Further biopsy specimens taken after a period of 6 months were histologically compatible with MDE. Elastica staining showed band-like and sharply demarcated elastolysis in the upper reticular dermis with conservation of the fine vertically orientated elastic fibres of the papillary dermis. In addition, focal areas of fragmented and absent elastic fibres were observed in the mid-reticular dermis (Fig. 2c). Only a scant perivascular lymphohistiocytic infiltrate was seen in the upper dermis. On closer examination, isolated and small clusters of CD68 (PGM1)-positive multinucleated giant cells were detected in the mid-reticular dermis showing elastophagocytosis.This case documents the transition of AEGCG into a noninflammatory end stage, clinically and histologically compatible with MDE. The pathogenesis of MDE is still unknown. Exposure to natural or artificial UV radiation frequently precedes the onset of MDE suggesting a pathogenic UV-mediated immunological mechanism. 3 However, MDE lesions are not usually confined to sun-exposed areas, so that other cofactors are likely to play a role. Extensive sun exposure was denied by our patient.An association of MDE with nicotine abuse and oral contraceptives as in our case has repeatedly been reported. It is still unclear if this is mere coincidence or if these substances represent relevant trigger factors. 4 MDE has been described after resolution of urticaria, erythematous skin changes and lesions resembling granuloma annulare. 5,6 In the majority of cases, however, MDE develops without a clinically obvious inflammatory prodromal stage.The clinical course in our patient suggests that AEGCG and MDE might represent different stages in the clinical spectrum of dermal elastolysis. After the inflammatory prodromal stage of AEGCG and phagocytosis of elastic fibres by multinucleate giant cells the noninflammatory 'burned-out' end stage of MDE could result in a loss of elastic fibres in the mid-dermis. As elastophagocytosis by macrophages is, to a much lesser extent, also a feature of early inflammatory MDE lesions, 7 AEGCG might represent a severe inflammatory variant of the same entity.

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