Methotrexate in Linear Scleroderma: Long-Term Efficacy in Fifty Children From a Single Pediatric Rheumatology Center

S2k guideline: Diagnosis and therapy of localized scleroderma

The updated S2k guideline deals with the diagnosis and therapy of localized scleroderma (LoS). LoS represents a spectrum of sclerotic skin diseases in which, depending on the subtype and localisation, structures such as adipose tissue, muscles, joints, and bones may also be affected. Involvement of internal organs or progression to systemic sclerosis does not occur. LoS can be classified into four main forms: limited, generalized, linear, and mixed forms, with some additional subtypes. For cases of limited skin involvement, the guideline primarily recommends therapy with topical corticosteroids. UV therapy can also be recommended. In subtypes with severe skin or musculoskeletal involvement, systemic therapy with methotrexate is recommended. During the active phase of the disease, systemic glucocorticosteroids can be used additionally. In cases of methotrexate and steroid refractory courses, contraindications, or intolerance, mycophenolate mofetil, mycophenolic acid, or abatacept can be considered as second-line systemic therapies. In the case of linear LoS, autologous adipose-derived stem cell transplantation can also be performed for correcting soft tissue defects.

S2k‐Leitlinie: Diagnostik und Therapie der zirkumskripten Sklerodermie

Die vorliegende aktualisierte S2k‐Leitlinie befasst sich mit der Diagnostik und der Therapie der zirkumskripten Sklerodermie (ZS). Diese umfasst ein Spektrum sklerotischer Erkrankungen der Haut mit, je nach Subtyp und Lokalisation, möglicher Beteiligung von hautnahen Strukturen wie Fettgewebe, Muskulatur, Gelenke und Knochen. Ein Befall innerer Organe oder ein Übergang in eine systemische Sklerodermie treten nicht auf. Eingeteilt werden kann die ZS in die vier Hauptformen der limitierten, generalisierten, linearen und gemischten Form. Teilweise existieren weitere Unterformen. Bei limitiertem Hautbefall empfiehlt die Leitlinie primär eine Therapie mit topischen Kortikosteroiden. Eine UV‐Therapie kann ebenfalls sinnvoll sein. Bei Subtypen mit schwerem Hautbefall oder muskuloskelettalem Befall wird eine systemische Therapie mit Methotrexat empfohlen. In der aktiven Phase der Erkrankung können ergänzend systemische Glukokortikosteroide eingesetzt werden. Bei MTX‐ und Steroid‐refraktären Verläufen, Kontraindikation oder Unverträglichkeit sollten Mycophenolat‐Mofetil, Mycophenolsäure oder Abatacept als Systemtherapie der zweiten Wahl eingesetzt werden. Bei einer linearen ZS kann zudem eine autologe Fettstammzelltransplantation zur Korrektur von Weichteildefekten erfolgen.

Remission rates and risk factors for relapse in pediatric morphea: a multicenter retrospective study of Pediatric Rheumatology Academy (PeRA)-Research Group (RG)

AIM

Morphea, also known as localized scleroderma, is an immune-mediated disease and the most common form of scleroderma in children. It is a localized sclerosing disease of the skin, but can also involve such adjacent tissues as the fascia, muscle, bone, and underlying tissues. This multicenter study aimed to evaluate Turkish pediatric morphea patients, regarding demographics, treatments, and response to treatment.

MATERIALS AND METHODS

The study was performed by the Pediatric Rheumatology Academy and included pediatric morphea patients from 6 Turkish pediatric rheumatology centers who were followed up for ≥6 months. Demographic, clinical, and laboratory findings and treatment modalities were analyzed. The patients were divided into 3 groups according to treatment response, as follows: group 1: topical treatment response, group 2: methotrexate response, and group 3: methotrexate resistance. Clinical findings were compared between the 3 groups.

RESULTS

The study included 76 patients, of which 53 (69.7%) were female. Mean age at diagnosis of morphea was 9.7 ± 4.3 years and mean duration of follow-up was 3.2 ± 2.9 years. Linear morphea was the most common form, accounting for 43.4% (n = 33) of the patients. Extracutaneous features were noted in 17 patients (22.4%) and anti-nuclear antibody positivity was noted in 32 (42.1%). In all, 14.4% of the patients received topical treatment only, whereas 86.6% received both topical and systemic treatment. The methotrexate response rate was 76.9% in the patients that received systemic immunosuppressive therapy. The overall relapse rate while under treatment was 19.7%.

CONCLUSION

In this study, most of the pediatric morphea patients responded well to methotrexate. Bilateral lesions were more common in the methotrexate-resistant group. Multiple involvement, and bilateral lesions, were more common in relapsed patients than in non-relapsed patients. Key points • Most of the pediatric morphea patients respond well to MTX. • Multiple involvement, and bilateral involvement, were more common in relapsed patients than in non-relapsed patients. • Presence of extracutaneous findings in patients increased relapse rate 5.7 times.

Diagnosing and Managing Linear Scleroderma in a Low-Resource Setting

Background

Linear scleroderma is one of the five forms of scleroderma, but it is the most common form of localized scleroderma in childhood. If left untreated, it can lead to severe disfigurement and functional impairment. The typical appearance is a linear streak with cutaneous induration on the face or head in association with various ophthalmological and neurological signs and symptoms. Treatment typically includes corticosteroids and/or methotrexate with life-long monitoring for recurrence. Case Presentation. A 12-year-old girl presented to our clinic in northern rural Cambodia with a history of a linear streak on her forehead that was growing down her nasal bridge. She denied any tenderness or family history of rheumatic disease. Her history was significant for strabismus as a child. A visiting pediatric rheumatologist assisted us with the appropriate diagnosis and treatment plan.

