DERMATOLYSIS

Synonyms.—Loose skin; Cutis laxa; Cutis pendula; Pachydermatocele (Mott);
Chalazodermia; Fr., Dermatolysie; Chalazodermie.

Definition.—A rare disease, consisting of hypertrophy and loose­
ness of the skin and subcutaneous connective tissue, with a tendency to
hang in folds.²

Symptoms.—The hypertrophic form of dermatolysis may be
congenital or acquired, and may be limited to a small or large area, or
develop simultaneously at several regions. The development may be
so extensive that the integument hangs in large folds, although ordinarily
it is much less marked. All parts of the skin, including the follicles,
glands, and subcutaneous connective tissue, share in the hypertrophy.
The skin and tissues are, however, soft and pliable, and sometimes show
variable elasticity. The follicular openings are often enlarged, and
occasionally contain comedo-like sebaceous plugs. The enlargement of
the follicles, and of the natural folds and rugæ, usually present to a varia­
ble degree, gives rise to an uneven surface, but soft, and sometimes slightly
unctuous to the touch. There is also a tendency to increased pigmenta­
tion, the integument becoming more or less brownish. It will be seen
that the condition bears a close resemblance to certain cases of fibroma,
but its looseness and absence of any “body” or tumor-like formation,

¹ Bircher, “Das Myxödem und die cretinische Degeneration,” Volkmann‘s Samm-
lung klinische Vorträge, No. 357 (Chirurgie, No. no) (a thorough exposition of the
malady, with case citations, review, references, and illustrations); Putnam, Amer. Jour.
Med. Sci., 1893, vol. cvi, p. 125; Osier (case resembling Bright's disease), Montreal
Med. Jour., 1896-97, vol. xxv, p. 642; Murray, “The Pathology of the Thyroid Gland,”
Lancet, 1899, vol. i, pp. 667 and 747 (a valuable contribution).

² For examples of extreme development, as well as its occasional resemblance and
identity to pendulous fibroma, the reader is referred to the following cases, some of
which are mentioned by Professor Duhring (Diseases of the Skin, third edit., p. 421);
Keen, Photo. Rev. of Med. and Surg., 1871-72, vol. ii, p. 45 (neck and shoulders, hanging
down to the buttocks; illustration); Mott, London Med.-Chirurg. Soc'y Trans., 1854,
vol. xxxvii, p. 155 (5 cases, some of which doubtful, with 2 illustrations); Fritsche,
London Clin. Soc'y Trans., 1873, vol. vi, p. 160 (2 cases with 1 illustration and sup­
plementary note by Tilbury Fox): John Bell, Principles of Surgery, edit., 1808, vol. iv
(Eleanor Fitzgerald case—2 illustrations, op. pp. 32 and 34); Stokes, Dublin Jour.
Med. Sci., 1876, p. 1 (scalp case—apparently a soft fibroma; with illustration); Cooke‘s
case (described by Duhring (loc. cit.), and also by Wilson, Lectures on Dermatology,
1874-75, P. 163.—the latter also describes Bell‘s case) (left hip and thigh, and hanging
in folds to the knee, like the legs of a pair of loose Turkish trousers); Alibert, Monogra­
phie des Dermatoses, 1855, vol. ii, p. 719, also pictured in La Pratique Dermatologie,
vol. i, p. 695 (face—numerous folds entirely concealing the visage); Wright, London
Patholog. Soc'y Trans., 1864-65, vol. xvi, p. 269 (on neck—2 illustrations).

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605

it seems to me, entitle it to a separate consideration. It is usually slowly
progressive, although it may, after reaching variable development,
remain stationary. There are no subjective symptoms, and, except
for its weight and inconvenience, gives rise to no discomfort. It may
be seated about the face, arms, neck, head, thighs; in fact, on almost
any part of the body.¹

The looseness and inelasticity of the integument (wrinkled skin,
loose skin) common to advancing years (see also Atrophia senilis), and
also resulting from the disappearance of fatty accumulations and follow­
ing the overdistention of pregnancy, etc, may here be briefly referred
to. In these instances the skin is not hypertrophied nor thickened,
but is somewhat loose or wrinkled, to a variable degree, from slight to
quite pronounced, as if too large for the enveloped part. In the senile
form, which is usually upon the face, or most marked on this region,
there is sometimes a trifling increase in the pigmentation. Its elasticity
is usually lost, and if picked up between the fingers returns but slowly
to its place.

