British Journal of Dermatology (1976) 94, 23.
Elastotic Degeneration A LIGHT AND ELECTRON MICROSCOPIC STUDY DANILO V. STEVANOViO Department of Dermatologyj Medical School, Belgrade
Accepted for publication 2 May 1975
SUMMARY
The formation of elastotic material in the dermis of the exposed skin of elderly persons, and of two younger patients with manifestations of precocious degeneration, was studied by light and by electronmicroscopy. Initially fine filaments or apparently granular material, or both, appeared around collageri fibres, which were mildly altered. On the exposed sites there was gradual loss of matrix and striation of tiie collagen forming an amorphous substance in which scattered, optically dense material appeared. Several appearances were common to all subjects. There are numerous opinions on the origin of elastotic material (Tunbridge era/., 1952; Teller, Vester & Pohl, i957;Niebauer& Stockinger, i965;Banfield&Brindley, 1963; Pierard, Kint & de Berasques, 1968; Braun-Falco, 1969). This may be because previous investigators have studied advanced examples of actinic degeneration. Earlier, and perhaps more subtle, changes are described in this work. MATERIALS AND METHODS
There were two patients, aged 21 and 41 years, who exhibited precocious light-influenced degenerative changes. The skin of their necks was scleroatrophic as in a superficial chronic radiodcrmatitis and that of the trunk, limbs and gluteal regions, in decreasing degree, was dry with macular and mosaiclike superficial atrophy. Biopsies were obtained from the trimk and the gluteal regions in both patients and from the neck in the older. Biopsies were also obtained from the back of the neck of three other men aged 50, 60 and 70 years, the first showing mild actinic degeneration and the third showing cutis rhomboidalis nuchae. The following stains were used: haematoxylin and eosin (H & E), alcian blue, periodic acid Schiff (PAS), Gomori's reticulin stain, and von Kossa's stain for calcitim salts. For electron microscopy the tissue was processed in the usual way, fixed in 1% OSO4 buffered in veronal, embedded in epon, and contrasted with uranyl acetate and lead citrate. RESULTS
Light microscopy: patients with precocious degeneration Exposed skin. Underlying a narrow subepidermal band of oedematous collagen, a variable number of 23
24
D. V.Stevanovic
parallelly arranged fibres were present which stained positively with orcein-Giemsa stain, negatively with alcian blue, and violet with PAS. Elastic-stain positive globules were seen between altered collagen fibres. Unexposed skin. The upper half of the dermis in all four specimens was oedematous, and the collagen bundles split. Throughout the dermis, often sparing a narrow subepidermal band, a considerable number of ovoid, spherical, elongated, or irregular masses, were present grouped or scattered, and measuring 12-25 /im (Fig. i). Many of them stained black with orcein-Giemsa stain, black with Gomori's and were alcian blue and PAS negative. Others exhibited a spectrum of lighter to dark hues when stained with orcein-Giemsa, stained blue with Gomori's stain, lighter magenta to deep purple (positive) with PAS, and were alcian blue negative. In H & E sections, these globules as well as the upper dermis appeared hyalinized. A smaller number of less mature globules were seen in specimens from the gluteal region than in those from the trunk.
