Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Net letter
2011:77:3;403-404
doi: 10.4103/0378-6323.79746
PMID: 21508594

Disfiguring morphology of tuberous sclerosis

Sujay Khandpur, Sandeep Gupta
 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Sujay Khandpur
Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi
India
How to cite this article:
Khandpur S, Gupta S. Disfiguring morphology of tuberous sclerosis. Indian J Dermatol Venereol Leprol 2011;77:403-404
Copyright: (C)2011 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Tuberous sclerosis complex (TSC) is characterized by the development of hamartomas in various organs. Approximately one in 8000 adults and one in 6000 newborns is affected by TSC. [1] Skin lesions occur in 60-70% of the cases and are a major cause of morbidity. We present an interesting case of TSC with florid cutaneous manifestations that produced significant disfigurement and physical morbidity.

A 25-year-old girl presented with malodorous plaques over the face and neck since 2 years of age, papules in the oral cavity since 5-6 years and brownish papules and plaques over the nail folds of almost all fingers and toes since 8-10 years. There was history of unprovoked violent behavior since 1-2 years with delayed mental milestones, but no history of seizures, abdominal pain, urinary complaints, blurring of vision or backache. The patient was brought to the skin outpatient department (OPD) as she was cosmetically distressed by the skin lesions. She was a product of non-consanguineous marriage. There was no family history of tuberous sclerosis. The patient′s general physical and systemic examinations were normal. Cutaneous examination revealed multiple, dark brown to erythematous, discrete to coalescent papules and plaques, some pedunculated, suggestive of angiofibromas, predominantly over the central face, retroauricular area, left forearm and bilateral thighs [Figure - 1]. There was a diffuse brown, firm bosselated plaque studded with nodules, predominantly over the left side of the neck and upper chest. Multiple forehead plaques and many brownish plaques suggestive of shagreen patch were present over the lower back. Peri- and subungual fibromas (Koenen′s tumors), few being globose or having verrucous surface, involving all finger and toe nails and producing longitudinal grooves in the nail plates, were present [Figure - 2]. The oral cavity showed multiple (12-15), skin-colored to hyperpigmented, 1-3-mm-sized sessile and pedunculated papules over the lower labial mucosa and tip of the tongue, suggestive of mucosal fibromas.

Figure 1: Numerous erythematous to hyperpigmented large and small angiofibromas over the face and neck
Figure 2: Periungual fibromas involving all fingers

Investigations were normal except urine analysis, which revealed hematuria and pyuria. X-ray of the hands showed sclerosis in all proximal and middle phalanges of the fingers bilaterally. Ultrasound and computed tomography (CT) scan of the abdomen showed multiple angiomyolipomas in both kidneys. Chest X-ray showed minimal bilateral pleural effusion with few nodules and cysts in the bilateral lower lobes. CT scan head showed calcified subependymal nodules in the bilateral lateral ventricles and right cerebellar hemispheres and tubers in the left posterior parietal cortex. ECG and echocardiography were normal. The patient was referred to a plastic surgeon for excision of the unsightly facial tumors.

TSC is one of the common genodermatosis encountered in the dermatology OPD. However, this case is interesting in view of the grotesque mucocutaneous manifestations.

Tuberous sclerosis is an autosomal-dominant disorder with variable expression and a high rate of spontaneous mutations. Consequently, the clinical picture is inconstant, with large differences in manifestations and course of the disease, even in members of the same family. The existence of a gene of major effect that produces disease, coupled with modifier genes that influence expressivity, may explain this variability. [2]

Among adults with TSC, skin lesions take on a greater significance and, for about 15%, are a regular problem. Facial angiofibromas and periungual fibromas may be a source of recurrent bleeding and chronic infection, and may become painful. For others, they represent a significant cosmetic concern.

Angiofibromas usually appear at the age of 6 years, and are most common around puberty. The severity of the angiofibromas varies from small, barely noticeable papules, to large, disfiguring bulbous nodules. They have been reported to produce generalized overgrowth of tissues of the forearm and wrist, causing pain and reduced function. [3] A very disfiguring case of TCS manifesting as large ulcerated angiomatous tumor covering the entire right side of the face with numerous angiofibromas over the head and neck, associated fibromatous scalp lesions and shagreen patches, which required excision and grafting for facial lesion, has been reported. [4]

In a cross-sectional study of cutaneous features in TSC, of the 131 affected individuals, 96% exhibited skin signs, 81% patients had facial angiofibromas at age up to 14 years while only 54% had shagreen patches till this age. [3] Hypomelanotic macules were identified in 61% of the patients, of which 89% had more than one and 40% had more than five. Ungual fibromas were multiple in 75% of the patients, and were more common on the toenails (90%) than on the fingernails. Extensive skin tags were present on the neck, axilla, upper back or inguinal area in 6% of the patients. Oral manifestations included gingival fibromas in 36% of the patients and involved the anterior gingivae and, occasionally, buccal mucosa or under false teeth. Multiple or large glossal hamartomas requiring surgical excision have been reported.

Many of the cutaneous manifestations of TSC have also been found in multiple endocrine neoplasia (MEN) type 1 syndrome. Of 32 MEN1 patients, 88% had multiple (range 2-50) facial angiofibromas and 72% had discrete papular collagenomas. [5] Angiofibromas in MEN1 patients were smaller and fewer than in severely affected patients of TSC, and were often observed on the upper lip and vermilion border, areas spared in TSC. Also observed were cafι au lait macules in 38%, confetti-like hypopigmented macules in 6% and multiple gingival papules in 6%.

References
1.
Napolioni V, Curatolo P. Genetics and molecular biology of tuberous sclerosis complex. Curr Genomics 2008;9:475-87.
[Google Scholar]
2.
Boesel CP, Paulson GW, Kosnik EJ, Earle KM. Brain hamartomas and tumors associated with tuberous sclerosis. Neurosurgery 1979;4:410-7.
[Google Scholar]
3.
Webb DW, Clarke A, Fryer A, Osborne JP. The cutaneous features of tuberous sclerosis: A population study. Br J Dermatol 1996;135:1-5.
[Google Scholar]
4.
Alvarez E. Unusual cutaneous manifestations of tuberous sclerosis: Case report. Plast Reconstr Surg 1967;40:153-6.
[Google Scholar]
5.
Darling TN, Skarulis MC, Steinberg SM, Marx SJ, Spiegel AM, Turner M. Multiple facial angiofibromas and collagenomas in patients with multiple endocrine neoplasia type 1. Arch Dermatol 1997;133:853-7.
[Google Scholar]

Fulltext Views
6,846

PDF downloads
2,430
Show Sections