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Peer Reviewed

Dermatologic Conditions

What Are These Raised, Yellow, Horizontal Streaks on an Older Man’s Back?

Volume 61 - Issue 8 - August 2021

AUTHORS:
Itohan H. Omorodion, MPH1 • Barbara B. Wilson, MD2

AFFILIATIONS:
1School of Medicine, University of Virginia, Charlottesville, Virginia
2Department of Dermatology, University of Virginia, Charlottesville, Virginia

CITATION:
Omorodion IH, Wilson BB. What are these raised, yellow, horizontal streaks on an older man’s back? Consultant. 2021;61(8):e11-e12. doi:10.25270/con.2021.02.00005

Received September 16, 2020. Accepted December 30, 2020. Published online February 10, 2021.

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Itohan Omorodion, MPH, University of Virginia, 1221 Lee Street, Charlottesville, VA, 22908 (iho5gp@virginia.edu)

 

A 50-year-old man presented to our dermatology clinic for a routine skin examination.

On physical examination, the patient had multiple asymptomatic, pale yellow, slightly raised, linear plaques on his lower back (Figures 1 and 2). The lesions were first noted when he was a teenager and had remained unchanged since then.

He denied any significant weight gain or abnormally rapid growth spurt when he first noticed the plaques as a teenager.

figure 1 stiae

Figure 1. Multiple pale yellow, horizontal, linear, striae-like plaques were noted on the patient’s lower back.

Figure 2 elevated appearance

Figure 2. An elevated appearance of the horizontal linear plaques is shown in the presence of a casted shadow.

 

 

Answer and discussion on next page.

 

    Correct answer: C. Linear focal elastosis

    Based on the appearance and history of the lesions, the diagnosis of linear focal elastosis (LFE) was made.

    Discussion. LFE is characterized by asymptomatic, pale yellow, palpable, and indurated linear horizontal plaques that primarily occur on the middle or lower back.1 Less common locations of the rash are the face, legs, and shoulders.2,3 LFE is a rare rash that is commonly misdiagnosed as striae distensae. Early presentation of LFE includes atrophy and erythema due to elastolysis, which is an underreported finding that was seen in a case series.1 Late presentation of LFE includes hypertrophy, no erythema, and a yellow appearance attributed to reactive elastogenesis.1 Hyperpigmentation has also been observed in some cases.4

    Biopsy can be performed to confirm the diagnosis of LFE. On histopathological evaluation, the key feature of LFE is increased elastic fiber content in the dermis, while the epidermis remains unaffected. In the dermis, bundles of collagen either have a normal or hypertrophic appearance, and aggregates of elastic fibers may be seen within them.2,5 Verhoeff-van Gieson and Weigert stains for elastic fibers demonstrate an increased presence of thin, wavy, elongated, and fragmented elastic fibers in between collagen bundles in the dermis.2 The papillary dermis of affected skin has a decreased presence or absence of elastin, fibrillin-1, fibrillin-2, and microfibril-associated glycoproteins 1 and 4.6 Other reported histological findings are a perivascular lymphocytic infiltrate and lack of calcification as evidenced by negative results of von Kossa staining for calcium.2,7 Early histological changes involve inflammation, elastolysis, and fragmentation of the elastic fibers, while late histological changes reflect elastosis and reactive regeneration.2

    Initially, LFE was thought to primarily occur in elderly men. However, recent literature has noted that LFE also affects younger individuals and women.2 The etiology of LFE is unclear; however, there are theories that it is a form of keloidal repair of striae distensae or an aberrant regeneration of elastic fibers.1,2,7,8 Historically, LFE has been theorized to be related to aging, androgenic changes, and mechanical trauma.2 However, new evidence suggests that LFE may also be related to abnormal alterations in the metabolism and degradation of elastic fibers, thus leading to hamartomatous and nevoid changes.2 A few reported cases included a risk factor of family history of LFE.1 LFE is generally not associated with any comorbidities, although previous case reports have observed blunt trauma, pregnancy, rapid weight loss, rigorous exercise, a growth spurt, and prolonged ultraviolet light exposure to be associated with its onset.1,4,9

    Striae distensae is a common misdiagnosis for LFE, but striae are distinguished from LFE by their pink or silvery color and atrophic appearance.10 Striae can be seen during pregnancy and are often associated with steroid use, hormonal changes, rapid weight gain or growth, smoking, and surgery.6 It commonly affects the abdomen, thighs, breasts, and buttocks.6 Most theories suggest that the striae are due to alterations in the structure of collagen in the dermis.6

    Treatment and management. Currently, there is no definitive treatment for LFE.1 According to a recent case report, avoiding intense physical activities can prevent the progression of lesions by reducing further mechanical damage.9 However, most cases of chronic LFE lesions are stable and do not tend to progress.11

    A previous case report noted partial regression of the lesions after treatment with a combination of Centella asiatica extract and sunblock.4

    Patient outcome. Since there is no standard effective treatment for LFE and our patient was asymptomatic, we offered him reassurance.

    References

    1. Seol JE, Kim DH, Cho GJ, Park SH, Jung SY, Kim H. Linear focal elastosis: A case report and institutional case series of 22 patients. Australas J Dermatol. 2019;60(3):e261-e263. https://doi.org/10.1111/ajd.12976
    2. Péc J, Chromej I. Linear focal elastosis: what's new? J Eur Acad Dermatol Venereol. 2004;18(3):247-249. https://doi.org/10.1111/j.1468-3083.2004.00914.x
    3. Andrés-Ramos I, Alegría-Landa V, Gimeno I, et al. Cutaneous elastic tissue anomalies. Am J Dermatopathol. 2019;41(2):85-117. https://doi.org/10.1097/dad.0000000000001275
    4. Inaloz HS, Kirtak N, Karakok M, Ozgoztasi O. Facial linear focal elastosis: a case report. Int J Dermatol. 2003;42(7):558-560. https://doi.org/10.1046/j.1365-4362.2003.01733.x
    5. Tamada Y, Yokochi K, Ikeya T, Nakagomi Y, Miyake T, Hara K. Linear focal elastosis: a review of three cases in young Japanese men. J Am Acad Dermatol. 1997;36(2 Pt 2):301-303. https://doi.org/10.1016/s0190-9622(97)80403-3
    6. Lung PW, Tippavajhala VK, de Oliveira Mendes T, et al. In vivo study of dermal collagen of striae distensae by confocal Raman spectroscopy. Lasers Med Sci. 2018;33(3):609-617. https://doi.org/10.1007/s10103-017-2431-3
    7. Arroyo MP, Soter NA. Linear focal elastosis. Dermatol Online J. 2001;7(2):18. https://escholarship.org/uc/item/90q6581j
    8. Hashimoto K. Linear focal elastosis: keloidal repair of striae distensae. J Am Acad Dermatol. 1998;39(2 Pt 2):309-313. https://doi.org/10.1016/s0190-9622(98)70378-0
    9. Kaur I, Jakhar D, Bhattacharya SN, Sharma S. Linear focal elastosis localized to bilateral knee of a marathon runner. J Postgrad Med. 2019;65(1):60-61. https://doi.org/10.4103/jpgm.jpgm_494_18
    10. Leung AK, Barankin B. Physiological striae atrophicae of adolescence with involvement of the upper back. Case Rep Pediatr. 2013;2013:386094. https://doi.org/10.1155/2013/386094
    11. Choi SW, Lee JH, Woo HJ, et al. Two cases of linear focal elastosis: different histopathologic findings. Int J Dermatol. 2000;39(3):207-209. https://doi.org/10.1046/j.1365-4362.2000.00848.x