A Case of Symmetrical Cutaneous 
Atrophy of the Extremities 
BY 
Edward Bennet Bronson, M. D. 
Professor of Dermatology in the "New York Polyclinic 
REPRINTED FROM THE 
Journal of Cutaneous and Genito-Urinarv Diseases 
FOR JANUARY, 1895 Journal of Cutaneous and Genito-IIrinary Diseases, January, 1895. 
DR. BRONSON’S CASE OF 
SYMMETRICAL CUTANEOUS ATROPHY OF THE EXTREMITIES A CASE OF SYMMETRICAL CUTANEOUS ATROPHY OF THE 
EXTREMITIES.* 
By EDWARD BENNET BRONSON, M. D., 
Professor of Dermatology in the New York Polyclinic. 
MR. President and Gentlemen : 
The case which I am about to report, while not a unique 
one, is nevertheless such a rare form of atrophy of the skin 
that it has seemed to me not unworthy of engaging your attention. 
The patient exhibiting the peculiar affection was sent to me at the 
Polyclinic by Dr. F. P. Griswold, of Meriden, Conn., about the 
middle of last October. I was then only able to make a few notes and 
secure some indifferent photographs before the patient returned to his 
home. A second visit was paid me at mv request about one month 
ago. At this time I could not see that any changes had taken place 
in the appearances of the disease during the six months’ interval. 
Apparently the case had remained quite stationary. In the presence 
of the patient on this occasion two of the photographs taken previously 
were colored. I regret that my opportunities for studying the case have 
been so meager. Such notes as I was able to make are as follows: 
The patient is a man forty-five years of age, native of Germany, 
by occupation a varnisher in brass and iron works. His appearance is 
that of a well-developed, well-nourished person, and his manner indi- 
cates fair intelligence. lie is of spare, sinewy build and of brownish 
complexion, with dark hair and eyes. He states that his mother died 
* Read before the American Dermatological Association, May 31, 1894. 2 
Original Communications. 
of “ brain disease,” and an aunt, it would seem, has some mild form of 
paranoia. In other respects the family history is good. The patient 
formerly drank rather freely, but has generally led a regular, hard- 
working life, is married, and has three healthy children. He gives no 
evidence of syphilis nor of arthritic disease, and his first and only seri- 
ous ailment, he states, is the skin trouble with which he is now af- 
fected. The first sign of this was noticed fourteen years ago, in the 
region of the left ankle. The skin at this place seemed thinner and 
more sensitive, and the blue veins began to show prominently. There 
was also some scaling of the skin, and from time to time rather dry 
sores appeared over the bony prominences and were difficult to heal. 
Little by little similar changes began to appear higher up. A year or 
two later the same thing was noticed upon the right leg. These 
changes, it would seem, were neither preceded nor accompanied with 
any form of inflammation excepting such as attended the ulcers or 
sores, and these were of a very indolent character. Nor had there 
been any previous disease or injury to which the affection could be 
ascribed. It was apparently spontaneous and idiopathic. In course 
of time the hands and arms became similarly affected, but not, the 
patient thinks, till about five years ago. As the disease progressed 
and extended higher, it has been attended with occasional pain or dis- 
comfort, which thus far has affected only the lower extremities. The 
chief thing complained of has been a sense of great fatigue after work 
and long standing. This lasts, he says, for an hour or two after his 
work is over, and then disappears. So far it does not seem to have 
been sufficient to seriously interfere with or curtail his working hours, 
but chiefly because of the apprehension that it would come to this was 
he led to seek medical aid. Besides this feeling of fatigue, there have 
occasionally been sharp, shooting pains that would come in little 
shocks, especially at night, and often in the soles of the feet. There 
has been some itching in the vicinity of the ulcers that have developed 
from time to time about the ankles and anterior surfaces of the legs. 
No other abnormal sensations, such as a sense of constriction, tingling, 
numbness, “ pins and needles,” heat or coldness, have been complained 
of. It was noticed, however, that the affected surfaces were abnor- 
mally sensitive to touch, though not particularly to changes of tem- 
perature. 
Status prcesens.—When the patient is stripped a marked contrast 
is presented between the skin of the legs from the hips down, together 
with the lower two thirds of the arms, on the one hand and the surface 
of the rest of the body on the other, which latter everywhere appears 
perfectly normal. By comparison with the trunk the extremities ap- Case of Symmetrical Cutaneous Atrophy of the Extremities. 
