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Knobler R, Geroldinger-Simić M, Kreuter A, Hunzelmann N, Moinzadeh P, Rongioletti F, Denton CP, Mouthon L, Cutolo M, Smith V, Gabrielli A, Bagot M, Olesen AB, Foeldvari I, Jalili A, Kähäri V, Kárpáti S, Kofoed K, Olszewska M, Panelius J, Quaglino P, Seneschal J, Sticherling M, Sunderkötter C, Tanew A, Wolf P, Worm M, Skrok A, Rudnicka L, Krieg T. Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes. J Eur Acad Dermatol Venereol 2024; 38:1251-1280. [PMID: 38456584 DOI: 10.1111/jdv.19912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/26/2024] [Indexed: 03/09/2024]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - M Geroldinger-Simić
- Department of Dermatology, Ordensklinikum Linz Elisabethinen, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - P Moinzadeh
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - F Rongioletti
- Vita Salute University IRCSS San Raffaele Hospital, Milan, Italy
| | - C P Denton
- Center for Rheumatology, Royal Free and University College Medical School, London, UK
| | - L Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, APHP-CUP, Hôpital Cochin, Paris, France
- Institut Cochin, Université de Paris Cité, Paris, France
| | - M Cutolo
- Laboratories for Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University Medical School of Genoa, IRCCS San Martino Genoa, Genoa, Italy
| | - V Smith
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - A Gabrielli
- Fondazione di Medicina Molecolare e Terapia Cellulare, Università Politecnica delle Marche, Ancona, Italy
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - A B Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - I Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - A Jalili
- Dermatology & Skin Care Clinic, Buochs, Switzerland
| | - V Kähäri
- Department of Dermatology and Venereology, University of Turku and Turku University Hospital, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- The Skin Clinic, Copenhagen, Denmark
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - J Panelius
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, CNRS, Immuno CencEpT, UMR 5164, Bordeaux, France
| | - M Sticherling
- Department of Dermatology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Tanew
- Private Practice, Vienna, Austria
| | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - M Worm
- Division of Allergy and Immunology, Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - T Krieg
- Department of Dermatology and Venereology, and Translational Matrix Biology, University of Cologne, Cologne, Germany
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Elnaquip E, Makki M, Mansour M, Moshrif A. Clinical and ultrasonographic evaluation of efficacy and safety of intralesional injection of autologous platelet-rich plasma in morphea: A comparative case series. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2024; 9:162-168. [PMID: 38910599 PMCID: PMC11188844 DOI: 10.1177/23971983231222664] [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: 10/17/2023] [Accepted: 12/10/2023] [Indexed: 06/25/2024]
Abstract
Objective To evaluate the efficacy and safety of platelet-rich plasma to restore skin changes in morphea by ultrasound and Localized Scleroderma Cutaneous Assessment Tool. Methods Nine morphea patients (21 lesions) were diagnosed clinically and by histopathology. Intradermal platelet-rich plasma was injected into morphea lesion once weekly for 12 sessions. The disease severity and damage were evaluated at baseline, after the last session (3 months later), and at 6 months follow-up using the LoSCAT and a high-resolution ultrasound. The healthy corresponding side was considered as a control. Results The Localized Scleroderma Cutaneous Assessment Tool score showed a significant improvement starting from 13 ± 7.28 up to 7.33 ± 6.82 after the therapeutic endpoint, reaching to 6.44 ± 7.09 after 6 months of follow-up with p value = 0.008 and 0.014, respectively. There was a significant positive correlation between the duration of the lesion and the improvement assessed by the ultrasound, with p value = 0.01. Regarding adverse effects, all patients reported having pain during platelet-rich plasma injection; transient edema of the face was reported by four patients (45%), and only two patients showed transient erythema. Conclusion Autologous platelet-rich plasma is a safe technique with great aesthetic outcomes for filling up the contour defects and correcting both hyper and hypopigmentation, in addition to softening the indurated lesions.
