.6%, respectively). PSM, probably caused by the dust present in the working environment was reported by 33.3% of the workers in the sole-cutting and scraping departments. Hyperkeratosis of the fingertips, as a reaction to the continuous trauma of leather on the skin, was observed most frequently (41.6%) in the sole-cutting department.

Vitiligo in patients with melanoma: normal tissue antigens can be targets for cancer immunotherapy

Patients with metastatic renal cell cancer and metastatic melanoma treated with high-dose interleukin-2-based immunotherapy were prospectively evaluated for the development of vitiligo. All patients seen in the Surgery Branch, NCI Immunotherapy Clinic, who had been followed for at least 1 year were evaluated. Of 104 patients with metastatic renal cancer none developed vitiligo, though vitiligo was seen in 11 of 74 (15%) patients with metastatic melanoma (p2 = 0.0001). No vitiligo was seen in 27 patients who did not respond to immunotherapy, although vitiligo was seen in 11 of 43 (26%) melanoma patients who had an objective response to IL-2-based immunotherapy (p2 = 0.0002). These findings provide further evidence that the presence of a growing melanoma can sensitize patients to melanocyte-differentiation antigens and that the immune response against these antigens is associated with cancer regression in patients undergoing immunotherapy.

In vivo destruction of melanocytes by the IgG fraction of serum from patients with vitiligo

There are conflicting results regarding the role of autoantibodies in the pathogenesis of vitiligo. To examine their in vivo effect, human skin was transplanted onto nude mice injected with purified IgG obtained from patients with vitiligo and from controls. The effect was evaluated by several techniques. Dihydroxyphenylalanine staining revealed a marked decrease in the number of melanocytes in skin grafted onto mice injected with patients' IgG. Direct immunofluorescence staining demonstrated the presence of human IgG throughout the epidermis in specimens injected with purified IgG from vitiligo patients. No staining was observed when control IgG was injected. Electron microscopy studies demonstrated a marked decrease in melanin pigmentation with only rare melanosomes and melanocytes detected in grafts injected with patients' IgG. Thus all three techniques showed the destructive effect of vitiligo patients' serum on melanocytes. Our study highlights the important role of autoantibodies in the pathogenesis of vitiligo.

Vogt-Koyanagi-Harada syndrome in a 4-year old child

PURPOSE

We studied a case of severe bilateral Vogt-Koyanagi-Harada syndrome in a 4-year-old boy.

METHODS

We evaluated the patient's clinical course.

RESULTS

The patient had severe bilateral, nongranulomatous uveitis and mild uveitic glaucoma. Initial examination and laboratory evaluation failed to provide a diagnosis. The patient subsequently developed areas of vitiligo, alopecia, and poliosis, suggesting the diagnosis of Vogt-Koyanagi-Harada syndrome. This diagnosis was confirmed by the eventual development of bilateral neurosensory retinal detachments. Vision was lost despite aggressive therapy with corticosteroids and chlorambucil.

CONCLUSION

Although uncommon, Vogt-Koyanagi-Harada may affect young children, and may be severe.

Implicating a role for immune recognition of self in tumor rejection: passive immunization against the brown locus protein

The immune system can recognize differentiation antigens that are selectively expressed on malignant cells and their normal cell counterparts. However, it is uncertain whether immunity to differentiation antigens can effectively lead to tumor rejection. The mouse brown locus protein, gp75 or tyrosinase-related protein 1, is a melanocyte differentiation antigen expressed by melanomas and normal melanocytes. The gp75 antigen is recognized by autoantibodies and autoreactive T cells in persons with melanoma. To model autoimmunity against a melanocyte differentiation antigen, mouse antibodies against gp75 were passively transferred into tumor-bearing mice. Passive immunization with a mouse monoclonal antibody against gp75 induced protection and rejection of both subcutaneous tumors and lung metastases in syngeneic C57BL/6 mice, including established tumors. Passive immunity produced coat color alterations but only in regenerating hairs. This system provides a model for autoimmune vitiligo and shows that immune responses to melanocyte differentiation antigens can influence mouse coat color. Immune recognition of a melanocyte differentiation antigen can reject tumors, providing a basis for targeting tissue autoantigens expressed on cancer.