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Calzavara-Pinton P, Bettolini L, Tonon F, Rossi M, Venturini M. The realistic positioning of UVA1 phototherapy after 25 years of clinical experience and the availability of new biologics and small molecules: a retrospective clinical study. Front Med (Lausanne) 2023; 10:1295145. [PMID: 38076241 PMCID: PMC10702775 DOI: 10.3389/fmed.2023.1295145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/08/2023] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Since the early 1990s, Ultraviolet (UV) A1 phototherapy has been described as an effective and safe treatment of a multitude of skin disorders. However, after 30 years, its use has remained limited to few dermatological centers. OBJECTIVE To analyze the changes over the years and the current position of UVA1 phototherapy through a Real-World Evidence (RWE) study at a single tertiary referral center. METHODS We reviewed the medical files of 740 patients treated between 1998 and 2022. Treatment results were collected, efficacy was assessed by a grading scale and acute adverse effects were registered. RESULTS We treated patients with 26 different diseases. We registered marked improvement (MI) or complete remission (CR) in 42.8% of patients with morphea, 50% with Urticaria Pigmentosa, 40.7% with Granuloma annulare and 85.7% with skin sarcoidosis. Good results were obtained also in the treatment of chronic Graft Versus Host Disease (GVHD), Eosinophilic Fasciitis, Sclero-atrophic Lichen, skin manifestations of systemic lupus erythematosus and psoriasis of HIV+ patients. Systemic Sclerosis, Romberg's Syndrome, Bushke's Scleredema, Nephrogenic Fibrosing Dermopathy, REM Syndrome, Follicular Mucinosis, Pretibial Myxedema, Scleromyxedema, pemphigus foliaceus, chronic cutaneous lupus erythematosus, erythroderma of Netherton Syndrome and Necrobiosis Lipoidica were no or poorly responsive. In clinical indications where UVA1 was used as a second line phototherapy after narrow-band (NB)-UVB, we saw good MI or CR rates in Mycosis Fungoides (57% of patients), Atopic Dermatitis (33.9%), Pitiryasis Lichenoides chronica (50%), Pityriasis Lichenoides et varioliformis acute (75%) and Lymphomatod Papulosis (62.5%). Short-term adverse events were uncommon and mild. CONCLUSION Over the past decade, the annual number of treated patients has progressively declined for several reasons. Firstly, UVA1 phototherapy has taken a backseat to the cheaper and more practical NB-UVB phototherapy, which has proven effective for common indications. Secondly, the emergence of new, safe, and effective drugs for conditions such as atopic dermatitis, GVHD, and connective tissue disorders. Finally, our research has shown that UVA1 therapy is often ineffective or minimally effective for some rare diseases, contrary to previous case reports and small case series. Nonetheless, UVA1 continues to be a valuable treatment option for patients with specific skin disorders.
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Affiliation(s)
- Piergiacomo Calzavara-Pinton
- Department of Dermatology, University of Brescia, Brescia, Italy
- Department of Dermatology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Luca Bettolini
- Department of Dermatology, University of Brescia, Brescia, Italy
- Department of Dermatology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Francesco Tonon
- Department of Dermatology, University of Brescia, Brescia, Italy
- Department of Dermatology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Mariateresa Rossi
- Department of Dermatology, University of Brescia, Brescia, Italy
- Department of Dermatology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Marina Venturini
- Department of Dermatology, University of Brescia, Brescia, Italy
- Department of Dermatology, ASST Spedali Civili di Brescia, Brescia, Italy
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2
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Foeldvari I, Marrani E. Systemic therapy in juvenile localized scleroderma. Expert Rev Clin Immunol 2023; 19:1225-1238. [PMID: 37462119 DOI: 10.1080/1744666x.2023.2237685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/26/2023] [Accepted: 07/13/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Juvenile localized scleroderma (JLS) is a rare sclerosing disorder of childhood which can result in permanent morbidity and functional disability, if not effectively treated. Treatment should be started in the inflammatory phase before the development of any complication and/or damage. AREAS COVERED In this review, we will discuss how to assess disease activity and damage in JLS, and propose an escalation plan for systemic treatment, according to a treat-to-target concept. We will discuss the definition of inactive disease and how and when to discontinue medications. EXPERT OPINION Before starting treatment, it is extremely important to assess baseline disease activity for treatment response to be adequately checked. Moreover, the activity of the extra cutaneous involvement is an important part of the assessment. Patients should be treated in the 'therapeutic window,' before significant fibrosis results. Most patients should receive systemic treatments; in these patients, Methotrexate should be used as the first-line disease-modifying anti-rheumatic drug (DMARD). However, methotrexate intolerance or non-response is an issue, and these patients should be proposed a treatment escalation according to results of latest studies. Future research can develop better prognostic markers to help to guide our decision.