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Affiliation(s)
- Esraa Elnaquip
- Dermatology, Andrology & STIs Department, Ras Eltin General Hospital, Alexandria, Egypt
| | - Mahmoud Makki
- Dermatology, Andrology & STIs Department, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Mofreh Mansour
- Dermatology, Andrology & STIs Department, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Abdelhfeez Moshrif
- Rheumatology Department, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
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Foti R, De Pasquale R, Dal Bosco Y, Visalli E, Amato G, Gangemi P, Foti R, Ramondetta A. Clinical and Histopathological Features of Scleroderma-like Disorders: An Update. Medicina (B Aires) 2021; 57:medicina57111275. [PMID: 34833493 PMCID: PMC8625286 DOI: 10.3390/medicina57111275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 11/25/2022] Open
Abstract
Scleroderma-like disorders include a set of entities involving cutis, subcutis and, sometimes, even muscular tissue, caused by several pathogenetic mechanisms responsible for different clinical–pathological pictures. The absence of antinuclear antibodies (ANA), Raynaud’s phenomenon and capillaroscopic anomalies constitutes an important element of differential diagnosis with systemic sclerosis. When scleroderma can be excluded, on the basis of the main body sites, clinical evolution, any associated pathological conditions and specific histological features, it is possible to make a correct diagnosis.
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Affiliation(s)
- Rosario Foti
- Division of Reumathology, A.O.U. “Policlinico-San Marco”, 95123 Catania, Italy; (R.F.); (Y.D.B.); (E.V.); (G.A.)
| | - Rocco De Pasquale
- U.O. Dermatologia, Ospedale San Marco, 95123 Catania, Italy; (R.D.P.); (R.F.)
| | - Ylenia Dal Bosco
- Division of Reumathology, A.O.U. “Policlinico-San Marco”, 95123 Catania, Italy; (R.F.); (Y.D.B.); (E.V.); (G.A.)
| | - Elisa Visalli
- Division of Reumathology, A.O.U. “Policlinico-San Marco”, 95123 Catania, Italy; (R.F.); (Y.D.B.); (E.V.); (G.A.)
| | - Giorgio Amato
- Division of Reumathology, A.O.U. “Policlinico-San Marco”, 95123 Catania, Italy; (R.F.); (Y.D.B.); (E.V.); (G.A.)
| | - Pietro Gangemi
- U.O. Anatomia Patologica, Ospedale San Marco, 95123 Catania, Italy;
| | - Riccardo Foti
- U.O. Dermatologia, Ospedale San Marco, 95123 Catania, Italy; (R.D.P.); (R.F.)
| | - Alice Ramondetta
- U.O. Dermatologia, Ospedale San Marco, 95123 Catania, Italy; (R.D.P.); (R.F.)
- Correspondence: ; Tel.: +39-095-479-4298
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Fairchild R, Chung M, Sharpless L, Li S, Chung L. Ultrasound Detection of Calcinosis and Association With Ulnar Artery Occlusion in Patients With Systemic Sclerosis. Arthritis Care Res (Hoboken) 2021; 73:1332-1337. [PMID: 32475057 DOI: 10.1002/acr.24327] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/19/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the ability of ultrasound (US) compared to radiographs to detect calcinosis in hands/wrists of patients with systemic sclerosis (SSc), and to assess US markers of pathologic perfusion. METHODS Patients with SSc were evaluated for calcinosis in the hands/wrists by radiograph and US. The presence or absence of calcinosis was recorded by patient, hand, and anatomic zone; sensitivity and specificity for calcinosis detection by US versus radiographs was determined. Bilateral US vascular measurements of ulnar artery occlusion (UAO) and finger pulp blood flow (FPBF) were obtained. For each hand, associations between markers of pathologic blood flow (UAO, FPBF, and a composite severity score of UAO and FPBF) and the presence of calcinosis were assessed using generalized estimating equations. RESULTS Of 43 patients with SSc (19 diffuse, 24 limited), 39.5% had calcinosis on radiographs compared to 30.2% on US. Sensitivity and specificity for US, respectively, were 61% and 95% by zone, 78% and 98% by hand, and 76% and 100% by patient. UAO was seen in 30% and 28% of left and right hands, respectively; FPBF was absent in ≥1 digit of the left and right hands in 49% and 44%, respectively. UAO was associated with radiograph-identified calcinosis by hand (odds ratio [OR] 8.08 [95% confidence interval (95% CI) 2.45-26.60], P < 0.001), whereas FPBF and the composite severity score were not significant. UAO was associated with calcinosis even in the absence of digital ulcers (OR 33.00 [95% CI 3.39-321.09], P = 0.003). CONCLUSION US was sensitive and highly specific in detecting calcinosis in SSc. UAO was strongly associated with radiograph-identified calcinosis.
