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Chen X, Zhou L, Xia Y, Wong YN, He Q, Tang P, Zhang S, Liu T, Wang Z, Xu N. Superb microvascular imaging for evaluating the activity of juvenile localised scleroderma: a preliminary study. Eur Radiol 2024:10.1007/s00330-024-10738-z. [PMID: 38652159 DOI: 10.1007/s00330-024-10738-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/25/2024] [Accepted: 03/21/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVES To investigate microvascular changes in juvenile localised scleroderma (JLS) lesions using superb microvascular imaging (SMI) and assess SMI's utility in evaluating disease activity. METHODS This prospective study enroled 16 children (7 males) with pathologically diagnosed JLS between January 2021 and June 2023. Lesions were assessed using Localised Scleroderma Cutaneous Assessment Tools, including the localised scleroderma skin activity index (LoSAI) and localised scleroderma skin damage index (LoSDI). Lesions with LoSAI scores > 0 were classified as active. The thickness and blood flow of the lesions and healthy skin layers of the contralateral site were evaluated using ultrasound. SMI was used to detect microvascular blood flow in the lesions and healthy skin, and the vascular index (VI) was calculated. The difference in VI between active lesions and healthy skin was correlated with LoSAI and total scores. RESULTS Of 46 lesions, 23 were active and 23 inactive. The skin thickness of the lesion was 0.094 ± 0.024 cm, and that of the healthy site was 0.108 ± 0.026 cm (p < 0.001). The VI of the active lesions and healthy skin were 7.60 (3.60, 12.80)% and 1.10 (0.50, 2.10)%, respectively (p < 0.001). The VI of the inactive lesions and the healthy skin were 0.85 (0.00, 2.20)% and 1.60 (1.00, 3.10)%, respectively (p = 0.011). VI differences between active lesions and healthy skin positively correlated with the LoSAI clinical score (r = 0.625, p = 0.001) and total score (r = 0.842, p < 0.001). CONCLUSION SMI can quantitatively detect microvascular blood flow changes in JLS skin, indicating lesion activity and severity. CLINICAL RELEVANCE STATEMENT SMI is a convenient, non-invasive, technique for detecting active JLS lesions and can provide valuable information to guide treatment options. KEY POINTS Current grading systems of juvenile localised scleroderma rely on subjective clinical information. Superb Microvascular Imaging identified that vascular indexes between active lesions and healthy skin positively correlated with clinical scores. Superb Microvascular Imaging effectively assesses microvascular blood flow, aiding juvenile localised scleroderma lesion activity evaluation.
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Affiliation(s)
- Xiaoyi Chen
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, 518000, China
| | - Luyao Zhou
- Department of Ultrasound, Shenzhen Pediatrics Institute of Shantou University Medical College, Shenzhen, 518000, China
| | - Yu Xia
- Department of Rheumatology and Immunology, Shenzhen Pediatrics Institute of Shantou University Medical College, Shenzhen, China
| | - Yik Ning Wong
- Canon Medical Systems (China) Co. Ltd., Beijing, China
| | - Qiancheng He
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, 518000, China
| | - Pengyue Tang
- Department of Dermatology, Shenzhen Pediatrics Institute of Shantou University Medical College, Shenzhen, China
| | - Shuangshuang Zhang
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, 518000, China
| | - Tingting Liu
- Department of Ultrasound, Shenzhen Pediatrics Institute of Shantou University Medical College, Shenzhen, 518000, China
| | - Ziyi Wang
- Department of Ultrasound, Shenzhen Pediatrics Institute of Shantou University Medical College, Shenzhen, 518000, China
| | - Na Xu
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, 518000, China.
- Department of Ultrasound, Shenzhen Pediatrics Institute of Shantou University Medical College, Shenzhen, 518000, China.
