STRIAE ET MACULAE ATROPHICAE

Synonyms.—Atrophic lines and spots; Atrophoderma striatum et maculaturn;
Atrophia maculosa et striata; False cicatrices; Fr., Vergetures; Stries atrophiques.

Symptoms.—The atrophic striae (atrophia cutis linearis; striæ
atrophicæ; linear atrophy) are usually one or two lines in width, of
variable length, somewhat depressed, and commonly closely set and ar­
ranged in parallels; or they may be irregular and undulating, and with
a scarcely perceptible depression. In color they are a pinkish-white,
grayish, or white, with usually a glistening, scar-like appearance. Occa­
sionally with the lines are noted pin-head to bean-sized or larger spots
(maculæ atrophicæ), of closely similar appearances, and slightly depressed;
these latter may rarely be the sole manifestation. There are, with rare
exceptions, no subjective symptoms and no change in sensibility. The
hairs on the involved areas or lines usually show atrophic tendency, and
sometimes completely disappear. In origin these atrophic lines and
spots may be idiopathic or symptomatic, although there is a predominant
belief that they, or most cases at least, belong in the latter class, and due
essentially to mechanical overstretching. The most familiar example
is that of lineæ albicantes, observed on the abdomen of pregnant women
(lineæ gravidarum) and others in whom abdominal stretching has re­
sulted from tumors or, and on other parts as well, from rapid develop­
ment of fat. They are mostly closely set, in parallels, and running trans­
versely to the direction of greatest distention, although in some instances

¹ Unna, Histopathology, p. 1032.

² D. W. Montgomery, Philadelphia Med. Jour., Jan. 20, 1899. See Keratosis senilis
for other suggestions as to treatment.

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ATROPHIES

in which the stretching is fairly uniform in all directions they may be
concentrically arranged (Langer). Independent of pregnancy, however,
probably from the other cause mentioned—from fat development—
these atrophic lines are quite common; Schultze, quoted by Jar-
isch,¹ found in 36 per cent, of unmarried adult women parallel atrophic
lines running perpendicularly on the front of the upper thighs, and the
same, but of less regular direction, in 6 per cent, of men examined; he
believed that the preponderance is explained by the fact that at puberty
there is pronounced broadening of this region in women, whereas in men,
in whom the streaks were just as frequently transverse, the rapid growth
is in the length.

While such instances are probably to be designated as symptomatic,
others have been observed which cannot be so readily placed in this
class, but are more properly to be considered idiopathic, as, for example,
those in which the condition has followed typhoid fever, of which Shep­
herd² has reported a remarkable example. In his patient, a boy of fifteen,
the stripes were situated above both knees and over both patellae, de­
pressed, thin, and dry, purplish in color, elliptic in shape, and tapering
to a fine point at each end, the largest being \ inch wide and 6 inches
long. There was a distinct tendency to parallelism, transversely to
the limb, and a few atrophic macules were also to be seen. The new
lesions which appeared while the patient was under observation were,
for the most part, in spots which united to form a stripe. The first
step was the appearance of a shiny, depressed, cicatricial-looking spot,
and no antecedent hypertrophy, as described by Liveing, Duhring, and
others. Bradshaw, quoted by Shepherd, had almost a precisely similar
case as to location and characters in a girl aged thirteen. Plagge³
has observed the striæ on the abdomen in typhoid fever, in which there
had been no abdominal distention, but, on the contrary, extreme emacia­
tion. Barrs⁴ had a case under observation in which there were striæ paral­
lel with the ribs in the dorsolumbar region, four on left side and eight on
right, the widest \ inch wide, and the longest, 4 inches, having
the ordinary appearances, and which had followed an attack of pneu­
monia a year previously, and appearing without preliminary edema
or inflammation or distention. The patient, a nervous woman, had
experienced, at the time, intense pain over the streaks. There was no
anesthesia. Wilks,⁵ quoted by Shepherd, also noted 2 instances of
linear atrophy, about the knees in a youth aged nineteen, and a girl of
eighteen, with striæ all over the body, but especially the legs; in the latter
the marks were tender and sensitive, at first faint red, subsequently

¹ Jarisch, Hautkrankheiten, 1900 p. 918.

² Shepherd, Jour. Cutan. Dis., 1891, p. 59 (with illustration and some valuable liter­
ature and references, to which I am indebted. Several recent interesting cases of these
striæ about the knees (striœ patellares) have been reported by Northrup (1 case),
Fischer (1 case), Köbner (2 cases), and by Bunch (2 cases), Brit. Jour. Derm., Jan., 1905,
who reviews the subject with reference to the above cases and others. The condition
in these 6 cases was observed in growing children, and, with the exception of 1 case,
developed during or after typhoid fever.

³ Plagge. Zeitschrift f. die Staatsarzneikunde, 1861, p. 369.

⁴ Barrs, Brit. Jour. Derm., 1891, p. 152.

⁵ Wilks, Guys Hosp. Reps., 1861, p. 297.

