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RESIDENT'S PAGE
Year : 2005  |  Volume : 71  |  Issue : 1  |  Page : 57-59

Lines of Blaschko


Departments of Skin and V.D. Govt. Medical College, Patiala, India

Correspondence Address:
Sunita Tagra
55, Surjit Nagar, Kapurthala Road, Jalandhar City - 144 002, Punjab
India
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DOI: 10.4103/0378-6323.13796

PMID: 16394371

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How to cite this article:
Tagra S, Talwar AK, Walia RS. Lines of Blaschko. Indian J Dermatol Venereol Leprol 2005;71:57-9

How to cite this URL:
Tagra S, Talwar AK, Walia RS. Lines of Blaschko. Indian J Dermatol Venereol Leprol [serial online] 2005 [cited 2014 Apr 19];71:57-9. Available from: http://www.ijdvl.com/text.asp?2005/71/1/57/13796



  Introduction Top




The lines of Blaschko represent a pattern assumed by many different nevoid and acquired skin diseases on the human skin and mucosae.[1] These lines do not correspond to any known nervous, vascular or lymphatic structures but represent the developmental growth pattern of the skin.[2] The epidermis and its appendageal structures such as melanocytes, vascular system, fatty hypoderm, all, separately or in combination, may be involved in the morphological manifestations which follow the Blaschko's lines. The embryological basis of these lines is not clear.[1]




  Historical background Top




The lines of Blaschko were described and drawn in 1901 by Alfred Blaschko (1858-1922), a private practitioner of dermatology in Berlin.[3] He examined more than 140 patients with nevoid and acquired linear skin diseases and carefully transposed the pattern in each patient onto dolls and statues. The lines thus obtained were schematically transferred to the back and front view of the human body. A composite diagram of these distribution patterns was then drawn that has subsequently been referred to as the lines of Blaschko. His original description of the lines has been translated as 'a system of lines on the surface of the human body which the linear nevi and dermatoses follow'.[1] About 75 years later, Jackson provided a detailed review of the 1901 publication and introduced the concept of the lines of Blaschko in the English language medical literature.[1]




  Description of the lines of blaschko Top




In Blaschko's lines [Figure - 1] and [Figure - 2], there is a V-shape over the upper spine, an S-shape on the abdomen, and an inverted U-shape from the breast area onto the upper arm. There are perpendicular lines down the front and back of the lower extremities.[1] As the distribution of the lines is linear, these were earlier thought to represent Koebner's phenomenon but the curvature of the lesions does not support this hypothesis.[4] The lines of Blaschko are less well-defined on the head and neck. Happle et al[5] added lines to the posterior scalp whereas Bolognia et al[4] further delineated the lines on the lateral aspect of the face and neck. The anatomic equivalent of Blaschko's lines has been described in the teeth and eyes as well.[4]



Blaschko's lines have been confused with dermatomes most commonly as both the distribution patterns are characterized by a striking demarcation of cutaneous lesions at the midline. But on close comparison the two do not seem to be related, though on the upper extremities there is a resemblance to the anatomical location of the motor nerves.[1],[4] Similarly, Blaschko's lines can be differentiated from Voigt's lines (the boundaries of the areas of distribution of the main cutaneous nerve stems) as these lines do not explain the V-shape on the back or the S-shape on the abdomen.[1],[4]




  Basis of distribution pattern of the lines of blaschko Top




The embryological basis of distribution pattern of these lines is so far an enigma, but certainly these are distinct from other known linear patterns. They do not relate to any vascular or lymphatic structures in the skin.[1],[4] Jackson suggested that their localization is partly determined by the dermal tissues.[1] An inborn error of morphogenesis due to a single mutant gene[6] or stretching of the skin during embryogenesis[4] have also been proposed as the underlying mechanisms. Their characteristic distribution pattern points to the presence of two different clones of cells in early embryogenesis. Thus, possibly, these lines represent a form of human 'mosaicism' where two or more genetically distinct cell populations are present in an individual derived from a single zygote. These different clones may be due to lyonization (random inactivation of one of the two X chromosomes in all cells in females), post-zygotic somatic mutations during early embryogenesis or gametic half chromatid mutation occurring before fertilization.[1],[4] But no single theory as yet clearly elucidates the localization of Blaschko's lines.