3 
pear thin, as if slightly shrunken ; they are darker in color, show the 
courses of the veins more clearly, and are covered with multitudes of 
wrinkles diversified with 
smooth brownish or white 
interspaces that have a 
glazed appearance, resem- 
bling, but for the dusky 
color, a crumpled sheet of 
waxed paper or gold-beater’s 
skin. (See colored plate.) 
The wrinkling for the most 
part follows the cleavage 
lines of the skin. It is most 
marked about the extensor 
aspects of the knees and 
wrists, especially the for- 
mer. About the ankles and 
lower part of the legs the 
skin is a little scaly. 
The extent of the disease 
on the lower extremities is 
about the same on either 
side. It begins below at a 
pretty sharply defined line, 
about an inch and a half 
above the soles at the side 
and back of the feet, and 
one inch back of the roots 
of the toes in front, whence 
the affection extends up- 
ward continuously, embra- 
cing the entire circumfer- 
ence and length of the legs; 
in front to a point within 
two or three inches of the 
flexure of the thigh ; at the 
sides is bounded by a line 
that curves over the tro- 
chanter and behind reaches 
above the nates and half 
way up the surface of the 
sacrum. The cleft of the 
Fig. 1. 4 
Original Communications. 
nates, the perinseum, and genitals remain unaffected. The line of 
definition above is not very clear, though there is a marked contrast 
between the normal white velvety skin above and the reddish purplish 
brown, wrinkled, dry, and parchmentlike surfaces below. 
Upon the upper extremities the skin is affected from the base of 
the fingers (which latter are not affected) posteriorly and the palms 
anteriorly to an oblique line encircling the arm a little above the 
elbow. Its highest point, which on both sides is at the back of the 
arm, is near the junction of the lower and middle thirds, and is a trifle 
higher on the left side than on the right. Here, as on the lower ex- 
tremities, while there is a sufficiently marked contrast between the 
atrophied and the sound skin, the line of definition is somewhat indis- 
tinct. 
The Color.—This appears to be due to a blending of purple, red, 
and brown. (See colored plate.) Those elements of the skin upon 
which its opacity and consequent whiteness depend seem to have dis- 
appeared, permitting the blood-vessels underneath to show through. 
This is especially evident near the margins of the atrophied portions, 
where veins which are clearly perceptible in the latter are suddenly 
lost to view as they enter the area of normal skin. Besides the purple 
hue of the numerous veins there is a red reflex from the arterioles and 
capillaries. In some places there is a lilac coloring due to the com- 
bined effect of arteries and veins. Almost everywhere also there is a 
brownish discoloration which is made more evident when pressure is 
used so as to produce a temporary ischaemia of the part. In many 
places this brown pigmentation is seen to be punctate or in small lenti- 
golike spots. It occurs over almost the entire atrophic area, and con- 
tributes a considerable quota to the general dusky discoloration. The 
color varies, however, with the patient’s posture. Especially in the 
legs after the patient has been standing for a length of time the veins 
become turgid and greatly dilated, standing out as prominent tortu- 
ous ridges, and their deep purple color becomes everywhere predomi- 
nant, giving the appearance of cyanosis. 
In certain places, more especially over the legs and on the backs 
of the feet and hands, there are numerous whitish, scarlike patches 
where the atrophy has been more profound, and perhaps in some places 
corresponding to the sites of old ulcerations. (Fig. 1.) Even in many 
of these scarlike patches the punctate brown spots are distinctly pres- 
ent. Aside from these scarlike patches there are scattered over all the 
atrophic regions a multitude of small, slightly depressed spots wdiich 
are apparent only on closer inspection, and which seem to imply that 
the degenerative process has not been absolutely uniform, but has been Case of Symmetrical Cutaneous Atrophy of the Extremities. 
5 
more pronounced in certain places than others. Sucli shallow depres- 
sions are scattered abundantly over the thighs, buttocks, and arms. 
Near the outer malleoli of both legs are shallow, indolent ulcers 
with sharp-cut adherent edges and gray base, devoid of granulations 
and showing a scanty serous secretion. 