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Al-Gburi S, Kreuter A, Moinzadeh P. [Localized scleroderma]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:197-207. [PMID: 38363312 DOI: 10.1007/s00105-024-05297-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/17/2024]
Abstract
Localized scleroderma (LS), also called circumscribed scleroderma or morphea, comprises a heterogeneous group of diseases that can be classified into four subtypes: limited, linear, generalized, and mixed LS. All manifestations are primarily due to chronic progressive fibrosis of the skin or structures close to the skin. Involvement of internal organs or the transition to systemic sclerosis is excluded by definition. A distinction is made between forms that primarily affect the skin (up to the dermis) or that severely involve subcutaneous fat tissue, muscle fascia or muscles. A detailed examination is required for clinical diagnosis. In order to improve comparability of findings, photo documentation and the use of clinical scores should be carried out. For superficial subtypes the use of topical glucocorticosteroids, calcineurin inhibitors or phototherapy is initially recommended, whereas for severe forms with deep involvement or overall therapy refractoriness, the diagnosis should first be expanded and systemic therapy initiated at an early stage. Especially, in cross joint or extremity-dominant forms of linear LS or in cases with head and neck involvement, such as en coup de sabre, Parry-Romberg syndrome and other subtypes with a prominent musculoskeletal affection, an MRI examination should be arranged. Depending on location, an ophthalmological, neurological, orthodontic, rheumatological or orthopedic consultation may be necessary. For systemic therapy, methotrexate alone or in combination with systemic glucocorticosteroids as pulse therapy is recommended as first-line treatment.
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Affiliation(s)
- Suzan Al-Gburi
- Klinik und Poliklinik für Dermatologie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Alexander Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Klinik Oberhausen, Oberhausen, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Johannes Klinik Duisburg, Duisburg, Deutschland
| | - Pia Moinzadeh
- Klinik und Poliklinik für Dermatologie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
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Papara C, De Luca DA, Bieber K, Vorobyev A, Ludwig RJ. Morphea: The 2023 update. Front Med (Lausanne) 2023; 10:1108623. [PMID: 36860340 PMCID: PMC9969991 DOI: 10.3389/fmed.2023.1108623] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/18/2023] [Indexed: 02/15/2023] Open
Abstract
Morphea, also known as localized scleroderma, is a chronic inflammatory connective tissue disorder with variable clinical presentations, that affects both adults and children. It is characterized by inflammation and fibrosis of the skin and underlying soft tissue, in certain cases even of the surrounding structures such as fascia, muscle, bone and central nervous system. While the etiology is still unknown, many factors may contribute to disease development, including genetic predisposition, vascular dysregulation, TH1/TH2 imbalance with chemokines and cytokines associated with interferon-γ and profibrotic pathways as well as certain environmental factors. Since the disease may progress to permanent cosmetic and functional sequelae, it is crucial to properly assess the disease activity and to initiate promptly the adequate treatment, thus preventing subsequent damage. The mainstay of treatment is based on corticosteroids and methotrexate. These, however, are limited by their toxicity, especially if applied long-term. Furthermore, corticosteroids and methotrexate often do not sufficiently control the disease and/or the frequent relapses of morphea. This review presents the current understanding of morphea by discussing its epidemiology, diagnosis, management and prognosis. In addition, it will describe recent pathogenetic findings, thus proposing potential novel targets for therapeutic development in morphea.