Conclusion

In our case report, we present a child with linear scleroderma who fortunately came to medical attention early and received appropriate treatment before the onset of complications. She was treated with systemic immunosuppression as well as topical steroids. After treatment, she had no further progression on her face and continued to follow up with us to monitor for disease activity. To summarize, linear scleroderma is an uncommon diagnosis for general pediatricians and should be recognized early to provide appropriate treatment and follow-up.

Researchers in rheumatology should avoid categorization of continuous predictor variables

BACKGROUND

Rheumatology researchers often categorize continuous predictor variables. We aimed to show how this practice may alter results from observational studies in rheumatology.

METHODS

We conducted and compared the results of two analyses of the association between our predictor variable (percentage change in body mass index [BMI] from baseline to four years) and two outcome variable domains of structure and pain in knee and hip osteoarthritis. These two outcome variable domains covered 26 different outcomes for knee and hip combined. In the first analysis (categorical analysis), percentage change in BMI was categorized as ≥ 5% decrease in BMI, < 5% change in BMI, and ≥ 5% increase in BMI, while in the second analysis (continuous analysis), it was left as a continuous variable. In both analyses (categorical and continuous), we used generalized estimating equations with a logistic link function to investigate the association between the percentage change in BMI and the outcomes.

RESULTS

For eight of the 26 investigated outcomes (31%), the results from the categorical analyses were different from the results from the continuous analyses. These differences were of three types: 1) for six of these eight outcomes, while the continuous analyses revealed associations in both directions (i.e., a decrease in BMI had one effect, while an increase in BMI had the opposite effect), the categorical analyses showed associations only in one direction of BMI change, not both; 2) for another one of these eight outcomes, the categorical analyses suggested an association with change in BMI, while this association was not shown in the continuous analyses (this is potentially a false positive association); 3) for the last of the eight outcomes, the continuous analyses suggested an association of change in BMI, while this association was not shown in the categorical analyses (this is potentially a false negative association).

CONCLUSIONS

Categorization of continuous predictor variables alters the results of analyses and could lead to different conclusions; therefore, researchers in rheumatology should avoid it.

Treatment of juvenile localized scleroderma: current recommendations, response factors, and potential alternative treatments

PURPOSE OF REVIEW

Juvenile localized scleroderma (jLS) is a chronic autoimmune and fibrosing disease associated with a high risk for functional impairment. Antifibrotic options are limited, so current treatment strategies are focused on disease activity control. Pediatric rheumatologists are in consensus on the need to treat with systemic immunosuppressants, in particular, methotrexate. However, more than 30% of patients fail initial methotrexate treatment. This review provides an update on current management and reviews reports on potential alternative treatments.

RECENT FINDINGS

An overview of current treatment recommendations and its efficacy are discussed. Recent studies have identified several factors associated with likelihood of treatment response. These include time to initiation of treatment, certain subtypes, and extracutaneous involvement. Findings from recent reports of alternative systemic immunomodulators, including biologic medications, will be summarized.

SUMMARY

Methotrexate treatment has greatly improved outcome for most jLS patients but a substantial portion have refractory cutaneous and/or extracutaneous disease. Treatment response factors are being identified, which could lead to improved management strategies. Recent studies provide further support on mycophenolate mofetil as an alternative treatment. Data on biologic therapies is encouraging, with data suggesting efficacy for many extracutaneous manifestations but more studies are needed to evaluate these and other options for jLS.

Narrow-band reflectance spectrophotometry and infrared thermography for assessment of skin lesions in localized scleroderma

BACKGROUND

Infrared thermography (IRT) is a useful method to detect activity/inflammation in localized scleroderma (LoS), however inactive skin lesions with a severe degree of dermal and subcutaneous atrophy may show false positive results. Narrow-band reflectance spectrophotometry (NBRS) is an objective, noninvasive technique of measuring erythema and hyperpigmentation severity, yet has not been extensively studied in LoS.

OBJECTIVES

The aim of this research was to compare the spectrophotometric results with thermographic examination of LoS lesions.

METHODS

The lesions were assessed using the Localized Scleroderma Assessment Tool (LoSCAT), Dyspigmentation, Induration, Erythema, and Telangiectasias (DIET) score, NBRS and IRT. The difference of the erythema index (ΔEI), melanin index (ΔMI) and average temperature Tavg (ΔTavg) were calculated between each lesion and its normal control.

RESULTS

Fifty-five patients with 49 active and 64 inactive LoS lesions were examined. The ΔEI strongly correlated with the erythema (r_s =0.62, p <0.0000002) and DIET score (r_s = 0.66, p <0.0000001) and moderately correlated with the telangiectasias score (r_s =0.58, p <0.00001). ΔMI showed strong correlation with the dyspigmentation score (r_s =0.65, p <0.0000001). There was a strong correlation between the ΔTavg and the erythema score (r_s =0.7, p <0.000001). A moderate correlation between the Δ EI and ΔTavg was found in active LoS lesions (r_s =0.53 p <0.0001).

CONCLUSION

NBRS may be a complementary method for determining erythema in LoS active lesions, although this technique remains inferior to IRT, because is unable to distinct between active and inactive lesions. However, NBRS enables to evaluate the severity of hyperpigmentation and telangiectasias, and it can be useful for the assessment of disease severity which is poorly evaluated by IRT.