Etiology and Pathology.—Its etiology is obscure. As already
remarked, it is congenital in some instances, and occasionally it has been
noted to be hereditary, as in Graf's case,² involving the left side of the
neck and lower eyelids, and which had occurred in several generations,
developing between the fortieth and fiftieth years. In the congenital
cases there is usually increased growth subsequently, generally most
marked beginning with puberty. It is undoubtedly allied to fibroma,
with which it is by most authors considered to be identical, and also
possesses some analogy to elephantiasis (Hebra and Kaposi), and, in
some instances, to mollusciform and lipomatous nævi and elephantiasis
telangiectodes, or angio-elephantiasis. These various growths, though
usually decided variants clinically, have a suggestive family resemblance.
In acquired dermatolysis the process sometimes takes its start at the
site of an injury or slight traumatism, as noted by Bell, Crocker, Demar-
quay,³ and others. This has led some writers to believe the affection
to be trophoneurotic in origin. There is much confusion as to the his-
topathologic findings, owing to the fact that in many instances they have
been based upon the formations known as mollusciform nævus and fibro­
ma. According to Duhring, “the growth consists of a simple hypertrophy
of the integument, including all its parts, especially of the subcutaneous

¹ Cutis verticis gyrata (Unna). Brief reference may be made here to a peculiar con­
dition of the scalp skin, first described by Jadassohn, subsequently by Unna, and by
von Veress (Dermatolog. Zeitschr., B. xv, Heft 11); the skin of the crown and back of
the head is found to be in furrows, giving an appearance reminiscent of the gyri and
sulci over the surface of the cerebrum. All cases have been males and, with one ex­
ception, dark-haired subjects. Its etiology is unknown, on the one hand being con­
sidered as consecutive to chronic inflammation, and on the other as a slow develop­
ment of a congenital abnormality. Audry (Annales, 1909, p. 257) and Vörner (Derma­
tolog. Wochensch., March, 16, 1912, liv, p. 309) have each recently reported a case;
Vörner believes it always free from inflammatory signs, and believes, therefore, that
von Veress’ case and also Vignolo Lutati‘s case should not be considered as representing
the condition.

² Graf, Casper‘s Wochenschrift, 1836, p. 225, quoted by Esmarch and Kulenkampff,
Die Elephantiaschen Formen, Hamburg, 1885, p. 204.

³ Demarquay, Bull, de Soc. de Chirurg., 1864, p. 343.

6o6

HYPERTROPHIES

connective tissue. Under the microscope it is seen to consist largely
of soft fibrous or lipomatous tissue, or of both in varying proportions.”

Prognosis and Treatment.—There is no tendency to spontane­
ous disappearance in this affection; on the contrary, there is usually a dis­
position to increase and extend, although often, after a time, or at periods,
there is a relative or complete cessation of growth. The treatment,
when desirable from the extent and situation of the hypertrophic mass,
consists in excision, bringing the skin together with sutures, the scar left
being linear and comparatively insignificant.

For the senile and similar wrinkling or looseness of the skin, referred
to above, for which, more especially that occurring about the face,
advice is sometimes sought, a variable degree of benefit can usually be
brought about by careful massage, the application of the faradic and
galvanic currents, and sometimes also by the employment of slightly
stimulating remedies, such as a 2 to 5 per cent, salicylic acid or resorcin
salve; and, occasionally, by plaster-like applications which bring about
a slight or moderate reactionary redness or dermatitis and consequent
exfoliation. A preparation that can be used for this last is that which
is referred to in the treatment of acne as the “peeling paste,” of one­ third
to full strength there given. It should be constantly worn from one to
several days or longer, according to the action, and then a mild salve
applied until exfoliation has been completed. The constant application
of one of the commercial, 10 to 25 per cent, salicylic acid plasters,
will also usually bring peeling of the skin and often lessening of the
blemish. The application should be constant and continuous. These
severe measures should not, of course, be employed in those eczema-
tously inclined.