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Affiliation(s)
| | - Melody Chung
- Stanford University School of Medicine, Palo Alto, California
| | | | - Shufeng Li
- Stanford University Medical Center, Palo Alto, California
| | - Lorinda Chung
- Stanford University School of Medicine and Veterans Administration Palo Alto Health Care System, Palo Alto, California
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Cüzdan N, Türk İ, Çiftçi V, Arslan D, Doğan MC, Ünal İ. The effect of a home-based orofacial exercise program on oral aperture of patients with systemic sclerosis: A single-blind prospective randomized controlled trial. Arch Rheumatol 2021; 36:176-184. [PMID: 34527921 PMCID: PMC8418773 DOI: 10.46497/archrheumatol.2021.8295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/29/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study aims to evaluate the effect of a home-based orofacial exercise program on the oral aperture (OA) of systemic sclerosis (SSc) patients. PATIENTS AND METHODS This single-blind prospective randomized controlled study performed between March 2017 and January 2019 included 56 SSc patients (3 males, 53 females; mean age 52.9±10.6 years; range, 31 to 70 years) with an OA of <40 mm. Patients were divided into two groups. Group 1 (n=28, mean age 53.8±9.6 years) was given orofacial exercise program twice a day for one month in addition to oral hygiene care advices, followed by no activity for the next month. Group 2 (n=28, mean age 50.0±11 years) received oral hygiene care advices for the first month followed by the same exercise program for the next month. Patients' OA was measured at baseline, and at first and second months. RESULTS After the first month, OA increased in Group 1 (p<0.001), whereas no change was observed in Group 2 (p=0.579). At the end of two months, there was no additional increase in Group 1 (p=0.352), while there was a significant increase in Group 2 (p<0.001). There was no difference between OAs of the groups at the end of the trial (p=0.564). CONCLUSION Our results suggest that home-based orofacial exercise program improves OA of SSc patients.
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Affiliation(s)
- Nihan Cüzdan
- Department of Physical Therapy and Rehabilitation & Rheumatology, Balıkesir Atatürk City Hospital, Balıkesir, Turkey
| | - İpek Türk
- Rheumatology, Osmaniye State Hospital, Osmaniye, Turkey
| | - Volkan Çiftçi
- Pediatric Dentistry, Çukurova University Faculty of Dentistry, Adana, Turkey
| | - Didem Arslan
- Department of Internal Medicine, Rheumatology, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Muharrem Cem Doğan
- Pediatric Dentistry, Çukurova University Faculty of Dentistry, Adana, Turkey
| | - İlker Ünal
- Department of Biostatistics, Çukurova University Faculty of Medicine, Adana, Turkey
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Ophthalmic manifestations in patients with collagen vascular disorders: a hospital-based retrospective observational study. Int Ophthalmol 2021; 41:2765-2775. [PMID: 33830371 DOI: 10.1007/s10792-021-01833-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/29/2021] [Indexed: 01/19/2023]
Abstract
AIM To study frequency and characteristics of ocular manifestations in Indian patients with collagen vascular disorders. METHODS The medical records of 73 patients (Males: Females 16:57) aged between 22 and 78 years (mean ± SD = 43.5 ± 12.9 years) with collagen vascular diseases were analyzed retrospectively for demography, subtypes of collagen vascular disease, and findings of complete ophthalmic examination. RESULTS Lupus erythematosus (LE) in 39(53.4%, (SLE 18, DLE 21), systemic sclerosis in 27(37%), dermatomyositis in 5(6.8%), and primary Sjögren's syndrome in 2(2.7%) patients, respectively, were observed. Only 35(47.9%) patients had ocular manifestations. In LE keratoconjunctivitis sicca (n = 6), keratitis (n = 5), severe blepharitis (n = 3), retinopathy (n = 2), and optic neuritis in one patient, respectively, were major ocular manifestations. Major abnormalities occurring in systemic sclerosis included restricted eyelid mobility of variable severity (n = 8), eyelid telangiectasia (n = 5), keratoconjunctivitis sicca (n = 6), cataract (n = 5), shallow fornices (n = 4), conjunctival surface disease (n = 4), and uveitis, keratitis, episcleritis in one patient each, respectively. One patient with dermatomyositis had heliotrope rash. Two patients with primary Sjögren's syndrome had keratoconjunctivitis sicca. CONCLUSIONS The study shows that LE frequently presented with keratoconjunctivitis sicca, retinopathy, and optic neuritis. Systemic sclerosis commonly develops eyelid immobility, blepharitis and telangiectasia, ocular surface disease and keratoconjunctivitis sicca, corneal abnormalities, and uveitis. A comprehensive ocular evaluation is imperative for early detection and management particularly of ocular surface disease, uveitis, and retinopathy to prevent potential sight-threatening complications. Limitations include retrospective study design and small number of patients for stratification.
