Solar elastosis & Favre-Racouchot
Cutis rhomboidalis nuchae · sailor's skin · farmer's skin · nodular elastosis with cysts and comedones (Favre-Racouchot)
Solar elastosis is the histological and clinical hallmark of chronic UV photoaging — accumulation of degraded, disorganised elastin in the upper reticular dermis. It clinically manifests as thickened, yellow, leathery skin with deep wrinkles and is associated with multiple skin-cancer risk factors. Favre-Racouchot syndrome is a periorbital / temporal expression with characteristic open and closed comedones plus cysts on a background of severe solar elastosis. Recognition is important as solar elastosis is the principal field-cancerisation marker on the face, scalp and dorsal hands.
Pathogenesis
- Cumulative UV-A → fibrillin / elastin fragmentation; degraded elastotic material accumulates in the upper reticular dermis.
- Concomitant collagen degradation, blood-vessel remodelling, melanocyte irregularity.
- Risk factors: light skin (Fitzpatrick I-II), outdoor occupations, smoking (acts synergistically — Favre-Racouchot), male sex.
Clinical features
- Generalised solar elastosis: yellow, thickened, leathery skin; deep wrinkles, loss of elasticity.
- Cutis rhomboidalis nuchae: rhomboidal-patterned thickening of the posterior neck.
- Favre-Racouchot syndrome: bilateral periorbital / temporal yellow plaques with multiple open and closed comedones, cysts, milia; men >65 with heavy lifetime UV and tobacco exposure.
- Citrine skin (Milian): yellow papular cobblestoning.
- Erythrosis interfollicularis colli: erythema sparing follicular openings on neck.
- Stellate pseudoscars: white stellate scars on forearms / shins.
- Frequently background to actinic keratoses, lentigo maligna, BCC, cSCC.
Differential diagnosis
- Pseudoxanthoma elasticum — neck / flexures; younger; cardiac / ocular features.
- Mid-dermal elastolysis — fine wrinkling without yellowing.
- Cutis laxa — generalised loss of elasticity, congenital or acquired.
- Necrobiosis lipoidica — shins; yellow-brown plaques.
- Granuloma annulare.
- Necrobiotic xanthogranuloma, xanthelasma.
Management
- Prevention: rigorous daily SPF 30-50 broad-spectrum; sun-avoidance counselling; protective clothing.
- Topical: tretinoin 0.025-0.1% reverses some elastotic change over months-years; vitamin C; alpha-hydroxy acids; niacinamide.
- Procedures:
- Fractional CO2 / Er:YAG laser for textural improvement.
- Chemical peels (medium-depth TCA, phenol-croton) for moderate-severe elastosis.
- Intense pulsed light, photodynamic therapy (which also addresses subclinical actinic keratosis field).
- Favre-Racouchot:
- Topical retinoids; surgical / mechanical comedone extraction; CO2 laser ablation; isotretinoin in severe cases.
- Counsel about field cancerisation — examine for AK, Bowen, lentigo maligna, BCC; consider topical 5-FU / imiquimod / MAL-PDT field treatment.
References
- Yaar M, Gilchrest BA. Photoageing: mechanism, prevention and therapy. Br J Dermatol. 2007;157:874-887.
- Favre M, Racouchot J. Le syndrome élastoïdosique cutané nodulaire à kystes et à comédons. Ann Dermatol Syphiligr. 1951;78:681-702.
- Bhawan J et al. Photoaging versus intrinsic aging: a morphologic assessment of facial skin. J Cutan Pathol. 1995;22:154-159.
- Sherber NS, Hoang MP, Hile GA. Cutis rhomboidalis nuchae and Favre-Racouchot syndrome: classic clinical signs of chronic UV damage. JAMA Dermatol. 2018;154:225.
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