Dermatological manifestations of Down syndrome

Author: Vanessa Ngan, Staff Writer, 2006. Updated by Dr Arun Gangakhedkar, Paediatrician, Waitemata District Board, Auckland. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. October 2018.


What is Down syndrome?

Down syndrome is a common genetic disorder resulting from the chromosomal abnormality, Trisomy 21. Individuals with Down syndrome have a cognitive delay and characteristic appearances associated with certain medical conditions [1–8].

Who gets Down syndrome?

Down syndrome incidence rises with advancing maternal age, but most are born to younger mothers under 30 years owing to a greater number of pregnancies in this age group. Due to an increase in the terminations of pregnancies with Down syndrome, the live birth prevalence decreased from one in 700 to about one in 1000 in New Zealand.

Studies suggest marginally higher rates of Down syndrome in boys than girls.

What causes Down syndrome?

A cell division error during early conception results in three copies of chromosome 21 instead of the usual two. The chromosomal abnormality results from a lack of normal separation (non-disjunction) during cell division as the pair of chromosomes in either the sperm or egg fail to separate. This results in a gain of an additional chromosome 21 and the occurrence of Down syndrome [1–8].

  • Standard trisomy 21 is the most common form of Down syndrome (affecting 95% of cases).
  • Translocation Down syndrome also has three copies of chromosome 21, but one of the 21 chromosomes is attached to another chromosome instead of being separate (3–4% of cases).
  • Mosaic Down syndrome can result from the cell division error resulting in two populations of cells within the same individual: one group with normal 46 chromosomes and another with trisomy 21 (1–2% of cases).

The clinical phenotype in all types of Down syndrome is similar, with subtle differences in mosaic Down syndrome which depends on the extent of the trisomy 21 cell population.

What are the clinical features of Down syndrome?

The diagnosis is suspected or confirmed in the neonatal period in most infants with Down syndrome. Characteristic physical features of Down syndrome include [1–8]:

  • Small hands and feet
  • Single transverse palmar crease
  • Associated central hypotonia
  • Congenital heart defects
  • Gastrointestinal malformations
  • Behavioural abnormalities
  • Refractive errors
  • Hearing impairment
  • Thyroid dysfunction
  • Distinct facial characteristics
    • Flat facial profile
    • Upward palpebral slant
    • Low set ears
    • Brachycephaly.

Cognitive delay is present in all individuals with Down syndrome. Children are reported to have higher rates of a seizure disorder (8%), coeliac disease and diabetes (1%).

Red cell macrocytosis and polycythaemia may affect up to two-thirds of infants. Transient myeloproliferative disorder (TMD) may be present in up to 10% of newborns with Down syndrome. Acute leukaemias are reported in 1 in 300 individuals with Down syndrome.

What are the cutaneous features of Down syndrome?

A single transverse palmar crease is the main cutaneous phenotype and is easily detectable. However, a single transverse palmar crease may also occur as a normal variant that is unilateral in 4% and bilateral in 1% of general population [9–18].

Other cutaneous features include dry skin and a large tongue with a scrotal appearance.

A variety of dermatological disorders are more common in Down syndrome due to combination of immune and genetic dysregulation and inefficient physiological processes.

Defective regulation of genes located on chromosome 21 may play a role in keratosis pilaris, alopecia areata, and vitiligo. Immune dysregulation leads to increased susceptibility to bacterial and fungal skin infections.

Transient physiological cutaneous manifestations are common during infancy, and chronic skin conditions appear with age.

Cutaneous features of Down syndrome

What are the physiological cutaneous manifestations of Down syndrome?

Acrocyanosis of hands and feet

Acrocyanosis is due to poor peripheral circulation and is more pronounced in Down syndrome. It is commonly observed in newborns.

Cutis marmorata

Cutis marmorata is a lacy mottled skin discoloration common during early infancy due to altered blood flow in the small blood vessels of the skin. Discolouration is most marked in the skin exposed to cooler environmental temperatures.