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Kaushik A, Mahajan R, De D, Handa S. Paediatric morphoea: a holistic review. Part 1: epidemiology, aetiopathogenesis and clinical classification. Clin Exp Dermatol 2020; 45:673-678. [PMID: 32472964 DOI: 10.1111/ced.14234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 12/29/2022]
Abstract
Morphoea, also known as localized scleroderma, is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Paediatric-onset disease is not uncommon and is associated with frequent relapses. The disease has complex pathogenetic mechanisms and multiple clinical subtypes, and affects children of all ages. Recent research has focused on elucidating the disease pathophysiology and identifying measures of disease activity. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected, and results were analysed before being summarized. In the first of this two-part review, we provide a bird's-eye view of the current literature concerning the epidemiology, aetiopathogenesis and clinical classification of paediatric morphoea; in Part 2, we review the diagnosis, markers of disease activity, management and natural history.
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Affiliation(s)
- A Kaushik
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - R Mahajan
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - D De
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Handa
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Chung MP, Dontsi M, Postlethwaite D, Kesh S, Simard JF, Fiorentino D, Zaba LC, Chung L. Increased Mortality in Asians With Systemic Sclerosis in Northern California. ACR Open Rheumatol 2020; 2:197-206. [PMID: 32198914 PMCID: PMC7164633 DOI: 10.1002/acr2.11126] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 02/18/2020] [Indexed: 11/21/2022] Open
Abstract
Objective The objective of this study is to evaluate racial/ethnic differences in disease manifestations and survival in a US cohort of patients with systemic sclerosis (SSc), with a focus on Asian patients. Methods A retrospective cohort study was conducted among Kaiser Permanente Northern California adults with an incident SSc diagnosis by a rheumatologist from 2007 to 2016, confirmed by a chart review to fulfill 2013 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria. Self‐reported race/ethnicity was categorized as non‐Hispanic white, Asian, Hispanic, and black. Disease manifestations and survival were compared, using white patients as the reference. Results A total of 609 patients with incident SSc were identified: 89% were women, and 81% had limited cutaneous SSc, with a mean age at diagnosis of 55.4 ± 14.8 years. The racial/ethnic distribution was 51% non‐Hispanic white (n = 310), 25% Hispanic (n = 154), 16% Asian (n = 96), and 8% black (n = 49). Compared with white patients, black patients had a greater prevalence of diffuse disease (14.5% vs. 44.9%; P < 0.001), and Asians had higher rates of anti‐U1‐RNP antibodies (32.1% vs. 11.9%; P = 0.005). Nine‐year overall survival rates following SSc diagnosis were lower in Asian (52.3%), black (52.2%), and Hispanic patients (68.2%) compared with white patients (75.8%). Pulmonary hypertension and infections were the leading causes of death in Asian patients. Asian race was associated with higher mortality on univariable (hazard ratio [HR] 1.83 [95% confidence interval (CI) 1.08‐2.99]; P = 0.020) and multivariable analyses (HR 1.80 [95% CI 0.99‐3.16]; P = 0.047) when adjusting for age, sex, body mass index, cutaneous subtype, smoking status, interstitial lung disease, pulmonary hypertension, renal crisis, and malabsorption syndrome. Conclusion Asian patients with SSc in this US cohort had increased mortality compared with white patients. These patients warrant close monitoring for disease progression.