FIGURE I. Throughout the upper dermis numerous orceinophilic globules are present. The elastic fibres are reduced. (The younger patient, skin of the trunk, acid orcein-Giemsa stain, x 87.) Older patients with chronic actinic damage
Exposed skin (neck). Again there was a narrow subepidermal band of oedematous collagen. In the upper half of the dermis a variable number of thinner and thicker, often parallelly arranged fibres, staining positively with orcein-Giemsa staiti, negatively with alcian blue, and violet with PAS, were present. In the two older persons, elastotic globules were present between the altered fibres. In the oldest person there were large irregular masses formed by thin, closely packed and randomly orientated
Elastotic degeneration
25
fibrils. They stained moderately darkly with orcein-Giemsa, were PAS negative, and were basophilic in H&Esections. Electron microscopy: patients with precocious degeneration
Exposed skin. Large 'fibres' and irregular masses of amorphous structure, often containing dense granules, were seen in the dermis. In some similar appearing fibres, striations could still be recognized. Their inner portion was translucent, and their membranes were often blurred and confluent. Optically denser material was sometimes present. Masses consisting of densely packed microfibrillar and/or granular material were rarely seen. Unexposed skin (trunk and gluteal region). Within the upper dermis there were degenerative changes of varying intensity. The initial change consisted of thinly fibrillar and apparently granular material surrounding a segment of one to several fibres (Eig. 2a). Normal striation of such a segment could sometimes be recognized. Within such a group all fibres were not equally affected. The presence of optic-
FiGURE2(a). Longitudinal section through the central segment of an altered bundle. Rarefied fibres have lost their striation; fibrils are seen around them. (The older patient, skin of the trunk; X 24,000.) (b). Cross-section of a bundle. Central lyingfibresarc degenerate. Single oedematous fibres form the membrane-like structure within which some dense material is present. Fibrils and granular material arc present at the periphery (asterisk). (The older patient, skin of the trunk; X 24,000.)
FIGURE 3. A segment of a bundle cross-sectioned. The outer region has changed into an amorphous mass, while fibrils are present nearer its centre. (The younger patient, skin of the trunk; X 16,000.)
FIGURE 4(a). Longitudinal section through two 'elastotic fibres'. In one, striation can be recognized. Between fibres optically dense material is present. (Male,aged 60 years, neck; x 41,000.) (b). Crosssection of similarly affected fibres. The inner structure of the fibres has become lighter and the membranes partly confluent. A 'lace-like' pattern is also recognizable (asterisk). (Male, aged 60 years, neck; x 375,000.)
Elastotic degeneration
27
ally clear areas between such degenerating material suggested the disappearance of some material (Figs 2a & b), whereas increased density of some other areas suggested a more advanced stage in the degenerative process (Fig. 2b). Sections parallel to the long axis revealed that the centrally lying fibres were the first to degenerate. Frequently at a certain distance from the centre of a degenerating bundle a membrane-like structure was formed by partly degenerate and confluent fibres. Outside it fibres were also variably oedematous and optically lighter (Fig. 2b). In some bundles only the membranelike structure with some inner and outer lying material remained. Some bundles developed into a more or less condensed fibrillar mass with only a few recognizable fibres. These and similar granular areas were sometimes replaced by amorphous material. For instance, a large degenerate bundle exhibited an amorphous periphery, while its central part was microfibrillar and granular (Fig. 3). In the more superficial part of the dermis, the altered bundles consisted mainly of closely packed fibrils surrounded by less altered fibres at the periphery. Such bundles were often surrounded by normal-looking fibroblasts. Older patients with chronic actinic damage Exposed skin. The findings (Figs 4a, b and 5) were virtually identical to those observed on the exposed skin in the older patient with precocious degeneration as described above.
FIGURE 5. Side-by-side, fibrillar and amorphous stages of degeneration are present. Fibrils are also seen in the amorphous mass (asterisk). (Male, aged 60 years, neck; x 32,000). DISCUSSION
Actinic elastosis has been explained on the basis of transformation of collagen fibres (Tunbridge et al., 1952; Teller, Vester & Pohl, 1957; Niebauer & Stockinger, 1965), or of elastic fibres (Banfield &
28
D. V.Stevanovic
