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University of Pittsburgh


What is cutis laxa?

Cutis laxa (CL) is a rare disorder of connective tissue that affects only about 400 families worldwide, or 1 in every 2,000,000 babies. Connective tissue also referred to as the extracellular matrix, provides the structural framework for many parts of the body, including skin, muscles, joints, blood vessels, and even internal organs. The most obvious symptom of cutis laxa is loose wrinkled skin, especially around the face, trunk, arms, and legs, which hangs in folds and causes an aged appearance. There are many different types of cutis laxa, including an acquired form as well as several different inherited forms. Since cutis laxa is caused by a defect or deficiency of the connective tissue, the skin symptoms are often also observed in conjunction with problems involving the respiratory, skeletal, intestinal, and cardiovascular systems. The involvement of which, if any, additional body systems depends on the type of CL and/or the genetic cause.

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How is cutis laxa inherited?

Cutis laxa (CL) is inherited in many different ways, depending on the type of cutis laxa. There are autosomal dominant (AD), autosomal recessive (AR), and X-linked recessive (XLR) forms of inherited cutis laxa. Cutis laxa can also be acquired by an individual who does not have one of the inherited forms of CL. The cause of the acquired form of CL is unknown, but it typically affects older adults following a severe illness with fever and rash. These individuals may have incurred damage to their connective tissue from some environmental cause such as exposure to certain medications, infections, cancer treatments, or secondary to an autoimmune disease such as lupus or rheumatoid arthritis. For more information on the inheritance of cutis laxa, please visit our Inheritance of Cutis Laxa page.

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What are the different types of cutis laxa?

Occipital Horn Syndrome (OHS)

OHS is rare, with fewer than 100 cases reported worldwide. Symptoms usually begin within the first decade of life, and include cutis laxa, skeletal problems (bony growths on the back of the skull, loose joints, and short stature), and pulmonary (lung), cardiovascular (heart), and gastrointestinal problems such as emphysema, aneurysms, and hernias. There can also be muscle weakness, and intelligence ranges from low normal to mild mental retardation. OHS is a disorder of copper metabolism caused by mutations (changes) in the ATP7A gene. Mutations in this gene prevent the body's cells from obtaining enough copper, which is necessary for the proper function of enzymes within many cell types, including bone, skin, and hair, as well as cells that comprise blood vessels and the nervous system. OHS is considered a less severe form of Menkes Syndrome, which is also caused by mutations in the ATP7A gene. OHS has previously been referred to as Ehlers-Danlos syndrome Type IX and X-linked Cutis Laxa. It has been called X-linked cutis laxa because the ATP7A gene is located on the X chromosome and inherited as an X-linked recessive (XLR) disease. For this reason, OHS typically affects only males. For an explanation of X-linked recessive inheritance, please visit our Inheritance of Cutis Laxa page.

Autosomal Dominant Cutis Laxa (ADCL)

ADCL symptoms begin anytime between birth and young adulthood. Symptoms include only cutis laxa in some of these patients. However, some families also exhibit specific facial features mainly involving the nose and ears, and cardiovascular and pulmonary problems such as aortic aneurysm and emphysema. Echocardiography and pulmonary function testing is recommended for these patients in order to identify heart and lung complications before they become life-threatening. Although most cases of ADCL result from mutations in the elastin (ELN) gene, at least one family with ADCL has been found to have a mutation in the fibulin 5 (FBLN5) gene, which is the cause of autosomal recessive cutis laxa type 1A (ARCL1A). For an explanation of autosomal dominant inheritance, please visit our Inheritance of Cutis Laxa page.

Autosomal Recessive Cutis Laxa (ARCL)

ARCL is divided into several subtypes, based both on specific symptoms and the gene which causes the condition. ARCL is divided into ARCL1 (often associated with severe diseases of lung and blood vessels), ARCL2 (characterized by growth or developmental delay), and ARCL3, which are then further divided into additional subtypes. For a detailed explanation of autosomal recessive inheritance, please visit our Inheritance of Cutis Laxa page.

ARCL1A or FBLN5-Related Cutis Laxa is characterized by cutis laxa, hernias, and pulmonary involvement such as emphysema from a young age. However, there is some variability in onset age for these symptoms. ARCL1A is caused by mutations in the FBLN5 gene.

ARCL1B or FBLN4 (EFEMP2)-related cutis laxa is characterized by cutis laxa and the involvement of other body parts, namely the cardiovascular system (arterial problems such as tortuosity, aneurysms and stenosis), skeletal system (loose joints, long thin fingers, hernias, and bone fragility), and some distinctive features involving the face and head (small chin, high-arched palate, and widely spaced eyes). ARCL1B can be extremely severe resulting in death soon after birth, or it can be limited to only the blood vessel and facial features noted above. ARCL1B is caused by mutations in the FBLN4 (EFEMP2) gene.