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Affiliation(s)
- Ivan Foeldvari
- Hamburger Zentrum Für Kinder- Und Jugendrheumatologie, Hamburg, Germany
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3
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Stubbs LA, Ferry AM, Guffey D, Loccke C, Wade EM, Pour P, Ardalan K, Chira P, Ganske IM, Glaser D, Higgins G, Luca N, Moore KF, Sivaraman V, Stewart K, Vasquez-Canizares N, Hunt RD, Maricevich RS, Torok KS, Li SC. Barriers to care in juvenile localized and systemic scleroderma: an exploratory survey study of caregivers' perspectives. Pediatr Rheumatol Online J 2023; 21:39. [PMID: 37098622 PMCID: PMC10131373 DOI: 10.1186/s12969-023-00819-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/12/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Juvenile localized scleroderma (LS) and systemic sclerosis (SSc) are rare pediatric conditions often associated with severe morbidities. Delays in diagnosis are common, increasing the risk for permanent damage and worse outcomes. This study explored caregiver perspectives on barriers they encountered while navigating diagnosis and care for their child's scleroderma. METHODS In this cross-sectional study, caregivers of juvenile LS or SSc patients were recruited from a virtual family scleroderma educational conference and a juvenile scleroderma online interest group. The survey queried respondents about their child's condition and factors affecting diagnosis and treatment. RESULTS The response rate was 61% (73/120), with 38 parents of LS patients and 31 parents of SSc patients. Most patients were female (80%) and over half were non-Hispanic white (55%). Most families had at least one person with a college education or higher (87%), traveled ≤ 2 h to see their rheumatologist (83%), and had private insurance (75%). Almost half had an annual household income ≥ $100,000 (46%). Families identified the following factors as barriers to care: lack of knowledge about scleroderma in the medical community, finding reliable information about pediatric scleroderma, long wait times/distances for a rheumatology/specialist appointment, balance of school/work and child's healthcare needs, medication side effects, and identifying effective medications. The barrier most identified as a major problem was the lack of knowledge about juvenile scleroderma in the medical community. Public insurance, household income less than $100,000, and Hispanic ethnicity were associated with specific barriers to care. Lower socioeconomic status was associated with longer travel times to see the rheumatologist/specialist. Diagnosis and systemic treatment initiation occurred at greater than one year from initial presentation for approximately 28% and 36% of patients, respectively. Families of LS patients were commonly given erroneous information about the disease, including on the need and importance of treating active disease with systemic immunosuppressants in patients with deep tissue or rapidly progressive disease. CONCLUSION Caregivers of children with LS or SSc reported numerous common barriers to the diagnosis, treatment, and ongoing care of juvenile scleroderma. The major problem highlighted was the lack of knowledge of scleroderma within the general medical community. Given that most of the caregiver respondents to the survey had relatively high socioeconomic status, additional studies are needed to reach a broader audience, including caregivers with limited English proficiency, geographical limitations, and financial constraints, to determine if the identified problems are generalizable. Identifying key care barriers will help direct efforts to address needs, reduce disparities in care, and improve patient outcomes.
