Secondary anetoderma overlying schwannoma.

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Acta Derm Venereol 89
219
Letters to the Editor
© 2009 The Authors. doi: 10.2340/00015555-0625
Journal Compilation © 2009 Acta Dermato-Venereologica. ISSN 0001-5555
Sir,
Anetoderma is a clinical entity characterized by localized
atrophy of the skin owing to destruction of dermal elastic
fibres. Anetoderma may be classified as primary or secon-
dary. Primary anetoderma develops on clinically normal
skin without any other preceding dermatoses. Secondary
anetoderma occurs in association with another disease.
Here, we describe a patient with anetoderma occurring
in association with schwannoma.
CASE REPORT
A 46-year-old woman presented with a tumour on her
left upper arm of 3 years’ duration. There was no history
of trauma at the site. Physical examination revealed
a 1.5 × 1.5 cm, wrinkled, pink, elliptical, redundant
lesion with a firm underlying subcutaneous mass (Fig.
1). The patient complained of pain and tenderness. A
biopsy specimen showed well-demarcated nodules
composed of spindle cells with alternating Antoni A
and B areas, consistent with schwannoma. The collagen
bundles were pale and attenuated in the oedematous
overlying dermis, but appeared normal in the dermis
opposite the lower tumour margin. Verhoeff-van Gieson
staining showed a marked reduction in the quantity of
elastic fibres in the upper dermis above the schwan-
noma, but not in the dermis below the tumour (Fig.
2A and B). The patient was therefore diagnosed with
anetoderma secondary to schwannoma. The tumour
was completely excised and the patient healed well
without recurrence.
DISCUSSION
Secondary anetoderma is a rare disorder, most com-
monly observed in women aged 20–40 years. Histo-
pathological examination of the dermis reveals atrophic
and oedematous changes associated with diminished
fragmented collagen and absent elastic tissue. Secon-
dary anetoderma is usually associated with inflamma-
tory cutaneous diseases, including lupus erythematosus,
acne, and granuloma annulare; cutaneous infections,
such as herpes zoster and syphilis; and use of medica-
Secondary Anetoderma Overlying Schwannoma
Woo Jin Lee, Ji Hye Yang, Sung Eun Chang, Mi Woo Lee*, Jee Ho Choi, Kee Chan Moon and Jai Kyoung Koh
Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnapdong Songpagu, Seoul, 138-736, Korea.
*E-mail: jijulee@hanmail.net
Accepted October 20, 2008.
Fig. 1. A wrinkled, pinkish, elliptical, protruding lesion was observed on the
left upper arm of the patient.
Fig. 2. Histologic appearance of
the lesion. (A) Verhoeff-van Gieson
staining of the dermis overlying the
tumor, showing loss of elastic fibers.
(B) Verhoeff-van Gieson staining
of the lower dermis, showing intact
elastic fibers (arrows).

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220
Letters to the Editor
tions such as penicillamine (1). Secondary anetoderma
can also be a complication of cutaneous neoplasms,
such as pilomatricoma (2), xanthogranuloma (3),
lym phoma (4) and plasmacytoma (5). The underlying
tumour may be visible through soft and atrophic aneto-
dermic skin. The association with schwannoma is very
rare, with only one previous case report to date (6).
There are various hypotheses regarding the pathoge-
nesis of anetoderma. Elastolysis has been regarded as
enzymatically mediated, probably by elastases released
from macrophages in inflammatory diseases (7). Tumour
cells may release catabolic enzymes when subjected to
mechanical stress or irritation, and these enzymes may
damage elastic fibres (2). Continuous mechanical sti-
mulation of a cutaneous tumour would thus predispose
to secondary anetoderma, as observed in our patient, in
whom we observed a difference in elastolysis between
the upper and lower dermis. Tumour cells in the upper
marginal zone are prone to experience more mechanical
stress and release more catabolic enzymes than those in
the lower dermis. It could be postulated that secondary
anetoderma is more likely to occur in association with
cutaneous tumours located on sites exposed to continu-
ous pressure and/or mechanical irritation, tumours with
hard indurations, such as pilomatricomas, and tumours
located in the superficial dermis.
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Acta Derm Venereol 89