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Affiliation(s)
- Cristian Papara
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany,*Correspondence: Cristian Papara, ✉
| | - David A. De Luca
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Artem Vorobyev
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Ralf J. Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Rao M, Young K, Jackson-Cowan L, Kourosh A, Theodosakis N. Post-Inflammatory Hypopigmentation: Review of the Etiology, Clinical Manifestations, and Treatment Options. J Clin Med 2023; 12:jcm12031243. [PMID: 36769891 PMCID: PMC9917556 DOI: 10.3390/jcm12031243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/09/2023] [Accepted: 01/30/2023] [Indexed: 02/08/2023] Open
Abstract
Post-inflammatory hypopigmentation is a common acquired pigmentary disorder that is more prominent in skin of color, leading to great cosmetic and psychosocial implications. Often, a diagnosis with a pigmentary disorder can negatively impact an individual's health-related quality of life and may result in stigma. Although most cases of post-inflammatory hypopigmentation resolve spontaneously over time, a systematic diagnostic approach can help with identifying the underlying etiology and informing treatment strategies. It can be due to cutaneous inflammation, sequelae of inflammatory or infectious dermatoses, or dermatologic procedures. Therefore, a thorough understanding of the epidemiology, patient history, physical exam findings, and clinical features of post-inflammatory hypopigmentation phenomenon can explain the primary cause to providers and allow for patient education. It is also important to understand the various therapeutic approaches available and the efficacy of these options, which will inform providers to choose the appropriate therapy for patients. Although algorithms exist for classifying acquired disorders of hypopigmentation, there are no established algorithms for the diagnosis and treatment of post-inflammatory hypopigmentation, which warrants further exploration and discourse.
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Affiliation(s)
- Medha Rao
- Department of Dermatology, Massachusetts General Hospital, Boston, MA 02114, USA
- Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | | | - Ladonya Jackson-Cowan
- The Medical College of Georgia at Augusta University, AU/UGA Medical Partnership, Athens, GA 30602, USA
| | - Arianne Kourosh
- Department of Dermatology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nicholas Theodosakis
- Department of Dermatology, Massachusetts General Hospital, Boston, MA 02114, USA
- Correspondence: ; Tel.: +617-724-2919
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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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Vieyra-Garcia PA, Wolf P. A deep dive into UV-based phototherapy: Mechanisms of action and emerging molecular targets in inflammation and cancer. Pharmacol Ther 2020; 222:107784. [PMID: 33316286 DOI: 10.1016/j.pharmthera.2020.107784] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
UV-based phototherapy (including psoralen plus UVA (PUVA), UVB and UVA1) has a long, successful history in the management of numerous cutaneous disorders. Photoresponsive diseases are etiologically diverse, but most involve disturbances in local (and occasionally systemic) inflammatory cells and/or abnormalities in keratinocytes that trigger inflammation. UV-based phototherapy works by regulating the inflammatory component and inducing apoptosis of pathogenic cells. This results in a fascinating and complex network of simultaneous events-immediate transcriptional changes in keratinocytes, immune cells, and pigment cells; the emergence of apoptotic bodies; and the trafficking of antigen-presenting cells in skin-that quickly transform the microenvironment of UV-exposed skin. Molecular elements in this system of UV recognition and response include chromophores, metabolic byproducts, innate immune receptors, neurotransmitters and mediators such as chemokines and cytokines, antimicrobial peptides, and platelet activating factor (PAF) and PAF-like molecules that simultaneously shape the immunomodulatory effects of UV and their interplay with the microbiota of the skin and beyond. Phototherapy's key effects-proapoptotic, immunomodulatory, antipruritic, antifibrotic, propigmentary, and pro-prebiotic-promote clinical improvement in various skin diseases such as psoriasis, atopic dermatitis (AD), graft-versus-host disease (GvHD), vitiligo, scleroderma, and cutaneous T-cell lymphoma (CTCL) as well as prevention of polymorphic light eruption (PLE). As understanding of phototherapy improves, new therapies (UV- and non-UV-based) are being developed that will modify regulatory T-cells (Treg), interact with (resident) memory T-cells and /or utilize agonists and antagonists as well as antibodies targeting soluble molecules such as cytokines and chemokines, transcription factors, and a variety of membrane-associated receptors.
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Affiliation(s)
- Pablo A Vieyra-Garcia
- Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, Graz A-8036, Austria.
| | - Peter Wolf
- Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, Graz A-8036, Austria.