The wrinkling of the skin is apparent almost everywhere in the 
affected regions, though less marked on the legs than on the thighs and 
buttocks. In most places the wrinkles are extremely fine, looking at 
Fig. 2 
a little distance like minute striae. About the knees they are most 
pronounced. (See Fig. 2.) Here the thinned skin is thrown into 
numberless parallel transverse folds curving above and below the 
patellae, leaving between them flat, smooth, glistening surfaces that 
look as if waxed or varnished. These flat, smooth surfaces are most 
marked over the patellae. The wrinkling is well marked also over 
the nates, especially near the folds between the nates and thighs. The 6 
Original Communications. 
lines curve gracefully from the outer aspect of the thigh around the 
nates toward the cleft. Just back of the toes the skin is thrown into 
line wrinkles or striations that radiate outward from the atrophied por- 
tion, which here is whitish and scarlike with a lilac-colored border. 
The hairy growth has almost entirely disappeared from the affected 
region, including the lanugo as well as the coarser hairs. Apparently 
the little dots of pigment scattered over the legs and arms mark the 
sites of degenerated hair follicles. 
No sweating is apparent in the areas of atrophy. The patient 
states that his legs and arms are always dry, while the palms and soles 
sweat freely. While examining him, it was noticed that all around 
the borders of the teet, just without the atrophied portion, the skin was 
decidedly moist, while just above it was perfectly dry. To the touch 
the skin was like dry parchment. There seemed to be no change of 
temperature. It was neither below nor above the normal. Almost 
everywhere the skin was freely movable over the subjacent structures. 
On the legs, however, it was less so than elsewhere, and in places here 
was adherent. Elsewhere it could be readily pinched up, always in 
very thin folds, however, which on being released returned again to 
the niveau, though a little more slowly than in the normal skin. 
The sense of touch over the affected region is very little if any 
diminished, but the skin is distinctly hvperaesthetic. The patient 
shrinks away from the points of the aesthesiometer much more when the 
latter touch the atrophied skin than when the sound skin is touched, 
due evidently to loss or thinning of the protective layers of the 
epidermis. 
So far as could be ascertained, the organic muscles of the extremi- 
ties were not noticeably atrophic. The patient was not aware of any 
weakness of the limbs, and the muscles were firm and hard to the 
touch. The abnormal sense of fatigue, however, of which the patient 
complained, would imply that they were not entirely unaffected. The 
thinner appearance of the legs is doubtless, chiefly at least, attributable 
to the loss of subcutaneous fat. The muscular strength of the limbs 
seems little if any impaired, and apparently there is perfect co-ordi- 
nation as well as normal tendon reflexes. 
The above, though evidently a case of idiopathic atrophy of the 
skin, differs very materially from all the common forms of macular, 
striate, or diffuse atrophia cutis propria. The latter, as a rule, are sim- 
ply of the quantitative type, and resemble merely superficial cicatrices. 
Still less does this case resemble the stationary form of the xeroderma 
of Kaposi. Nor does it correspond to the symptomatic atrophies, such, 
for example, as succeed scleroderma and morphcea. Not only is there Case of Symmetrical Cutaneous Atrophy of the Extremities. 
7 
the history in such cases of a precedent condition of infiltration or in- 
duration, with more or Jess stiffness of the skin, but rarely even in the 
atrophied stage is the affected area devoid of a certain degree of con- 
densation and immobility. Nevertheless, in their ultimate state they 
may come to resemble the case which I have described above, and such 
cases have occasionally been reported as cases of idiopathic atrophy. 
In this category should, in all probability, be classed the “ general iodio- 
pathic cutaneous atrophy” of Wilson, as well as the cases of Schwim- 
mer* and Glax,f though these latter are both improperly referred to the 
xeroderma of Kaposi, that of Schwimmer being also denominated 
“atrophia cutis universalis.” 
A case reported by Judassohn before the German Dermatological 
Society in September, 18914 under the name of atrophia maculosa 
cutis, bore a certain resemblance in some of its features to the one just 
described. The lesions were symmetrical, and in some of the affected 
places the skin had the same dusky-red color and translucency, and 
was inelastic, wrinkled, and loosely adherent, but the atrophied spots 
were preceded by an eruption of papular elevations, that remained 
circumscribed and discrete, varying in size from that of a lentil to that 
of a silver mark piece. On account of the looseness and inelasticity of 
the skin, together with the preceding papulo-erythematous condition, he 
proposed the name anetodermia erythematodes. In a similar case 
presented by Beer # at the Yienna Dermatological Society in Febru- 
ary, 1892, the lesions were preceded by pronounced oedema. In both 
of these cases the atrophy affected chiefly the connective tissue, and 
more particularly the elastic fibers. 