ARCL1C or LTBP4-Related Cutis Laxa is characterized by cutis laxa, as well as severe pulmonary, gastrointestinal, and urinary problems. ARCL1C is also known as Urban-Rifkin-Davis Syndrome (URDS). ARCL1C is caused by mutations in the LTBP4 gene.

ARCL2A or ATP6V0A2-related cutis laxa is caused by mutations in the ATP6V0A2 gene. Individuals with this type of cutis laxa have wrinkly skin over the entire body, which typically improves with age. Other features in these children include an enlarged anterior fontanel, dislocation of the hips that is present at birth, hernias, and nearsightedness. Many individuals with this condition have severe developmental delay and seizures. Wrinkly Skin Syndrome, which causes wrinkled skin, small head size, and mental retardation, as well as muscle and skeletal problems, is caused by mutations in the same ATP6V0A2 gene.

ARCL2B or PYCR1-related cutis laxa is caused by mutations in the PYCR1 gene. Clinical features of this disease include cutis laxa leading to an aged appearance, growth delay, developmental delay, joint and skeletal problems, small head size, large forehead, triangular-shaped face, and large ears.

ARCL3A This is otherwise known as De Barsy syndrome A. This subtype is characterized by growth retardation (limitations and delays in growth), variable intellectual disability, age experience, abnormalities with the eye like cataracts, and loose skin and joints. Inguinal and umbilical hernias are also sometimes associated with this syndrome. This subtype is caused by mutations in ALDH18A1. A portion of people with mutations this gene have issues producing certain types of amino acids and might have elevated levels of ammonia in the blood.

ARCL3B Also known as De Barsy syndrome B, this subtype has the same symptoms as ARCL3A. However, this subtype is mostly caused by mutations in the PYCR1 gene.

Gerodermia Osteodysplasticum (GO)

GO is a type of cutis laxa that occurs in babies or young children. These children have loose skin, mostly on the hands, feet, and stomach, as well as their face. Other features include a small jaw, hip dislocations, hernias, osteoporosis, fractures, and dwarfism. As with ARCL3, there are typically neither cardiovascular nor pulmonary symptoms. GO is also an autosomal recessive condition caused by mutations in theGORAB(SCYL1BP1)gene.

MACS Syndrome

MACS Syndrome is macrocephaly (large head), alopecia (sparse hair), cutis laxa, and scoliosis. Other features include puffy eyelids, flat feet, loose joints, and short stature. MACS is an autosomal recessive disorder caused by mutations in the RIN2 gene.

Acquired Cutis Laxa

Acquired cutis laxa typically occurs in older adults. Although its cause is unknown, it has been observed in some individuals after certain environmental exposures, such as some medications, infections, or autoimmune diseases. Acquired cutis laxa is not inherited. However, one aspect of Dr. Urban's research is to determine whether some individuals may have a genetic susceptibility to developing cutis laxa after certain exposures.

Unknown or Undescribed Types of Cutis Laxa

About half of the participants in our study to date cannot be assigned to any of the above listed types. These individuals may have mutations in genes that have not been identified as possible causes of cutis laxa yet. An important goal of Dr. Urban’s research is to find these unknown cutis laxa genes and to define the health problems associated with them.

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How do you diagnose cutis laxa?

Diagnosis of cutis laxa is typically made by physical examination of the skin by a physician such as a geneticist or dermatologist. The specific type of cutis laxa is determined by the associated features, family history information, and in some cases can be confirmed by genetic testing. However, some patients with or without a clinically identified cutis laxa gene mutation may choose to enroll in Dr. Urban's cutis laxa research study at the University of Pittsburgh.

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Are there any available treatments for cutis laxa?

After initial diagnosis, patients with cutis laxa typically receive cardiovascular and pulmonary evaluations, such as echocardiograms and lung function testing. Management of individuals with cutis laxa includes treatment of symptoms, such as surgical repair of hernias, medications such as beta-blockers may be considered to prevent growth of aortic aneurysms, and pulmonary emphysema is treated symptomatically. Regular cardiovascular and pulmonary follow-up should begin at birth or immediately after diagnosis. Environmental triggers such as cigarette smoking, which can worsen emphysema, and sun bathing, which can damage the skin, should be avoided, especially by patients with cutis laxa. Some individuals with cutis laxa may choose to undergo plastic surgery. Although the results from plastic surgery are typically very good, they may not be permanent, as the loose skin may reoccur.

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