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Abstract
PURPOSE OF REVIEW Treatment of scleroderma in children is challenging since little is known about its pathogenesis. Herein, we review the most recent evidence regarding the treatment of juvenile scleroderma. RECENT FINDINGS According to the recent recommendations for Pediatric Rheumatology in Europe (SHARE), systemic treatment in localized scleroderma is needed when there is a risk for disability, such as in generalized or pansclerotic morphea and progressive linear scleroderma. In juvenile systemic sclerosis, the introduction of the severity score, J4S, has standardized the assessment of the patients in the daily practice and allowed a more tailored therapeutic approach. Since, to date, no clinical trial is available in JSSc, due to its rarity, the treatment is based on adults' experience. The recent recommendations for juvenile scleroderma represent an important instrument to standardize the treatment approach, confirm the role of methotrexate, and open new windows for effective experimental treatments, such as mycophenolate mofetil and biological agents, for severe or refractory cases.
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Affiliation(s)
- Francesco Zulian
- Department of Woman's and Child's Health, University of Padua, Via Giustiniani 3, 35128, Padua, Italy.
| | - Francesca Tirelli
- Department of Woman's and Child's Health, University of Padua, Via Giustiniani 3, 35128, Padua, Italy
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Abstract
There is a long history of utilization of phototherapy for treatment of skin conditions. Because of its longer wavelength, UVA1 phototherapy is able to penetrate into the dermis and subcutis. This depth of penetration, combined with its unique immunomodulating properties, makes UVA1 an effective treatment modality for many immune-mediated skin diseases. In some cases, it performs better than other types of phototherapy.
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Affiliation(s)
- Smriti Prasad
- University of Texas at Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9069, USA
| | - Jennifer Coias
- University of Texas at Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9069, USA
| | - Henry W Chen
- University of Texas at Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9069, USA
| | - Heidi Jacobe
- University of Texas at Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9069, USA.
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Singh D, Parihar AK, Patel S, Srivastava S, Diwan P, Singh MR. Scleroderma: An insight into causes, pathogenesis and treatment strategies. ACTA ACUST UNITED AC 2019; 26:103-114. [PMID: 31130325 DOI: 10.1016/j.pathophys.2019.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 05/02/2019] [Accepted: 05/13/2019] [Indexed: 12/11/2022]
Abstract
Scleroderma is an autoimmune disorder, characterized by morphological changes in skin followed by visceral organs. The pathogenesis of scleroderma involves immune imbalance and generation of auto antibodies. The major causes of scleroderma include multitude of factors such as immune imbalance, oxidative stress, genetics and environment factors. A constant effort has been made to treat scleroderma through different approaches and necessitates life time administration of drugs for maintenance of a good quality life. It has been reported more in women compared to men. Traditional treatment strategies are restricted by limited therapeutic capability due to associated side effects. Advancement in development of novel drug delivery approaches has opened a newer avenue for efficient therapy. Current review is an effort to reflect scleroderma in provisions of its pathogenesis, causative factors, and therapeutic approaches, with concern to mode of action, pharmacokinetics, marketed products, and side effects of drugs.
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Affiliation(s)
- Deependra Singh
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, C.G, 492010, India; National Centre for Natural Resources, Pt. Ravishankar Shukla University, Raipur, C.G, 492010, India
| | - Arun Ks Parihar
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, C.G, 492010, India; Drugs Testing Laboratory Avam Anusandhan Kendra, Raipur (C.G), 492001, India
| | - Satish Patel
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, C.G, 492010, India
| | - Shikha Srivastava
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, C.G, 492010, India; Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University, Greater Noida, U.P, India
| | - Prakriti Diwan
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, C.G, 492010, India
| | - Manju R Singh
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, C.G, 492010, India; National Centre for Natural Resources, Pt. Ravishankar Shukla University, Raipur, C.G, 492010, India.