Livedo reticularis

The skin change due to livedo reticularis is similar but less marked than cutis marmorata. It mostly affects the lower limbs but may also be present on the arms and trunk. Livedo reticularis becomes more pronounced in cold weather.

Premature ageing

Signs of premature ageing reported in Down syndrome include greying or thinning of the hair, skin atrophy, early development of rhytids (wrinkles) and lentigines. The overexpression of the SOD gene, which regulates free radical metabolism, is located on chromosome 21, and is overexpressed as a result of trisomy 21. This leads to excess production of hydrogen peroxide, causing release of cytotoxic hydroxyl radicals. This in turn causes cell membrane lipid oxidation, altering the structure and function of the skin and involved tissues.

What are the chronic skin manifestations in Down syndrome?

The skin texture is soft and velvety in newborn infants with Down syndrome in comparison to unaffected infants. The skin becomes rough with altered texture through the school years with most adolescents and adults showing chronic skin changes [9–18].

Chronic skin conditions associated with Down syndrome may be related to immune insufficiency; autoimmune processes; infections and infestation-related complications; and defects of keratinisation or connective tissue.

Dry skin (xerosis)

The skin becomes increasingly dry, rough and inelastic and there is patchy lichenification with increasing age.

Eczema or atopic dermatitis

  • Recent studies report a prevalence of atopic eczema of up to 5%, which is similar to the general population.
  • Patches of eczema are red, scaly, and itchy. They generally involve the cheeks, behind the ears, knees and elbow flexures.
  • Malar erythema is more commonly seen in Down syndrome than in unaffected individuals.
  • Dry skin predisposes to irritant contact dermatitis and allergic contact dermatitis.

Seborrhoeic dermatitis

  • Seborrhoeic dermatitis occurs in about a third of patients, often associated with malassezia folliculitis.
  • It presents as an erythematous rash with yellow-brown scales involving the scalp, midfacial ‘T’ region, behind the ears, upper chest and back.

Palmoplantar keratoderma

  • Palmoplantar keratoderma is thickened skin on the palms and soles and affects up to 40% of those with Down syndrome.
  • Although uncommon in infants under 5 months, the prevalence of palmoplantar keratoderma is up to 75% for children over 5 years with Down syndrome.

Keratosis pilaris

  • Keratosis pilaris describes rough pinpoint spots (which may contain twisted hair) with varying red-brown pigmentation.
  • The papules affect the upper outer arms, sometimes the thighs, outer cheeks, trunk, and buttocks, and occasionally the forearms and lower legs.
  • Keratosis pilaris usually appears in adolescence.

Pityriasis rubra pilaris

  • Pityriasis rubra pilaris (PRP) is a rare chronic papulosquamous disorder of unknown cause.
  • It is characterised by well-defined areas of hyperkeratotic follicular papules which may evolve to erythroderma.
  • PRP causes thick, smooth, yellow palms and soles and abnormal nails.
  • Immunodeficient states may trigger severe forms of PRP.

Psoriasis

  • The incidence of psoriasis in the general population is 1–3%; the range is 0.5–8% in people with Down syndrome.
  • Immunocompromised patients may develop severe psoriasis.

Syringoma

  • Syringomas are benign tumours of the eccrine appendages.
  • They are reported in 18–39% of Down syndrome (up to 30 times more common than in the general population). There is a female preponderance.
  • Syringomas often develop during adolescence.
  • They are small (0.5–3 mm) flesh coloured or yellow-brown dermal papules and are typically distributed in the periorbital area.

Milia-like idiopathic calcinosis

  • Cutaneous calcinosis may present as asymptomatic discreet, firm, small, chalky-white milia-like papules. They mostly arise on the hands and feet.
  • Their pathogenesis is unclear. Increased sweat calcium and calcification of eccrine ducts may contribute, as there is no preceding injury or calcium metabolism abnormality.
  • The calcinosis heals without scarring.
  • Differential diagnosis includes molluscum contagiosum, viral warts, milia, and inclusion cysts.