Brindley, 1963; Pierard et al., 1968), or of both with incorporation of a granular material (Mitchell, 1967). Braun-Eaico (1969) felt the first step to be the appearance of homogeneous—possibly elastotic— material which led to a disordered arrangement within the collagen fibres, and to a disintegration of collagen fibrils which split into microfibrils. Elastotic fibres have also been found in skin of patients with chronic radiodermatitis (Ledoux-Corbusier & Achten, 1974). These findings permitted a study of the degenerative process from its onset to the final stage of elastotic degeneration. More advanced stages were common both to the unexposed skin in the patients with precocious degeneration and to the exposed neck of the elderly persons. Eirst of all either collagen fibres split into microfibrils and granular material, with subsequent appearance of the amorphous mass, or the latter is formed directly through the gradual loss of the matrix and membrane with subsequent confluence into future 'elastotic fibres'. At the amorphous stage, optically denser material appears. The formation of the amorphous material by the direct way seems to be more common in the exposed skin. Various stages of the degenerative process were seen side by side with normal looking collagen fibres. Cellular debris was often seen. Before acquiring elastic stain properties, the degenerating material passes through a PAS positive phase. However, it is never alcian blue positive, though an increased amount of acid mucopolysaccharides can be seen in the upper dermis. In the two patients with precocious degeneration there was an unusual number of fibroblasts seen around incompletely degenerated bundles. The fact that these bundles were more altered in their inner part may suggest an attempt at repair, presumably insufficient, rather than secretion of qualitatively altered collagen precursors. The elastic fibres were also often altered. When amorphous, their smaller size was helpful in distinguishing them from similarly altered collagen bundles. Elastotic changes such as 'a lace-like pattern, or multilobular holes' described as being of unknown origin (Ledoux-Corbusicr & Achten, 1974) are most likely advanced stages of collagen degeneration. The denser material which appears towards the end of the process needs further elucidation. Although at variance with the view of Ebner & Gebhard (1974) it would appear that.'elastic globes' are due to altered collagen rather than bcing^ new elastic fibres The clinical features in the patients could not be accurately classified into previously described lightinfluenced conditions. Some features were similar to those in 'hereditary sclerosing poikiloderma' (Weary et al., 1969) a condition observed in black people and not influenced by sunlight. The patients and findings will be fully described separately (Stevanovic 1975). ACKNOWLEDGMENT
This investigation was supported by a grant from the Association of Medical Eaculties of Serbia. REFERENCES BANFIELD, W . G . & BRINDLEY, D . C . (1963) Preliminary observations on senile elastosis using the electron microscope.yuHrwa/qZ/fwe^n^d/ft'e Dermatology, 41, 9. BRAUN-FALCO, O. (1969) Die Morphogenese der senil-aktinischen Elastose. Eine elektron-mikroskopische Untersuchung. Archivfur klinische und experimenlelle Dermatologie, 235,138. EBNER, H . & GEBHART, W . (1974) Elastic globes. Histochemische und elektronmikroskopische Untersuchungen. Archiv Dermatologische Forschung, 249, 329. LEDOUX-CORBUSIER, M . & ACHTEN, G . (1974) Elastosis in chronic radiodermatitis. British Journal of Dermatology 91,287. MITCHELL, R.E. (1967) Chronic solar dermatosis: a light and electronmicroscopic study of the dermis. Journal of Invemgalive Dermatology, 48, 203.
Elastotic degeneration
29
NiEBAtJER, G. & STOCKINGER, L . (1965) tJber die senile Elastosis. Histochemische und elektronmikroskopische Untersuchungen. Archivfur klinische und experimenlelle Dermalologie, 221, 122. Pl^RARD, J., KiNT, A. & DE BERASQUES, J. (1968) L'elastose senile. In: Maladie dii lissu elaslique cutane. XII' Congris de I'Association de Dermatologistes et Syphiligraphes de Langue Franfaise, Paris, 1965, Vol. I, p. 373. Masson et Cie, Paris. STEVANOVIC D . (1975) The difFuse and atrophic macular dermatosis. A premature and progressive light degenerative condition. Dermarologische Monarschrifr, To be published. TELLER, H.G., VESTER, G . & POHL, L . (1975) Elektronmikroskopische Untersuchungsergebnisse an der Inter-
zelluiarsubstanz des Coriums bei Altersatrophie. Zeitschrift fur Haut und Geschlechtskrankheiten, 22, 67. TUNBRIDGE, R.E., TATTERSALL, R.N., HALL, D.A., ASTBURY, W . T . & REED, R. (1952) The fibrous structure of
normal and abnormal human skin. Clinical Science, 11, 315. WEARY, P.E., Hsu, Y.T., RICHARDSON, D.R., CARAVATTI, C M . & WOOD, B . T . (1969} Hereditary Sclerosing
Poikiloderma. Archives of Dermatology, 100,413.