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Abstract
RATIONALE Bee venom has been reported to demonstrate antinociceptive and anti-inflammatory effects in experimental studies, but there remain questions regarding the clinical use of bee venom, especially for scleroderma. This case report shows the successful outcome of bee venom acupuncture for circumscribed morphea in a patient with systemic sclerosis, which is considered to be a rare condition. PATIENT CONCERNS A 64-year-old Korean woman had circular white areas (3 and 1 cm diameter) with severe itch in the right lateral iliac crest. Based on an initial diagnosis of systemic sclerosis (1 year prior to presentation at our clinic), she had been treated with painkillers, steroids, antitussive expectorants, and aspirin, with minimal effect on her recent skin symptoms. DIAGNOSES In this study, the diagnosis of circumscribed morphea was based on localized skin symptoms of the patient with systemic sclerosis. INTERVENTIONS The patient visited Gachon University Korean Medical Hospital for treatment of topical skin symptoms. After being evaluated for bee venom compatibility, she was administered subcutaneous bee venom acupuncture along the margins of the patches (superficial circumscribed lesions) using the shallow surround needling method twice per week for 1 week and then once per week for the following 3 weeks. OUTCOMES Itch levels were evaluated before each treatment session: by her second visit, her itch had decreased from 8 to 3 on a 10-point numerical rating scale; by her sixth visit, her itch had decreased from 3 to 0. She did not experience adverse effects, and these improvements were maintained until the 2-month follow-up evaluation. LESSONS Bee venom treatment demonstrates the potential to serve as an effective localized therapy for circumscribed morphea.
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Affiliation(s)
- Ji Hye Hwang
- Department of Acupuncture and Moxibustion Medicine, College of Korean Medicine, Gachon University, Seongnam
| | - Kyung-Ho Kim
- Department of Acupuncture and Moxibustion Medicine, Dongguk University Ilsan Oriental Hospital, Goyang, Republic of Korea
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Cho A, Jantschitsch C, Knobler R. Extracorporeal Photopheresis-An Overview. Front Med (Lausanne) 2018; 5:236. [PMID: 30211164 PMCID: PMC6119964 DOI: 10.3389/fmed.2018.00236] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/03/2018] [Indexed: 12/23/2022] Open
Abstract
Extracorporeal photopheresis (ECP) has been in clinical use for over three decades after receiving FDA approval for the palliative treatment of the Sézary Syndrome variant of cutaneous T-cell lymphoma (CTCL) in 1988. After the first positive experiences with CTCL, additional indications have been successfully explored including areas such as graft-vs.-host disease (GVHD), scleroderma, and solid organ transplantation. The mechanism of action is still not fully resolved, but important steps in understanding ECP in recent years have been very informative. Originally, the primary hypothesis stated that psoralen and ultraviolet A (UVA) in combination induce apoptosis in the treated immune cells. This view shifted in favor of dendritic cell initiation, modification of the cytokine profile and stimulation of several T-cell lineages, in particular regulatory T-cells. A number of ECP guidelines have been produced to optimize treatment regimens in the clinical context. In CTCL, enough evidence is available for the use of ECP as a first line treatment for Sézary Syndrome (SS), but also as a second line or rescue treatment in therapy-refractory forms of mycosis fungoides (MF). ECP in the treatment of acute and chronic GVHD has shown promising results as second line therapy in steroid-refractory presentations. In solid organ transplantation, ECP has been used to increase tissue tolerance and decrease infections with opportunistic pathogens, attributed to the use of high doses of immunosuppressive medication. Infection with cytomegalovirus (CMV) remains a limiting factor affecting survival in solid organ transplantation and the role of ECP will be discussed in this review. A trend toward prophylactic use of ECP can be observed and may further contribute to improve the outcome in many patients. To further deepen our knowledge of ECP and thus facilitate its use in patients that potentially benefit most from it, future prospective randomized trials are urgently needed in this rapidly growing field. The aim of this review is to (1) introduce the method, (2) give an overview where ECP has shown promising effects and has become an essential part of treatment protocols, and (3) to give recommendations on how to proceed in numerous indications.
