Focal Dermal Hypoplasia
NORD is very grateful to Kristina Bundra, NORD Editorial Intern, and V. Reid Sutton, MD, Associate Professor, Department of Molecular & Human Genetics, Baylor College of Medicine/Texas Chidlren’s Hospital, for assistance in the preparation of this report.
Synonyms of Focal Dermal Hypoplasia
- Combined Mesoectodermal Dysplasia
- Ectodermal and Mesodermal Dysplasia, Congenital
- Ectodermal and Mesodermal Dysplasia with Osseous Involvement
- Focal Dermal Dysplasia Syndrome
- Focal Dermato-Phalangeal Dysplasia
- Goltz-Gorlin Syndrome
- Goltz Syndrome
- No subdivisions found.
Focal dermal hypoplasia (FDH), also known as Goltz syndrome, is a rare multisystem disorder that principally involves the development of the skin, hands and feet and eyes. It is a type of ectodermal dysplasia, a group of heritable disorders causing the hair, teeth, nails, and glands to develop and function abnormally. A majority of the cases of FDH (about 90 percent) are seen in females. This disorder is characterized by skin abnormalities that develop into streaks or lines of tumor-like lumps on various parts of the body. This syndrome displays a wide array of symptoms and may affect almost any organ. FDH is caused by mutations or duplications/deletions in the PORCN gene.
FDH is a rare disorder that primarily affects females and has extreme variability. It is characterized by skin lesions that look streaked, underdeveloped or "punched-out", birth defects of the hands and feet and birth defects of the eyes. There may be inflammation, itching, reddening, blistering, and crusting of the skin. Skin may be absent, discolored or lack color (pigmentation) in some areas. The nails may be absent or appear abnormal. Wart-like growth (papillomas) are usually not present at birth but develop with age and are typically found on the gums, tongue, lips, nose, genetalia, and anus. Overgrowth of tissue may be found on the palms of the hands and soles of the feet. Excessive sweating (hyperhidrosis) or absence of sweating (hypohydrosis) is often present on the palms of the hands and soles of the feet. Nearly all individuals with focal dermal hypoplasia display at least a few of the skin abnormalities. The hair may be sparse, brittle, and/or missing.
Eye abnormalities are common and are present at birth and can include: drooping eyelids (ptosis); clouding of the cornea; a cleft along the edge of the eyeball (colobmas), involuntary rapid movement of the eye (nystagmus); absence of an eye (anophthalmia), wide spacing between the eyes; more than one color within the iris (heterochromia); dislocation of the lens; crossed eyes (strabismus); and/or exposure of the lining of the eyelid (ectropion).
Individuals with FDH may also have a variety of skeletal abnormalities, some of which may be present at birth. Curvature of the spine (scoliosis), fused vertebrae, underdeveloped or missing fingers or toes, extra fingers or toes (polydactyly), fingers or toes that have grown together (syndactyly), fingers that bend to the side (clinodactyly), permanently bent fingers (camptodactyly), and/or fusion of bones of the fingers and toes may be present. Other malformations of the skeleton may include a small skull, an underdeveloped jaw, a forward projection of the jaw, and/or uneven development of the face, limbs, or trunk. Cleft lip and palate may be present and may cause feeding, breathing, and vision problems.
Problems within the mouth are seen in more than 50 percent of patients affected. Failure of the teeth to develop properly often occurs in these patients. The teeth may be missing or underdeveloped and are unusually small or improperly spaced. Missing enamel may aid in the development of cavities.
Abnormalities of the ears, the eyes, the heart, central nervous system, gastrointestinal system, and the kidneys may also be present. Abnormalities within the gastrointestinal system may lead to problems with breathing and feeding. Intellectual disability can be found in some instances. Most patients with FDH are noted to be small at birth and have mild short stature.
An extremely wide range of symptoms characterizes FDH, making it difficult to diagnose.
In June 2007, research funded in part by the National Institutes of Health led to the identification of the gene that accounts for all cases of FDH. The gene is known as PORCN, and it creates proteins important in the development of the skin, skeleton, and eyes in a developing embryo and fetus. Recent studies of patients displaying symptoms consistent with FDH have found mutations or deletions in the PORCN gene in nearly all affected females.
The PORCN gene is found on the X chromosome, and the syndrome is a dominant X-linked trait. Chromosomes, which are present in the nucleus of human cells, carry the genetic information for each individual. Human body cells normally have 46 chromosomes. Pairs of human chromosomes are numbered from 1 through 22, and the sex chromosomes are designated X and Y. Males have one X and one Y chromosome and females have two X chromosomes. Each chromosome has a short arm designated "p" and a long arm designated "q". Chromosomes are further sub-divided into many bands that are numbered. For example, "chromosome 11p13" refers to band 13 on the short arm of chromosome 11. The numbered bands specify the location of the thousands of genes that are present on each chromosome. Thus, the identified location of the PORCN gene is Xp11.23.
Genetic diseases are determined by the combination of genes for a particular trait that are on the chromosomes received from the father and the mother.
X-linked dominant disorders are caused by an abnormal gene on the X chromosome and occur mostly in females. Females with these rare conditions are affected when they have an X chromosome with the gene for a particular disease. Males with an abnormal gene for an X-linked dominant disorder are more severely affected than females and often do not survive. Living males with FDH are “mosaic” for a change in the PORCN gene. This means that the change is seen in some, but not all, of the cells in their body.