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Affiliation(s)
- Leigh A Stubbs
- Department of Pediatrics, Division of Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Andrew M Ferry
- Department of Plastic Surgery, Division of Pediatric Plastic Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Christina Loccke
- Board of Directors, National Scleroderma Foundation, Danvers, MA, USA
| | | | - Pamela Pour
- Advisory Board Member, Scleroderma Foundation Michigan Chapter, Southfield, MI, USA
| | - Kaveh Ardalan
- Department of Pediatrics, Division of Rheumatology, Duke University School of Medicine, Durham, NC, USA
| | - Peter Chira
- Department of Pediatrics, Division of Rheumatology, University of California San Diego, San Diego, CA, USA
| | - Ingrid M Ganske
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel Glaser
- Department of Pediatrics, Section of General Pediatrics, Yale University, New Haven, CT, USA
| | - Gloria Higgins
- Department of Pediatrics, Division of Rheumatology, Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH, USA
| | - Nadia Luca
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Calgary and Alberta Children's Hospital Research Institute, Calgary, AB, Canada
| | - Katharine F Moore
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Vidya Sivaraman
- Department of Pediatrics, Division of Rheumatology, Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH, USA
| | - Katie Stewart
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Texas Southwestern, Dallas, TX, USA
| | - Natalia Vasquez-Canizares
- Department of Pediatrics, Division of Pediatric Rheumatology, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, NY, USA
| | - Raegan D Hunt
- Department of Dermatology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Renata S Maricevich
- Department of Plastic Surgery, Division of Pediatric Plastic Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Kathryn S Torok
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Suzanne C Li
- Department of Pediatrics, Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack Meridian School of Medicine, 30 Prospect Avenue, Hackensack, NJ, 07601, USA.
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Tang JC, Zheng WY, Han GM, Liu SF, Yang B. Successful Treatment of Paediatric Morphea with Tofacitinib. Acta Derm Venereol 2023; 103:adv4805. [PMID: 37083093 PMCID: PMC10134061 DOI: 10.2340/actadv.v103.4805] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/15/2023] [Indexed: 04/22/2023] Open
Abstract
Abstract is missing (Short communication)
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Affiliation(s)
- Jun-Chi Tang
- Department of Dermatology, Guangdong College of Clinical Dermatology, Anhui Medical University, Guangzhou, China
| | - Wen-Yue Zheng
- 2Department of Dermatology and Rheumatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Guang-Ming Han
- 2Department of Dermatology and Rheumatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Shuang-Fei Liu
- Department of Dermatology, Guangdong College of Clinical Dermatology, Anhui Medical University, Guangzhou, China
| | - Bin Yang
- Department of Dermatology, Guangdong College of Clinical Dermatology, Anhui Medical University, Guangzhou, China.
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Tognetti L, Marrocco C, Carraro A, Guerrini G, Mariotti GI, Cinotti E, Rubegni P. Clinical and laboratory characterization of patients with localized scleroderma and response to UVA-1 phototherapy: In vivo and in vitro skin models. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2022; 38:531-540. [PMID: 35324032 PMCID: PMC9790552 DOI: 10.1111/phpp.12786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/07/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND/PURPOSE Localized scleroderma (LS) is a rare disease leading to progressive hardening and induration of the skin and subcutaneous tissues. LS is responsive to UVA-1 phototherapy, though its exact mechanism of action dermal fibrosis is yet to be fully elucidated. We aimed to investigate the molecular changes induced by UVA-1 rays in human primary fibroblasts cultures. METHODS A total of 16 LS patients were treated with medium-dose UVA-1 phototherapy. At baseline, during and after therapy, Localized Scleroderma Assessment Tool, Dermatology Life Quality Index and lesions' staging and mapping were performed along with high-frequency ultrasound (HFUS) examination for dermal thickness assessment. Gene expression analysis for 23 mRNA transcripts, in vitro UVA-1 irradiation and viability tests were realized on lesional fibroblasts' primary cultures, before and 3 months after therapy. RESULTS The dermal thickness, the LoSCAT and the DLQI progressively decreased starting from the last phototherapy session up to the 6 and 9 month follow-ups (-57% and -60%, respectively). Molecular gene analysis (rt-PCR) revealed that UVA-1 phototherapy exerts multiple effects: the activation of specific anti-fibrotic pathways (e.g., overexpression of CTHRC1 and metalloproteases 1, 2, 7, 8, 9, 12, suppression of TIMP-1), the downregulation of peculiar pro-fibrotic pathways (e.g., downregulation of TGF-ß, TGF-ßrII, Grb2, SMAD 2/3, TNRSF12A, CTGF) through a significant overexpression of IL-1ß; the stabilization of collagen synthesis acting on genes COL1A1, COL3A1, COL8A1, COL10A1, COL12A1. CONCLUSION UVA-1 phototherapy adds significant benefits in local tissue remodeling, rebalancing the alteration between pro-fibrotic and anti-fibrotic pathways; these changes can be well monitored by HFUS.