Elastotic Degeneration A LIGHT AND ELECTRON MICROSCOPIC STUDY DANILO V. STEVANOViO Department of Dermatologyj Medical School, Belgrade
Accepted for publication 2 May 1975
SUMMARY
The formation of elastotic material in the dermis of the exposed skin of elderly persons, and of two younger patients with manifestations of precocious degeneration, was studied by light and by electronmicroscopy. Initially fine filaments or apparently granular material, or both, appeared around collageri fibres, which were mildly altered. On the exposed sites there was gradual loss of matrix and striation of tiie collagen forming an amorphous substance in which scattered, optically dense material appeared. Several appearances were common to all subjects. There are numerous opinions on the origin of elastotic material (Tunbridge era/., 1952; Teller, Vester & Pohl, i957;Niebauer& Stockinger, i965;Banfield&Brindley, 1963; Pierard, Kint & de Berasques, 1968; Braun-Falco, 1969). This may be because previous investigators have studied advanced examples of actinic degeneration. Earlier, and perhaps more subtle, changes are described in this work. MATERIALS AND METHODS
There were two patients, aged 21 and 41 years, who exhibited precocious light-influenced degenerative changes. The skin of their necks was scleroatrophic as in a superficial chronic radiodcrmatitis and that of the trunk, limbs and gluteal regions, in decreasing degree, was dry with macular and mosaiclike superficial atrophy. Biopsies were obtained from the trimk and the gluteal regions in both patients and from the neck in the older. Biopsies were also obtained from the back of the neck of three other men aged 50, 60 and 70 years, the first showing mild actinic degeneration and the third showing cutis rhomboidalis nuchae. The following stains were used: haematoxylin and eosin (H & E), alcian blue, periodic acid Schiff (PAS), Gomori's reticulin stain, and von Kossa's stain for calcitim salts. For electron microscopy the tissue was processed in the usual way, fixed in 1% OSO4 buffered in veronal, embedded in epon, and contrasted with uranyl acetate and lead citrate. RESULTS
Light microscopy: patients with precocious degeneration Exposed skin. Underlying a narrow subepidermal band of oedematous collagen, a variable number of 23
24
D. V.Stevanovic
parallelly arranged fibres were present which stained positively with orcein-Giemsa stain, negatively with alcian blue, and violet with PAS. Elastic-stain positive globules were seen between altered collagen fibres. Unexposed skin. The upper half of the dermis in all four specimens was oedematous, and the collagen bundles split. Throughout the dermis, often sparing a narrow subepidermal band, a considerable number of ovoid, spherical, elongated, or irregular masses, were present grouped or scattered, and measuring 12-25 /im (Fig. i). Many of them stained black with orcein-Giemsa stain, black with Gomori's and were alcian blue and PAS negative. Others exhibited a spectrum of lighter to dark hues when stained with orcein-Giemsa, stained blue with Gomori's stain, lighter magenta to deep purple (positive) with PAS, and were alcian blue negative. In H & E sections, these globules as well as the upper dermis appeared hyalinized. A smaller number of less mature globules were seen in specimens from the gluteal region than in those from the trunk.