STRIÆ ET MACULÆ ATROPHICÆ

621

purple, and then dead white. In these two there was no apparent cause,
although the boy had a tuberculous knee-joint. A case was under my
own care in a male adult in whom, on the lumbar region, right side,
there were numerous parallel atrophic lines, with a few cross striæ,
of unknown origin, the patient being in good health, In some instances,
as in 1 of 2 cases of the striated type observed by Féré and Quermonne,¹
principally in the lumbar region, the lines present bordering pigmenta­
tion; in their other case, involving the throat, breast, lumbar and gluteal
regions, the malady began as brownish striæ, subsequently growing white.
Other examples by Troisier, Manouvrier, and Bouchard, of apparently
idiopathic origin, are also referred to by Shepherd (loc. cit.). It is
probable, therefore, that all cases of atrophic lines cannot be placed to
the score of being mechanically produced by overdistention, although
Bouchard suggests that the rapid increase of tissue after fevers might
be the factor, but this does not seem to be supported by a study of the
cases. Even with the acceptance of this there must be some underlying
inherent condition of the cutaneous tissues. According to the observa­
tions² of Auboger, Bouchard, and Manouvrier linear atrophy developing
in typhoid is a symptom of grave import, as the fever in such instances
generally assumes an ataxo-adynamic form.

Idiopathic atrophic macules usually present the same characters
as the lines as commonly met with. In the cases observed by Wilson,³
Liveing,⁴ and Duhring⁵ there was an antecedent erythematous tinge;
also in Taylor‘s⁶ case. In Jadassohn‘s⁷ patient, a woman aged twenty-
three, there were numerous lentil- to dime-sized, bright red, depressed,
and thin areas, covered with wrinkled epidermis, on the extensor surface
of both arms, from the wrist to the shoulder; shilling-sized, dark-red
similar spots over the olecranon, with depressed striæ branching from
them; and groups of red, depressed striæ blanching upon pressure; some
ordinary striæ on thighs; the first stage of the macules seemed to be a
small red papule. Some of these various cases referred to would, I
believe, better bear the interpretation of morphea than that of the
malady under consideration; the relationship is doubtless often a close
one.⁸ Jadassohn‘s case of so general and almost continuous involve-

¹ Féré and Quermonne, Le Progrés Med., 1881, p. 839.

² Paris letter, Brit. Med. Jour., 1887, i, p. 300.

³ Wilson, Diseases of the Skin; also Jour. Cutan. Med., 1868, vol. i, p. 140.

⁴ Liveing, Brit. Med. Jour., Jan. 19, 1878.

⁵ Duhring, Diseases of the Skin, third edit., p. 442.

⁶ Taylor, Arch. Derm., 1876, p. 114.

⁷ Jadassohn, Trans. Ger. Derm. Cong. III., Leipzig, 1891; full abs. in Brit. Jour.
Derm., 1893, p. 30.

⁸ Johnston and Sherwell (Jour. Cutan. Dis., 1903, p. 302, with histologic study and
cuts) describe a case of “white-spot disease,” the peculiar manifestation consisting
of a striking dead-white, snow-colored, slightly raised pin-head to about bean-sized
spots. Some undergo involution, a thin scale separates, and there result punctate and
striate atrophy. Histologically, the process was limited to the papillary body and up­
per portion of the reticular layer, and found to be a pure degeneration. A strong
irritative treatment (saturated alcoholic solution of resorcin) had a satisfactory result.
The cases of Westberg and F. H. Montgomery (considered a peculiar form of morphea)
are referred to. Two cases (mother and daughter), presenting a suggestive clinical
resemblance, have been observed by Macleod (Brit. Jour. Derm., 1904, p. 224). In a
recent paper (Jour. Cutan. Dis., 1907, p. 1), F. H. Montgomery and Ormsby add
3 cases (with histology and illustrations), review reported cases (10), and conclude

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ATROPHIES

ment seems midway between “atrophic lines and spots” and idiopathic
general atrophy.

Symptomatic or consecutive patch atrophy, sometimes presenting
a clinical analogy to idiopathic atrophic macules, is observed in certain
skin diseases, such as leprosy, lupus vulgaris, lupus erythematosus,
syphilis, lichen planus, etc., but this is considered in connection with
the disease with which they are associated.

Pathology.—Exclusive of the cases in which overstretching is
the factor it is probable the condition is, as Schwimmer and some others
believe, of trophoneurotic origin, and, as Shepherd states, that in those
instances following fevers the latter were severe and prolonged. The
symmetry of the lesions and the neurotic character of most patients also
lend weight to this view.

The pathologic histology of the atrophic lines has been studied by
Kaposi, Langer,¹ and a few others, who found an atrophic condition of
the epidermis, the papillæ obliterated, diminution of the blood-vessels,
and disappearance of the fat-cells, separation of the connective-tissue
fibers, and the glandular structures atrophied. Langer‘s investigations
led him to believe that the striæ are produced by violent stretching,
due to disarrangement or separation of the connective-tissue fibers,
and not to rupture. Jadassohn noted in his case thinning of the epider­
mis, but with no structural alteration, and more or less complete dis­
appearance of elastic fibers of the cutis; there were no signs of an in­
flammatory process, although some blood-vessels were surrounded by
slight round-cell infiltration; the papules referred to indicated, however,
Jadassohn believes, that inflammation is the initial factor.

When once the atrophic lines and spots are established, the condi­
tion is a permanent one, and not removable or influenced by treatment.

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