Elastosis perforans serpiginosa

  • Elastosis perforans serpiginosa (EPS) is rare, affecting about 1% of patients with Down syndrome.
  • It presents as asymptomatic, erythematous and coalescent 2–5 mm keratotic papules arranged in linear, arcuate, or serpiginous patterns.
  • The papules may have umbilicated centres.
  • EPS most commonly appears on the neck, but also affects the chin, cheeks, arms and knees with an asymmetrical distribution.
  • The lesions develop slowly during adolescence and spontaneously resolve over 6 months to several years leaving atrophic linear or retiform scars.
  • Generalised EPS is associated with Down syndrome while the idiopathic form is usually localised.
  • EPS may represent a connective tissue dysplasia with transepidermal elimination of thickened elastic fibres.
  • It is also associated with other connective tissues disorders such as Ehlers-Danlos syndrome, Marfan syndrome, cutis laxa, pseudoxanthoma elasticum and osteogenesis imperfecta; and it may also be induced by D-penicillamine.
  • The differential diagnosis of EPS includes granuloma annulare, tinea corporis, annular sarcoidosis, cutaneous calcinosis and porokeratosis of Mibelli.
Elastosis perforans serpiginosa

Anetoderma

  • Anetoderma is a circumscribed area of flaccid skin often with fat herniation and ‘button-hole’ sign on palpation.
  • It most often affects the chest, back, necks and arms.
  • It is usually secondary to elastolysis, which is induced by leukocytes or bacteria associated with chronic folliculitis.
  • The congenital malformation of elastic fibres in Down syndrome may predispose patients to anetoderma.

Oral lesions

  • Geographic tongue occurs in about 11% of patients with Down syndrome.
  • Up to 40% of individuals with geographic tongue also have a fissured tongue.
  • Fissures and red, scaly skin at the corners of the mouth and lips may also occur (angular cheilitis).
  • Oral bacterial infection and oral candidiasis may occur.
Angular cheilitis in Down syndrome

Vitiligo

  • Vitiligo presents at any age with loss of skin pigmentation anywhere on the body.
  • There is a 3% prevalence of vitiligo in Down syndrome, marginally above the 2% prevalence in general population.

Other pigmentation abnormalities

Alopecia areata  

  • Alopecia areata affects 6–10% of those with Down syndrome compared to under 2% prevalence in the general population.
  • Hair loss can persist, but patchy alopecia regrows in most cases.
  • Alopecia totalis or alopecia universalis affects up to 2.5%.
  • Trichotillomania may coexist in 2–4% of patients with alopecia areata.
  • Alopecia areata is associated with autoimmune conditions such as vitiligo, hypothyroidism and trachyonychia.
  • Mx1, the alopecia areata gene, is mapped to the distal critical region on chromosome 21. The gene protein MxA is highly expressed in lesional anagen hair bulbs in alopecia areata but not in normal follicles.
  • Trisomy 21 increases the chance of having the alopecia areata variant gene.

Dermatitis herpetiformis

  • Dermatitis herpetiformis is rare.
  • It causes a symmetrical, pruritic, 1–3 mm papulovesicular and erosive rash on the extensor aspects of limbs, buttocks, and the midline of the back.
  • Purpuric lesions may be seen on the fingers and toes in children.
  • A coeliac screen should be completed if dermatitis herpetiformis is suspected.
  • Subepidermal bullae with microabscesses in the dermal papillae, with IgA deposits on direct immunofluorescence, are confirmatory on skin biopsy.

Hidradenitis suppurativa

  • Hidradenitis suppurativa causes pustules, nodules and abscesses in the armpits and groins.
  • Response to treatment with standard antibiotics is often poor.
Hidradenitis suppurativa in Down syndrome

Bacterial infections

Folliculitis in Down syndrome

Fungal infections

Tinea pedis and onychomycosis are common in Down syndrome.

Dermatophyte infections in Down syndrome

Parasitic infestations

  • Down syndrome individuals are predisposed to scabies infestations.
  • Crusted scabies may occur in Down syndrome and can be asymptomatic and thus diagnosed late, leading to a risk of widespread infestation in the community.