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Affiliation(s)
- Melody P Chung
- Kaiser Permanente Santa Clara, Santa Clara, California, and Stanford University School of Medicine, Palo Alto, California
| | | | | | - Sumana Kesh
- Kaiser Permanente Santa Clara, Santa Clara, California
| | - Julia F Simard
- Stanford University School of Medicine, Palo Alto, California
| | | | - Lisa C Zaba
- Stanford University School of Medicine, Palo Alto, California
| | - Lorinda Chung
- Stanford University School of Medicine and Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Abstract
BACKGROUND Scleroderma is a chronic connective tissue disease that results in fibrosis of the skin and internal organs. Although internal organ involvement corresponds with poor prognosis, systemic agents are effective at improving the effects of scleroderma on internal organs. In contrast, skin manifestations are universally present in all patients diagnosed with scleroderma, yet no systemic agents have been shown to be successful. Fat grafting has been shown to improve skin quality and improve contour irregularities and may be helpful in the treatment of patients with scleroderma. METHODS The authors performed a thorough review of the pathophysiology of scleroderma and the current treatment options for scleroderma. The efficacy of fat grafting for the treatment of scleroderma and the mechanism by which fat grafting improves outcomes was also discussed. RESULTS Scleroderma is characterized by chronic inflammation and vascular compromise that leads to fibrosis of the skin and internal organs. Fat grafting has recently been the focus of significant basic science research. It has been shown to reduce inflammation, reduce fibrosis by limiting extracellular matrix proteins and increasing collagenase activity, and provide structural support through stem cell proliferation and differentiation. The adipocytes, adipose stem cells, endothelial cells, and vascular smooth muscle cells in the processed fat likely contribute to the effectiveness of this treatment. CONCLUSIONS Fat grafting in scleroderma patients likely improves skin manifestations by recreating fullness, correcting contour deformities, and improving skin quality. The injected fat provides a mixture of cells that influences the recipient site, resulting in improved outcomes.
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NOTCH3 T6746C and TP53 P72R Polymorphisms Are Associated with the Susceptibility to Diffuse Cutaneous Systemic Sclerosis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8465971. [PMID: 32185220 PMCID: PMC7060860 DOI: 10.1155/2020/8465971] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/15/2019] [Accepted: 01/21/2020] [Indexed: 02/06/2023]
Abstract
Introduction. NOTCH pathway and TP53 protein are involved in the development of fibrosis and autoimmune disorders, respectively. The aim of this study was to evaluate the role of single nucleotide polymorphisms (SNPs) of NOTCH3 and TP53 genes and serum anti-TP53 antibodies with the susceptibility, clinical subset of systemic sclerosis (SSc), and clinical profile of SSc patient, particularly with lung involvement and disease activity. Objects and Methods. 124 white Polish SSc patients (101 with limited cutaneous SSc-lcSSc, and 23 with diffuse cutaneous SSc-dcSSc) and 100 healthy individuals were included in the study. Patients were assessed for the presence of autoantibodies and interstitial lung disease. Two SNPs at position 6746 of NOTCH3 and TP53 genes and serum anti-TP53 antibodies with the susceptibility, clinical subset of systemic sclerosis (SSc), and clinical profile of SSc patient, particularly with lung involvement and disease activity. Results The genotypic frequencies of the NOTCH3 and p=0.03; χ 2 = 4.63). There was no significant difference between SSc patients and the control population in allele frequencies of both SNPs. The CT + CC genotypes of NOTCH3 and p=0.03; p=0.03; p=0.03; TP53 genes and serum anti-TP53 antibodies with the susceptibility, clinical subset of systemic sclerosis (SSc), and clinical profile of SSc patient, particularly with lung involvement and disease activity. p=0.03. Conclusion The CT + CC genotypes of NOTCH3 gene and PR + RR genotypes of the TP53 gene increased the risk of dcSSc development. Moreover, genotypes of CT + CC were associated with the active form of SSc suggesting the role of the NOTCH pathway in the pathogenesis of this disease.NOTCH3 and TP53 genes and serum anti-TP53 antibodies with the susceptibility, clinical subset of systemic sclerosis (SSc), and clinical profile of SSc patient, particularly with lung involvement and disease activity.