  Dermatoses following the lines of blaschko Top




Several congenital and acquired dermatological conditions are known to follow the lines of Blaschko. These dermatoses have been grouped as genodermatoses [Table - 1], congenital and/or nevoid conditions [Table - 2], and acquired conditions [Table - 3]. There are recent reports of the occurrence of the erythematous exanthem of scarlet fever along these lines in a child with hypomelanosis of Ito,[15] and of eosinophilic cellulitis[16] along these lines. Contrary to earlier belief, recently cases of linear scleroderma, both of the fronto-parietal type and those occurring on limbs, have been reported in a Blaschko pattern.[4],[14]



Becker's nevus, segmental neurofibromatosis, zosteriform leukemia cutis, cutaneous metastases and angiolipomas probably do not follow the lines of Blaschko.[4]



There have been successive theories to explain Blaschko's lines each more convincing than the previous one, but till date mosaicism remains the most widely accepted one. However, no definitive conclusion has been reached and therein lies scope for research.

 
  References Top

1.Jackson R. The lines of Blaschko: A review and reconsideration. Br J Dermatol 1976;95:349-60.  Back to cited text no. 1  [PUBMED]    
2.Harper JI. Genetics and Genodermatoses. In: Rook/Wilkinson/Ebling Textbook of Dermatology. Champion RH, Burton JL, Burns DA, Breathnech SM, editors. 6th Ed. Oxford: Blackwell Science; 1998, p. 360-1.  Back to cited text no. 2      
3.Blaschko A. Die Nervenverteilung in der Haut ihrer Beziehung zu den Erkrankungen der Haut. Wien: Wilhelm Braumuller, 1901. Quoted by Jackson R. The lines of Blaschko: A review and reconsideration. Br J Dermatol 1976;95:349-60.  Back to cited text no. 3      
4.Bolognia JL, Orlow SJ, Glick SA. Lines of Blaschko. J Am Acad Dermatol 1994;31:157-90.  Back to cited text no. 4  [PUBMED]    
5.Happle R, Fuhrmann-Rieger A, Fuhrmann W. Wie verlaufen die Blaschko-Linien am behaarten Kopf? Hautarzt 1984;35:366-9. Quoted by Bolognia JL, Orlow SJ, Glick SA. Lines of Blaschko. J Am Acad Dermatol 1994;31:157-90.  Back to cited text no. 5      
6.Holmes LB. Inborn errors of morphogenesis: A review of localized hereditary malformations. New Eng J Med 1974;291:763-73.  Back to cited text no. 6  [PUBMED]    
7.Rieger E, Kofler R, Borkenstein M, Schwingshandl J, Soyer HP, Kerl H. Melanotic macules following Blaschko's lines in McCune-Albright syndrome. Br J Dermatol 1994;130:215-20.  Back to cited text no. 7  [PUBMED]    
8.Duran-McKinster C, Rivera-Franco A, Tamayo L, de la Luz Orozco-Covarrubias M, Ruiz-Maldonado R. Bart syndrome: The congenital localized absence of skin may follow the lines of Blaschko. Report of six cases. Pediatr Dermatol 2000;17:179-82.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Requena C, Torrelo A, de Prada I, Zambrano A. Linear childhood cutaneous lupus erythematosus following Blaschko lines. J Eur Acad Dermatol Venereol 2002;16:618-20.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Nagai Y, Ishikawa O, Hattori T, Ogawa T. Linear lupus erythematosus profundus on the scalp following the lines of Blaschko. Eur J Dermatol 2003;13:294-6.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Choi SW, Yang JE, Park HJ, Kim CW. A case of extragenital lichen sclerosus following Blaschko's lines. J Am Acad Dermatol 2000;43:903-4.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Krasowka D, Schwartz RA, Lecewicz-Torun B. Generalised lichenoid drug eruption following Blaschko lines. Int J Dermatol 2001;40:774-6.  Back to cited text no. 12      
13.Danarti R, Bittar M, Happle R, Konig A. Linear atrophoderma of Moulin: postulation of mosaicism for a predisposing gene. J Am Acad Dermatol 2003;49:492-8.  Back to cited text no. 13      
14.Soma Y, Kawakami T, Yamasaki E, Sasaki R, Mizoguchi M. Linear scleroderma along Blaschko's lines in a patient with systematized morphea. Acta Derm Venerol 2003;83:362-4.  Back to cited text no. 14  [PUBMED]    
15.Duran-McKinster C, Moises C, Rodriguez-Jurado R, Tamayo-Sanchez L, Orozco-Covarrubias L, Ruiz-Maldonado R. Streptococcal exanthem in a blaschkolinear pattern: Clinical evidence for genetic mosaicism in hypomelanosis of ito. Pediatr Dermatol 2002;19:423-5.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.Sommer S, Wilkinson SM, Merchant WJ. Eosionophilic cellulitis following the lines of Blaschko. Clin Exp Dermatol 1999;24:449-51.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]  


    Figures

  [Figure - 1], [Figure - 2]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3]

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