FIGURE I. Throughout the upper dermis numerous orceinophilic globules are present. The elastic fibres are reduced. (The younger patient, skin of the trunk, acid orcein-Giemsa stain, x 87.) Older patients with chronic actinic damage
Exposed skin (neck). Again there was a narrow subepidermal band of oedematous collagen. In the upper half of the dermis a variable number of thinner and thicker, often parallelly arranged fibres, staining positively with orcein-Giemsa staiti, negatively with alcian blue, and violet with PAS, were present. In the two older persons, elastotic globules were present between the altered fibres. In the oldest person there were large irregular masses formed by thin, closely packed and randomly orientated
Elastotic degeneration
25
fibrils. They stained moderately darkly with orcein-Giemsa, were PAS negative, and were basophilic in H&Esections. Electron microscopy: patients with precocious degeneration
Exposed skin. Large 'fibres' and irregular masses of amorphous structure, often containing dense granules, were seen in the dermis. In some similar appearing fibres, striations could still be recognized. Their inner portion was translucent, and their membranes were often blurred and confluent. Optically denser material was sometimes present. Masses consisting of densely packed microfibrillar and/or granular material were rarely seen. Unexposed skin (trunk and gluteal region). Within the upper dermis there were degenerative changes of varying intensity. The initial change consisted of thinly fibrillar and apparently granular material surrounding a segment of one to several fibres (Eig. 2a). Normal striation of such a segment could sometimes be recognized. Within such a group all fibres were not equally affected. The presence of optic-
FiGURE2(a). Longitudinal section through the central segment of an altered bundle. Rarefied fibres have lost their striation; fibrils are seen around them. (The older patient, skin of the trunk; X 24,000.) (b). Cross-section of a bundle. Central lyingfibresarc degenerate. Single oedematous fibres form the membrane-like structure within which some dense material is present. Fibrils and granular material arc present at the periphery (asterisk). (The older patient, skin of the trunk; X 24,000.)
FIGURE 3. A segment of a bundle cross-sectioned. The outer region has changed into an amorphous mass, while fibrils are present nearer its centre. (The younger patient, skin of the trunk; X 16,000.)
FIGURE 4(a). Longitudinal section through two 'elastotic fibres'. In one, striation can be recognized. Between fibres optically dense material is present. (Male,aged 60 years, neck; x 41,000.) (b). Crosssection of similarly affected fibres. The inner structure of the fibres has become lighter and the membranes partly confluent. A 'lace-like' pattern is also recognizable (asterisk). (Male, aged 60 years, neck; x 375,000.)
Elastotic degeneration
27
ally clear areas between such degenerating material suggested the disappearance of some material (Figs 2a & b), whereas increased density of some other areas suggested a more advanced stage in the degenerative process (Fig. 2b). Sections parallel to the long axis revealed that the centrally lying fibres were the first to degenerate. Frequently at a certain distance from the centre of a degenerating bundle a membrane-like structure was formed by partly degenerate and confluent fibres. Outside it fibres were also variably oedematous and optically lighter (Fig. 2b). In some bundles only the membranelike structure with some inner and outer lying material remained. Some bundles developed into a more or less condensed fibrillar mass with only a few recognizable fibres. These and similar granular areas were sometimes replaced by amorphous material. For instance, a large degenerate bundle exhibited an amorphous periphery, while its central part was microfibrillar and granular (Fig. 3). In the more superficial part of the dermis, the altered bundles consisted mainly of closely packed fibrils surrounded by less altered fibres at the periphery. Such bundles were often surrounded by normal-looking fibroblasts. Older patients with chronic actinic damage Exposed skin. The findings (Figs 4a, b and 5) were virtually identical to those observed on the exposed skin in the older patient with precocious degeneration as described above.
FIGURE 5. Side-by-side, fibrillar and amorphous stages of degeneration are present. Fibrils are also seen in the amorphous mass (asterisk). (Male, aged 60 years, neck; x 32,000). DISCUSSION
Actinic elastosis has been explained on the basis of transformation of collagen fibres (Tunbridge et al., 1952; Teller, Vester & Pohl, 1957; Niebauer & Stockinger, 1965), or of elastic fibres (Banfield &
28
D. V.Stevanovic