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Affiliation(s)
- Linda Tognetti
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Camilla Marrocco
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Andrea Carraro
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Giuditta Guerrini
- Laboratory of Molecular Microbiology and Biotechnology, Department of Medical BiotechnologiesUniversity of SienaSienaItaly
| | - GIancarlo Mariotti
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Elisa Cinotti
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Pietro Rubegni
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
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OPTIMIZATION OF COMPLEX THERAPY OF PATIENTS WITH LOCALIZED SCLERODERMA. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-4-82-12-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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7
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Glaser D, Torok KS. Evaluation and Treatment of Pediatric Localized Scleroderma: Pearls and Updates. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00170-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sapra A, Dix R, Bhandari P, Mohammed A, Ranjit E. A Case of Extensive Debilitating Generalized Morphea. Cureus 2020; 12:e8117. [PMID: 32542170 PMCID: PMC7292686 DOI: 10.7759/cureus.8117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/14/2020] [Indexed: 11/13/2022] Open
Abstract
Morphea, also known as localized scleroderma, is an uncommon idiopathic inflammatory disorder leading to the development of sclerotic plaques in the skin. The disorder preferentially affects females. The pathogenesis of morphea is not well-understood. The disorder is likely to have an autoimmune basis; environmental and genetic factors may also play a role in its etiology. Morphea has a variety of clinical presentations. Lesions of morphea typically begin as inflammatory plaques or patches that evolve into firm sclerotic lesions. Involvement may be limited to the dermis or may extend to underlying subcutaneous fat, muscle, or bone. The identification of characteristic clinical findings is often sufficient for the diagnosis of morphea. A biopsy can be a useful tool when the diagnosis is in question or to obtain information on the depth and intensity of the disease, and it should always extend at least into the subcutaneous fat. Morphea may cause joint contractures and other impairments secondary to tissue sclerosis and can be very debilitating cosmetically and functionally.
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Affiliation(s)
- Amit Sapra
- Family Medicine, Southern Illinois University School of Medicine, Springfield, USA
| | - Rebecca Dix
- Family Medicine, Southern Illinois University School of Medicine, Springfield, USA
| | - Priyanka Bhandari
- Family Medicine, Southern Illinois University School of Medicine, Springfield, USA
| | - Asiya Mohammed
- Family Medicine, Southern Illinois University School of Medicine, Springfield, USA
| | - Eukesh Ranjit
- Family Medicine, Southern Illinois University School of Medicine, Springfield, USA
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Glaser DH, Schutt C, Schollaert-Fitch K, Torok K. Linear Scleroderma of the Head - Updates in management of Parry Romberg Syndrome and En coup de sabre: A rapid scoping review across subspecialties. Eur J Rheumatol 2020; 7:S48-S57. [PMID: 35929860 PMCID: PMC7004261 DOI: 10.5152/eurjrheum.2019.19183] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/24/2019] [Indexed: 07/27/2023] Open
Abstract
To provide an update on the current management, including evaluation and treatment, and the available diagnostic tools for linear scleroderma of the head, i.e., Parry-Romberg Syndrome and en coup de sabre (PRS/ECDS). A rapid scoping review of the literature was conducted to include manuscripts published in English between 2010 and 2019. Literature searches were performed in PubMed and EMBASE databases. The were analyzed for descriptive statistic reporting. This study reviewed 215 manuscripts reporting these 1430 patients. Surgical reports comprised the majority of the reviewed literature. Most PRS/ECDS did not appear to receive comprehensive multisubspecialty evaluation for extracutaneous manifestations; 21% of cases noted neurological screening, 4% noted dental screening, and 3% noted ophthalmologic screening. Methotrexate and glucocorticoids remain the most frequent choice for immunosuppressive treatment, though fewer than 7% of patients reported receiving systemic medical therapies. Surgical procedures for cosmetic or functional improvement were common (59%) among the reported patients. Autologous fat grafting was the most frequently utilized cosmetic treatment (50% of procedures) followed by free flap transfers (24% of procedures). There is ongoing need for standardized evaluation, monitoring, and treatment to prevent morbidity in PRS/ECDS, especially in children. When these patients are managed by rheumatologists, methotrexate, and steroids remain the first-line treatment, but a review of the published literature reflects that this may be a minority. Most PRS/ECDS patients are not evaluated in a multidisciplinary fashion. We propose comprehensive evaluations across subspecialties at the baseline and follow-up levels to monitor disease activity and record extracutaneous manifestations, treatment algorithms, and surgical intervention considerations.
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Affiliation(s)
| | | | | | - Kathryn Torok
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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