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Khan OA, Majeed R, Kamal K, Sherazi M, Saad M. Anxiety, Depression, and Obsessive-compulsive Disorder in a Recently Diagnosed Case of Systemic Sclerosis. Cureus 2019; 11:e4748. [PMID: 31363430 PMCID: PMC6663282 DOI: 10.7759/cureus.4748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Systemic sclerosis is an autoimmune condition that frequently affects women. It is a progressive, debilitating disease that has widespread manifestations, targeting different organs of the body with potentially fatal consequences due to lung and kidney involvement. Women with this disease mostly present with Raynaud’s phenomenon along with symptoms of gastro-esophageal reflux disease (GERD). Just like any chronic debilitating condition, patients with systemic sclerosis often suffer from mental health issues that can further worsen their condition, significantly affecting their quality of life. Further research regarding the effects and severity of the disease should be encouraged for a better understanding of the illness, its diagnosis, and treatment. We present a rare case of a 55-year-old woman who presented with complaints of a major depressive episode. She was diagnosed with systemic sclerosis last year and has a history of generalized anxiety disorder. She was prescribed Mirtazapine, an antidepressant. On her follow-up after one month, she started complaining of obsessive ruminations that were causing her significant distress. She was prescribed an add-on therapy with a selective serotonin reuptake inhibitor (SSRI) antidepressant with the emphasis being placed on cognitive behavioral therapy (CBT). She reported an improvement in her obsessive symptoms as well as depression after two months.
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Affiliation(s)
- Omair A Khan
- Internal Medicine, Fauji Foundation Hospital, Rawalpindi, PAK
| | - Ramsha Majeed
- Internal Medicine, Fauji Foundation Hospital, Rawalpindi, PAK
| | - Kaynat Kamal
- Public Health, Health Services Academy, Quaid-E-Azam University, Islamabad, PAK
| | - Mahnoor Sherazi
- Internal Medicine, Fauji Foundation Hospital, Rawalpindi, PAK
| | - Muhammad Saad
- Internal Medicine, Fauji Foundation Hospital, Rawalpindi, PAK
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Badshah II, Brown S, Weibel L, Rose A, Way B, Sebire N, Inman G, Harper J, O'Shaughnessy RFL. Differential expression of secreted factors SOSTDC1 and ADAMTS8 cause profibrotic changes in linear morphoea fibroblasts. Br J Dermatol 2019; 180:1135-1149. [PMID: 30367460 DOI: 10.1111/bjd.17352] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Linear morphoea (LM) is a rare connective tissue disorder characterized by a line of thickened skin and subcutaneous tissue and can also affect the underlying muscle and bone. Little is known about the disease aetiology, with treatment currently limited to immune suppression, and disease recurrence post-treatment is common. OBJECTIVES In order to uncover new therapeutic avenues, the cell-intrinsic changes in LM fibroblasts compared with site-matched controls were characterized. METHODS We grew fibroblasts from site-matched affected and unaffected regions from five patients with LM, we subjected them to gene expression analysis and investigation of SMAD signalling. RESULTS Fibroblasts from LM lesions showed increased migration, proliferation, altered collagen processing, and abnormally high basal levels of phosphorylated SMAD2, thereby rendering them less responsive to transforming growth factor (TGF)-β1 and reducing the degree of myofibroblast differentiation, which is a key component of the wound-healing and scarring process in normal skin. Conditioned media from normal fibroblasts could reverse LM-affected fibroblast migration and proliferation, suggesting that the LM phenotype is driven by an altered secretome. Gene array analysis and RNA-Seq indicated upregulation of ADAMTS8 and downregulation of FRAS1 and SOSTDC1. SOSTDC1 knock-down recapitulated the reduced TGF-β1 responsiveness and LM fibroblast migration, while overexpression of ADAMTS8 induced myofibroblast markers. CONCLUSIONS We demonstrate that cell-intrinsic changes in the LM fibroblast secretome lead to changes observed in the disease, and that secretome modulation could be a viable therapeutic approach in the treatment of LM.