Brindley, 1963; Pierard et al., 1968), or of both with incorporation of a granular material (Mitchell, 1967). Braun-Eaico (1969) felt the first step to be the appearance of homogeneous—possibly elastotic— material which led to a disordered arrangement within the collagen fibres, and to a disintegration of collagen fibrils which split into microfibrils. Elastotic fibres have also been found in skin of patients with chronic radiodermatitis (Ledoux-Corbusier & Achten, 1974). These findings permitted a study of the degenerative process from its onset to the final stage of elastotic degeneration. More advanced stages were common both to the unexposed skin in the patients with precocious degeneration and to the exposed neck of the elderly persons. Eirst of all either collagen fibres split into microfibrils and granular material, with subsequent appearance of the amorphous mass, or the latter is formed directly through the gradual loss of the matrix and membrane with subsequent confluence into future 'elastotic fibres'. At the amorphous stage, optically denser material appears. The formation of the amorphous material by the direct way seems to be more common in the exposed skin. Various stages of the degenerative process were seen side by side with normal looking collagen fibres. Cellular debris was often seen. Before acquiring elastic stain properties, the degenerating material passes through a PAS positive phase. However, it is never alcian blue positive, though an increased amount of acid mucopolysaccharides can be seen in the upper dermis. In the two patients with precocious degeneration there was an unusual number of fibroblasts seen around incompletely degenerated bundles. The fact that these bundles were more altered in their inner part may suggest an attempt at repair, presumably insufficient, rather than secretion of qualitatively altered collagen precursors. The elastic fibres were also often altered. When amorphous, their smaller size was helpful in distinguishing them from similarly altered collagen bundles. Elastotic changes such as 'a lace-like pattern, or multilobular holes' described as being of unknown origin (Ledoux-Corbusicr & Achten, 1974) are most likely advanced stages of collagen degeneration. The denser material which appears towards the end of the process needs further elucidation. Although at variance with the view of Ebner & Gebhard (1974) it would appear that.'elastic globes' are due to altered collagen rather than bcing^ new elastic fibres The clinical features in the patients could not be accurately classified into previously described lightinfluenced conditions. Some features were similar to those in 'hereditary sclerosing poikiloderma' (Weary et al., 1969) a condition observed in black people and not influenced by sunlight. The patients and findings will be fully described separately (Stevanovic 1975). ACKNOWLEDGMENT
This investigation was supported by a grant from the Association of Medical Eaculties of Serbia. REFERENCES BANFIELD, W . G . & BRINDLEY, D . C . (1963) Preliminary observations on senile elastosis using the electron microscope.yuHrwa/qZ/fwe^n^d/ft'e Dermatology, 41, 9. BRAUN-FALCO, O. (1969) Die Morphogenese der senil-aktinischen Elastose. Eine elektron-mikroskopische Untersuchung. Archivfur klinische und experimenlelle Dermatologie, 235,138. EBNER, H . & GEBHART, W . (1974) Elastic globes. Histochemische und elektronmikroskopische Untersuchungen. Archiv Dermatologische Forschung, 249, 329. LEDOUX-CORBUSIER, M . & ACHTEN, G . (1974) Elastosis in chronic radiodermatitis. British Journal of Dermatology 91,287. MITCHELL, R.E. (1967) Chronic solar dermatosis: a light and electronmicroscopic study of the dermis. Journal of Invemgalive Dermatology, 48, 203.
Elastotic degeneration
29
NiEBAtJER, G. & STOCKINGER, L . (1965) tJber die senile Elastosis. Histochemische und elektronmikroskopische Untersuchungen. Archivfur klinische und experimenlelle Dermalologie, 221, 122. Pl^RARD, J., KiNT, A. & DE BERASQUES, J. (1968) L'elastose senile. In: Maladie dii lissu elaslique cutane. XII' Congris de I'Association de Dermatologistes et Syphiligraphes de Langue Franfaise, Paris, 1965, Vol. I, p. 373. Masson et Cie, Paris. STEVANOVIC D . (1975) The difFuse and atrophic macular dermatosis. A premature and progressive light degenerative condition. Dermarologische Monarschrifr, To be published. TELLER, H.G., VESTER, G . & POHL, L . (1975) Elektronmikroskopische Untersuchungsergebnisse an der Inter-
zelluiarsubstanz des Coriums bei Altersatrophie. Zeitschrift fur Haut und Geschlechtskrankheiten, 22, 67. TUNBRIDGE, R.E., TATTERSALL, R.N., HALL, D.A., ASTBURY, W . T . & REED, R. (1952) The fibrous structure of
normal and abnormal human skin. Clinical Science, 11, 315. WEARY, P.E., Hsu, Y.T., RICHARDSON, D.R., CARAVATTI, C M . & WOOD, B . T . (1969} Hereditary Sclerosing
Poikiloderma. Archives of Dermatology, 100,413.