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Affiliation(s)
| | | | - Robert Knobler
- Department of Dermatology, Medizinische Universität Wien, Vienna, Austria
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Abstract
INTRODUCTION Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by vascular dysfunction, fibrosis, inflammation and autoantibodies. The pathophysiology of SSc is not completely understood, and many patients acquire organ or tissue damage despite advances in treatment. Current treatments target affected organs with modest improvements. Areas covered: This review evaluates several treatment strategies for SSc based on involved organs including skin, pulmonary, cardiac, renal, musculoskeletal, and gastrointestinal. Currently, pulmonary hypertension and interstitial lung disease are the primary causes of increased mortality. We will outline an approach to treatment of SSc based on disease manifestations and current evidence. Expert commentary: This complex disease is currently treated with therapies developed for similar indications such as for vascular manifestations of SSc using idiopathic pulmonary arterial hypertension treatments. Future directions in this field may include combination and maintenance therapy that is currently used in other autoimmune diseases, and tailoring these treatments according to the patients' phenotype. This will hopefully increase the efficacy of available treatments and decrease mortality from SSc.
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Affiliation(s)
- Maysoon Eldoma
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,b Rheumatologist, Connective Tissue Disease Fellow , University of Western Ontario , Ontario , Canada.,c Division of Rheumatology, Department of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Janet Pope
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,d Division Head Rheumatology and Professor of Medicine , University of Western Ontario , Ontario , Canada
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Karpec D, Rudys R, Leonaviciene L, Mackiewicz Z, Bradunaite R, Kirdaite G, Venalis A. The safety and efficacy of light emitting diodes-based ultraviolet A1 phototherapy in bleomycin-induced scleroderma in mice. Adv Med Sci 2018; 63:152-159. [PMID: 29120857 DOI: 10.1016/j.advms.2017.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/01/2017] [Accepted: 09/26/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE To define the efficacy and safety of narrowband ultraviolet A1 (UVA1) for the treatment of dermal fibrosis in bleomycin-induced mouse model of scleroderma. MATERIALS AND METHODS 42 DBA/2 strain mice were included in the study: healthy mice and mice with established scleroderma, treated with high or medium dose of UVA1. Non-treated groups served as control. The equipment emitting 365±5nm UVA1 radiation was used in the study. The average cumulative doses were 1200J/cm2 for high and 600J/cm2 for medium dose course. Histological analysis was performed for the evaluation of the dermal thickness and mast cells density. The expressions of p53 and Ki-67 proteins were assessed by immunohistochemical analyses. RESULTS Skin thickness of mice with scleroderma, treated with high and medium dose of UVA1, were lower (272.9±113.2μm and 394±125.9μm, respectively) in comparison to the dermal thickness of non-treated animals (599±55.7μm). The dermal mast cells count in mice with scleroderma was reduced after high and medium dose treatment to 11±1.7 and 13±2.2, respectively, as compared to that in non-treated mice (23±3.0). No significant upregulation of p53 nor Ki-67 proteins was observed in the skin of healthy mice and mice with scleroderma after high- and medium-dose of UVA1. CONCLUSIONS The results of this study indicate that 365nm UVA1 with the cumulative doses of 1200J/cm2 and 600J/cm2 is safe and effective for the dermal fibrosis treatment.