Prevalence estimates are not available for FDH. Approximately 200 to 300 cases have been reported worldwide, and only about 10 percent are live born males.
Symptoms of the following disorders can be similar to those of focal dermal hypoplasia. Comparisons may be useful for a differential diagnosis:
Ectodermal dysplasias are a group of hereditary, nonprogressive skin diseases in which the affected tissue derives primarily from the ectodermal germ layer. The skin, its derivatives, and some other organs are involved. Symptoms may include eczema, poorly functioning sweat glands, sparse or absent hair, abnormal hair, disfigured nails, and difficulty with the nasal passages and ear canals. (For more information on these disorders, choose "ectodermal dysplasias" as your search term in the Rare Disease Database.)
Microphthalmia with linear skin defects (MLS) is associated with similar skin and eye abnormalities as is seen in focal dermal hypoplasia. However, limb and skeletal abnormalities are uncommon in MLS.
Incontinentia pigmenti (IP) is a rare genetic dermatological disorder affecting the skin, hair, teeth, nails, eyes, and central nervous system. It is inherited as an X-linked dominant trait.
IP is characterized by four stages, some of which may overlap. The first stage may be present at birth or appear in early infancy and consists of redness or inflammation of the skin. This irritation includes the scalp as well as the extremities and can last from a few weeks to several months. In the second stage, blisters develop into a raised, wart-like appearance with lesions that look like pustules. The extremities are involved almost exclusively in this stage, which may last for several months but rarely as long as a year. In the third phase, the skin darkens in a swirled pattern sometimes described as a "marble cake" appearance. This phase occurs from approximately 6 months into adulthood. The fourth stage is called the "atrophic" stage. Pale, hairless patches in addition to abnormal tooth shape and nails appear among adolescent and adult patients. The skin changes may fade later in life. (For more information on this disorder, choose " incontinentia pigmenti " as your search term in the Rare Disease Database.)
Rothmund-Thomson syndrome (RTS) is a multisystem disorder characterized by skin abnormalities, sparse hair, eyelashes, and/or eyebrows, small stature, skeletal and dental abnormalities, cataracts, and an increased risk for cancer, mainly osteosarcoma. The skin typically presents normally at birth, however, the rash of RTS develops between the ages of three and six months as redness (erythema), swelling, and blistering of the face and subsequently spreads to the extremities. The rash typically evolves over the course of months to years into a chronic pattern of increased or decreased skin color, skin thinning, and presence of prominent blood vessels. (For more information on this disorder, choose "Rothmund-Thomson syndrome" as your search term in the Rare Disease Database.)
Proteus syndrome is a condition that involves the atypical overgrowth of skin, bones, and the body's organs. Most medical scientists now agree that Joseph Merrick, known famously as the "Elephant Man", suffered from Proteus syndrome. The overgrowth is progressive and limits the range of motion of affected joints making them massively overgrown and fixed. It usually begins with the fingers, toes, and knees but can occur in any part of the body. The spine is commonly affected and the result is scoliosis. Other affected organs include the lungs, spleen, thymus, uterus, and colon. Fatty tumors (lipomas) may invade the limbs, trunk and, in some instances, the spinal canal. Other serious complications are blood clots, and some patients have mental retardation. (For more information on this disorder, choose "Proteus syndrome" as your search term in the Rare Disease Database.)
Diagnosis is based on clinical findings and affected babies are usually recognized at birth. DNA testing for the PORCN gene is available to confirm the diagnosis.
Clinical Testing and Workup
The diagnosis of focal dermal hypoplasia should be considered in patients with either of the following: multiple skin manifestations or one typical skin manifestation in addition to characteristic limb malformations. In order to better establish the extent of the disease and the treatment of the patient diagnosed, the following evaluations are often recommended: chest x-ray, eye exams, abdominal MRI, kidney ultrasound, hearing evaluation, and medical genetics consultation.
Treatment for patients with focal dermal hypoplasia is directed at the symptoms. Dermatological creams and protective dressings may relieve skin discomfort and prevent secondary infections. Dentures and hearing aids may be required. Heat and over-exercise should be avoided. Limb deformities may be treated with occupational therapy, assistive devices, or surgery. Surgical or laser therapy may be recommended for patients demonstrating trouble swallowing due to large fat deposits in the throat.
Genetic counseling may be of benefit for patients and their families.
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Focal Dermal Hypoplasia Resources
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Sutton VR. Updated: 04/11/2013. Focal Dermal Hypoplasia. In: GeneReviews at GeneTests: Medical Genetics Information Resource (database online). Copyright, University of Washington, Seattle. 1993-2013. Available at http://www.genetests.org. Accessed November 12, 2013.
McKusick VA, ed. Online Mendelian Inheritance in Man (OMIM). The Johns Hopkins University. Focal Dermal Hypoplasia. Entry Number; 305600: Last Update: 03/21/2013.Available at: http://omim.org/entry/305600 Accessed November 12, 2013.
Goltz RW. Focal Dermal Hypoplasia Syndrome. Medscape Reference. Last Update: June 18, 2012. Available at: http://emedicine.medscape.com/article/1110936-overview Accessed November 12, 2013.
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