Lichen nitidus

  • Lichen nitidus causes asymptomatic, flesh-coloured shiny papules (1–2 mm) distributed in crops over the genitalia, abdomen, trunk and/or upper limbs in children.
  • The histopathology of lichen nitidus reveals focal papillary dermal lymphohistiocytic infiltrates resembling a ‘claw’ or ‘baseball glove and ball’.
  • The strength of association with Down syndrome is unknown but several case reports are cited in the medical literature [19].

Acanthosis nigricans

  • Acanthosis nigricans is a marker of insulin resistance and is associated with obesity.
  • It affects the flexures of the neck, the axilla and groin.
  • Rarely, it may also affect the flexor aspect of the elbow and knee and the dorsal interphalangeal and metacarpal joints.
Features associated with obesity in Down syndrome

Carotenaemia

  • Carotenaemia causes a benign yellow-orange hue of the skin involving the nasolabial folds, pinna, palms and soles but sparing the mucous membranes and sclera.
  • It is due to excessive intake of carotenoid-containing fruits and vegetables, such as carrots and pumpkin and has been reported in children on exclusion diets due to food allergy.
  • Hypothyroidism associated with Down syndrome may accentuate carotenaemia.

Leukaemia cutis

  • Rarely, blood dyscrasias such as transient myeloproliferative disorder or congenital leukemia are reported in Down syndrome infants.
  • Leukaemia cutis presents as characteristic blue, firm, infiltrated papules or nodular skin lesions.

How is Down syndrome diagnosed?

A clinical diagnosis of Down syndrome is always confirmed by cytogenetic analysis. A standard or conventional karyotype should be requested. A rapid FISH (fluorescent in-situ hybridisation) analysis for trisomy 21 should be specified on the laboratory request form when an urgent result is required.

Post-term, a diagnosis of Down syndrome can be made from identification of characteristic phenotypic features, but clinical diagnosis is not always possible in patients with mosaic Down syndrome.

Genetic disorders such as Smith-Magenis syndrome, Zelleweger syndrome and Beckwith-Weidemann syndrome may be confused for Down syndrome as these syndromes present with similar phenotypic features in early infancy. 

Careful skin examination is required as dermatological problems are reported in up to 87% of individuals with Down syndrome.

  • Clinical surveillance is required for associated conditions such as atlantoaxial instability, obstructive sleep apnoea, coeliac disease and diabetes.
  • Serum antibody titres and endoscopic biopsy results indicate a higher incidence of coeliac disease in Down syndrome (4.6–7.1%) compared to the general Western population (1–2%).
  • Routine antenatal screening and counselling are offered for high-risk pregnancies.

What is the general management of Down syndrome??

Managing skin and associated medical conditions is important for providing optimal medical care for individuals with Down syndrome.

  • Prenatal screening of the mothers, diagnosis in the early newborn period, regular health surveillance, supervision and support are important.
  • Obesity prevention measures are important to avoid skin conditions, musculoskeletal complications, insulin resistance and diabetes.

Other related support services should  include:

  • Educational and community support
  • Genetic counseling services
  • Antenatal screening during pregnancy: chorionic villus biopsy or amniocentesis should be considered in early pregnancy in at-risk mothers (see Prenatal diagnosis of inherited skin conditions), and the pregnancy should be managed with a multidisciplinary team approach. The risk of recurrence in a future pregnancy is slightly higher for the mother with a previous translocation or mosaic Down syndrome.

What is the outcome for patients with dermatological manifestations of Down syndrome?

Most skin conditions may be managed with optimal care and supervision.

Longevity in Down syndrome is influenced by the severity of congenital abnormalities or associated medical problems. Substantial improvements in the life span are observed with better health surveillance and management compared to a few decades ago.

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References

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  2. Fried K. A score based on eight signs in the diagnosis of Down syndrome in the newborn. J Ment Defic Res 1980; 24: 181–5. PubMed
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