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Karpec D, Rudys R, Leonaviciene L, Mackiewicz Z, Bradunaite R, Kirdaite G, Venalis A. The impact of high-dose narrowband ultraviolet A1 on dermal thickness, collagen and matrix-metalloproteinases in animal model of scleroderma. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2017; 173:448-455. [PMID: 28667931 DOI: 10.1016/j.jphotobiol.2017.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/13/2017] [Accepted: 06/20/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The main purpose of the present study was to define the impact of high-dose of 365±5nm ultraviolet A1 (UVA1) on dermal fibrosis in the pre-established, bleomycin-induced mouse model of scleroderma. METHODS DBA/2 strain mice with the pre-established, bleomycin-induced scleroderma were irradiated with cumulative UVA1 dose of 1200J/cm2 and in parallel were challenged with prolonged administration of bleomycin. Non-treated groups served as the control. Light source emitting a narrow band UVA1 light of 365±5nm and 21mW/cm2 power density was used in the study. Histological analysis was performed for the evaluation of dermal thickness. The expressions of matrix-metalloproteinase-1 (MMP-1), matrix-metalloproteinase-3 (MMP-3), collagen types I and III were evaluated by immunohistochemical analyses. The Mann - Whitney U test was used for statistical analysis. RESULTS Dermal thickness in mice injected with bleomycin during all the experiment (8weeks) and irradiated with UVA1 for the last 5weeks was significantly lower than that in mice challenged only with bleomycin for 8weeks (253.96±31.83μm and 497.43±57.83μm, respectively; P=0.002). The dermal thickness after phototherapy was lower as compared with the pre-existing fibrotic changes observed after 3weeks of bleomycin injections (253.96±31.83μm and 443.87±41.76μm, respectively; P=0.002). High-dose of UVA1 induced the 5.8- and 5.2-fold increase in MMP-1 and MMP-3 expressions, respectively, and the 1.2- and 1.4-fold decrease in collagen type I and collagen type III expressions in the pre-established, bleomycin-induced scleroderma model as compared to that in the control non-irradiated mice (P=0.002). CONCLUSIONS Our study has demonstrated that a cumulative 365±5nm UVA1 radiation dosage of 1200J/cm2 not only prevents the progression of dermal fibrosis, but also induces a regression of pre-existing fibrotic changes.
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Affiliation(s)
- Diana Karpec
- State Research Institute Centre for Innovative Medicine, Santariskiu St. 5, LT-08406 Vilnius, Lithuania; Vilnius University, Faculty of Medicine, Center of Rheumatology, Santariskiu St. 2, LT-08661 Vilnius, Lithuania.
| | - Romualdas Rudys
- State Research Institute Centre for Innovative Medicine, Santariskiu St. 5, LT-08406 Vilnius, Lithuania.
| | - Laima Leonaviciene
- State Research Institute Centre for Innovative Medicine, Santariskiu St. 5, LT-08406 Vilnius, Lithuania.
| | - Zygmunt Mackiewicz
- State Research Institute Centre for Innovative Medicine, Santariskiu St. 5, LT-08406 Vilnius, Lithuania.
| | - Ruta Bradunaite
- State Research Institute Centre for Innovative Medicine, Santariskiu St. 5, LT-08406 Vilnius, Lithuania.
| | - Gailute Kirdaite
- State Research Institute Centre for Innovative Medicine, Santariskiu St. 5, LT-08406 Vilnius, Lithuania.
| | - Algirdas Venalis
- State Research Institute Centre for Innovative Medicine, Santariskiu St. 5, LT-08406 Vilnius, Lithuania; Vilnius University, Faculty of Medicine, Center of Rheumatology, Santariskiu St. 2, LT-08661 Vilnius, Lithuania.
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Morphea - selected local treatment methods and their effectiveness. Reumatologia 2017; 55:305-313. [PMID: 29491539 PMCID: PMC5825969 DOI: 10.5114/reum.2017.72628] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/30/2017] [Indexed: 01/15/2023] Open
Abstract
Localised scleroderma is an uncommon connective tissue disease of multifactorial aetiology occurring in the paediatric and adult population. It is relatively difficult to conduct any research on the subject of this disease entity treatment due to the low number of patients suffering from morphea, a tendency of the disease to remit spontaneously, and not yet well recognised aetiology. Hence, there has been developed no causal treatment of well-proven effectiveness, and schedules of symptomatic therapy are not yet clearly determined. The paper depicts most widely used topical treatment methods in morphea therapy, which due to minor risk of systemic adverse effects seem to be a beneficial therapeutic alternative. The main aim of this article was to analyse different topical treatment options used in localised scleroderma therapy and to indicate the most appropriate, safe, and effective one.
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