Barber–Say syndrome

Barber-Say syndrome (BSS) is a very rare congenital disorder associated with excessive hair growth (hypertrichosis), fragile (atrophic) skin, eyelid deformities (ectropion), and an overly broad mouth (macrostomia).^[1]

Barber Say syndrome
Other names	Hypertrichosis-atrophic skin-ectropion-macrostomia syndrome
Barber-Say syndrome has an autosomal dominant pattern of inheritance
Usual onset	Neonatal

Barber-Say syndrome is phenotypically similar to Ablepharon macrostomia syndrome, which is also associated with dominant mutations in TWIST2.^[2]

Signs and symptoms

• Severe hypertrichosis, especially of the back
• Skin abnormalities, including hyperlaxity and redundancy
• Facial dysmorphism, including macrostomia
• Eyelid deformities
• Abnormal and low-set ears
• Bulbous nasal tip with hypoplastic alae nasi
• Low frontal hairline

Genetics

Multiple cases of parent-to-child transmission suggest that Barber-Say syndrome exhibits autosomal dominant inheritance.^[3] Exome sequencing and expression studies have shown that BSS is caused by mutations in the TWIST2 gene that affect a highly conserved residue of TWIST2 (twist-related protein 2). TWIST2 is a basic helix-loop-helix transcription factor that binds to E-box DNA motifs (5'-CANNTG-3') as a heterodimer and inhibits transcriptional activation.^[4] Because TWIST2 mediates mesenchymal stem cell differentiation^[5] and prevents premature or ectopic osteoblast differentiation,^[6] mutations in TWIST2 that disrupt these functions by altering DNA-binding activity could explain many of the phenotypes of BSS.^[2]

Diagnosis

Epidemiology

The prevalence of Barber Say syndrome is less than 1 in 1,000,000.^[7] As of 2017, only 15 cases have been reported in the literature.^[8]