Elastic Skin (Synonym: Cutis hyperelastica (Unna)).—This pecu­
liar condition, to which Crocker and a few others believe the term der-
matolysis is more appropriately applied, has only comparatively recently
received attention. It is that in which the integument is simply loosely
attached to the underlying tissues, and having the property of great
elasticity and distensibility; closely similar, in fact, to that which ob­
tains normally in the cat and many other animals. There are macro-
scopically no perceptible textural changes, the skin being to all appear­
ances perfectly normal, although usually with quite a sense of softness
to the touch. The amount of stretching permissible in these rare case
is almost beyond belief—the skin of the breast can be brought up over
the lower part of the face, and that of the chin can be stretched out like
a long beard, and as soon as let go, returns quickly to its place. The
subjects of this anomaly are known as “elastic-skin men,” “India-rubber
men,” several remarkable examples having been referred to or reported
by Turner,¹ Duhring,² Kopp,³ and Seifert.⁴ Such cases are occasionally

¹ Turner (Meekrin‘s case, a Spaniard, Georgius Albes), Diseases of the Skin, fifth
edit., 1736, introduction, p. x; this case is also referred to by Wilson (loc. cit., p. 162),
and of which an illustration is given in John Bell‘s Surgery, 1808, vol. iv, op. p. 36.

² Duhring, Medical News, 1883, vol. xliii, p. 705 (clinical demonstration, reported
by Henry Wile).

³ Kopp, Münch, med. Wochenschr., 1888, p. 259 (2 cases—father and son).

⁴ Seifert, Centralb. für klin. Med., 1890, p. 49.

DERMATOLYSIS

607

to be seen on exhibition around the country. The one referred to by
Duhring was also under my notice, the elasticity and distensibility being
really phenomenal. In this case, as Dr. Duhring stated, the skin was
more elastic in some directions than others—more when drawn trans­
versely to the natural lines than when drawn in a parallel direction.
When the stretched fold of skin was held up to the light, the cutaneous
circulation was beautifully seen. The elasticity may be general or only
in certain regions; in the case cited by Turner the skin of the left side of
the body was free, or relatively free, from this peculiarity.

Sections of the skin from Seifert‘s patient, which Du Mesnil¹ also
subsequently described, were made by the latter and histologically
studied by him and also by Williams and Unna, with some slight diversity
as to the findings. Kopp was of the opinion that the elastic fibers were
increased, but Du Mesnil did not find this to be the fact, but that the
fibers were merely wavy. The derma consisted of a more or less homo­
geneous mass, inclosing fusiform cells, and with absence of the normal
connecting tissue fibers; the latter Williams, in his examinations, found
present, but modified. This myxomatous condition would seem to
represent an arrest of development. In addition the nerves and vessels
showed elongation and were more or less winding, and, according to
Williams and Unna, the muscle-fibers were increased—to this last they
are inclined to attribute the elasticity of the skin in returning rapidly to
its normal position, flying back quickly. These several investigators
place most stress upon the abnormally winding course of the vessels and
nerves, permitting of considerable lengthening, and also believe, more­
over, that there is a special yielding property in the skin tissue itself.
These several facts, together with the comparative absence or modifica­
tion in the connecting fibrous tissue which normally binds the skin closely
to the underlying structure, would serve to explain the stretching of
which the integument in the cases is capable.

¹Du Mesnil, Verhandl. der. physic, med. Gesellsch. in Wurzburg, 1891, vol. xxiv
(same patient as described by Siefert, but a fuller account, with case illustration and 7
histologic cuts); Williams, Unna—Unna‘s Histopathology, p. 984.

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