The clinical type to which my case most clearly corresponds was 
first described by Buchwald,| and so peculiar is the type and well dif- 
ferentiated is it by this writer that it might well be known as Buch- 
wald’s atrophy. In his case the affection occurred in a man thirty-six 
years of age, and had existed for sixteen years. It began at both knees 
and extended at first both upward and downward, later the extension 
being only upward, but upon the legs below the knees indolent ulcers 
often formed. The greatest extent was reached in one year from the 
inception of the disease, though within the affected areas the degenera- 
tion continued to increase. There were no prodromal symptoms, and 
* Die neuropatliische Dermatosen, Wien, 1883, p. 189. 
j- Viertelj. f. Derm. u. Syph., 18*75, p. 114. 
X Monatshft. f. p. Derm., 1892, p. 621. 
* Arch. f. Derm. u. Syph., 1892, p. 835. 
|| Ein Fall von diffuser idiopathischer Haut-Atrophie. Viertelj. f. Derm. u. Syph., 1883,, 
p. 543. 8 
Original Communications. 
Fig. 3.—Buchwald’s Case. Case of Symmetrical Cutaneous Atrophy of the Extremities. 
9 
the setiology of the case was as obscure as that of mine. The entire 
surface of both knees and thighs was involved, reaching in front to 
within five centimetres of the inguinal fold, and behind extending up 
over the nates, much as in my own case. (Fig. 3.) The limits of the 
disease above were rather abrupt, the division between the normal, well- 
nourished, and fat skin above, and the somewhat sunken, darker-colored 
areas of atrophied skin below being marked by a pretty distinct ridge. 
The affected skin was freely movable over the subjacent structures, was 
nowhere bound down, rigid, nor cedematous. It could be raised in 
large folds which, when released, disappeared rather slowly or remained 
stationary until some movement caused them to disappear. Almost 
everywhere were multitudes of coarse or fine wrinkles. They were 
most marked about the knees, where they encircled the patellae, partly 
arranged in semicircles, partly in elliptical forms. On standing the 
wrinkling became more striking. Similar but finer wrinkles occurred, 
as in my case, over the nates. While in a recumbent posture the color 
of the skin was brown from pigmentation, but on standing the veins 
rapidly filled and became distended, and the color of the surface be- 
came cyanotic. There was no perceptible difference in temperature 
from the normal. The hairs had mostly disappeared from the affected 
areas. That the sweat glands were involved was shown not only by 
the customary dryness of the affected skin, but by the fact that when 
pilocarpine was injected hypodermically in a sufficient dose to cause 
copious diaphoresis the atrophied portions of the skin remained as dry 
as before. Sensation wTas not impaired. A microscopic examination 
of an excised bit of the diseased integument showed that the adipose 
layer had entirely disappeared. There was a general atrophy of all the 
elements of the skin, the sweat glands were largely diminished, there 
was marked atrophy of the hair follicles, and the papillae of the skin 
had disappeared. The connective tissue underneath the epithelial 
layer appeared swollen and infiltrated with cell nuclei. The nerves 
and blood-vessels were unchanged. 
Idiopathic cutaneous atrophy of the extremities, such as in this case 
of Buchwald’s, to which my case so closely corresponds, is undoubtedly 
rare. Several other cases, however, have been reported which are so 
nearly alike in their general characters as to warrant us in regarding 
Buchwald’s atrophy as a peculiar variety of disease. Two cases that 
are apparently of this variety have been reported by Pospolow,* 
though in these the symmetry was less pronounced and the laxity of 
the skin (judging from a photograph that accompanies one of the cases) 
* Annales de Derm, et de la Syph1886, p. 606. 10 
Original Communications. 
was somewhat greater than either in Buchwald’s case or in my own. 
The photograph shows dependent folds of skin resembling derma- 
tolysis. Also in Pospolow’s cases the sweat glands were unaffected; 
but in the main the features corresponded to those of Buchwald’s 
atrophy. 
Touton * and Kristian Groen f have reported cases that are more 
typical. In Touton’s case both upper and lower extremities were af- 
fected symmetrically. Groen’s case, in the location and extent of the 
atrophy, corresponded almost precisely to my own case. The patient 
was a sailor, forty-seven years of age, who entered the hospital for atonic 
ulceration of the leg, and had apparently paid little attention to the 
.atrophic condition, and of this no history was obtainable. 
* Deutsche med. Wochensch., 1886, p. 6. 
| Norsk Magazine. Referred to in the Lancet, Nov. 28, 1891, p. 1238.