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Affiliation(s)
- I I Badshah
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
| | - S Brown
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
- Restoration of Appearance and Function Trust, Leopold Muller Building, Mount Vernon Hospital, Northwood, Middlesex, U.K
| | - L Weibel
- Department of Dermatology, University Hospital, Zurich, Switzerland
| | - A Rose
- Division of Cancer Research, University of Dundee, School of Medicine, Dundee, U.K
| | - B Way
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
| | - N Sebire
- Histopathology, Great Ormond Street Hospital, London, U.K
| | - G Inman
- Division of Cancer Research, University of Dundee, School of Medicine, Dundee, U.K
| | - J Harper
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
| | - R F L O'Shaughnessy
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Queen Mary University of London, London, U.K
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Ogawa T, Okiyama N, Takamuki R, Inoue S, Saito A, Nakamura Y, Ishitsuka Y, Watanabe R, Fujisawa Y, Fujimoto M. Juvenile case of multiple morphea profunda resulting in joint contracture that was successfully treated with cyclosporin A: A case report and review of the published works. J Dermatol 2019; 46:354-357. [DOI: 10.1111/1346-8138.14801] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/14/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Tatsuya Ogawa
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Naoko Okiyama
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Risa Takamuki
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Sae Inoue
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Akimasa Saito
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Yoshiyuki Nakamura
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Yosuke Ishitsuka
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Rei Watanabe
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Yasuhiro Fujisawa
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
| | - Manabu Fujimoto
- Department of Dermatology Faculty of Medicine University of Tsukuba Tsukuba Japan
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Maxillofacial Implications of Scleroderma and Systemic Sclerosis: A Case Report and Literature Review. J Oral Maxillofac Surg 2019; 77:1203-1208. [PMID: 30794809 DOI: 10.1016/j.joms.2019.01.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 11/27/2022]
Abstract
Scleroderma and more generally systemic sclerosis comprise a group of autoimmune diseases characterized by increased collagen synthesis and deposition within connective tissue. The Scleroderma Foundation estimates that as many as 300,000 persons in the United States have scleroderma. Although the etiology of the disease is unknown, it is thought to be related to chronic inflammation secondary to autoimmune tissue damage. Scleroderma has variable presentations and may result in changes to the skin, blood vessels, muscles, and internal organs. Oral and maxillofacial findings can include limited mouth opening; xerostomia; periodontal disease; widening of the periodontal ligament space; zygomatic arch resorption; and resorption of the mandibular angle, coronoid process, and condyle. We present the case of a 26-year-old female patient with scleroderma who exhibited extreme maxillofacial manifestations of the disease.
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15
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Bordoni B, Morabito B, Mitrano R, Simonelli M, Toccafondi A. The Anatomical Relationships of the Tongue with the Body System. Cureus 2018; 10:e3695. [PMID: 30838167 PMCID: PMC6390887 DOI: 10.7759/cureus.3695] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The tongue plays a fundamental role in several body functions such as swallowing, breathing, speaking, and chewing. Its action is not confined to the oral cavity, but it affects lower limb muscle strength and posture. The tongue is an organ that has an autocrine/paracrine mechanism of action to synthesize different substances to interact with the whole body; according to a line of thought, it is also an extension of the enteric system. The aim of this study was to review the functions of the tongue and its anatomical association with the body system. According to the authors' knowledge, this is the first scientific article focusing on the tongue in a systemic context. In a clinical evaluation, connections with the tongue should be considered to optimize the clinical examination of the tongue and therefore enhance rehabilitation programs and therapeutic results.
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Affiliation(s)
- Bruno Bordoni
- Cardiology, Foundation Don Carlo Gnocchi / Institute of Hospitalization and Care, Milan, ITA
| | - Bruno Morabito
- Osteopathy, School of Osteopathic Centre for Research and Studies, Milan, ITA
| | - Roberto Mitrano
- Cardiology, Foundation Don Carlo Gnocchi/institute of Hospitalization and Care, Milan, ITA
| | | | - Anastasia Toccafondi
- Cardiology, Foundation Don Carlo Gnocchi/institute of Hospitalization and Care, Milan, ITA
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16
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Robledo-Sierra J, Bäckman K, Öhman J, Jontell M. Oral lichen sclerosus: an overview and report of three cases. Int J Oral Maxillofac Surg 2018; 47:1550-1556. [DOI: 10.1016/j.ijom.2018.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/16/2018] [Accepted: 04/08/2018] [Indexed: 01/15/2023]
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17
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The correlation between serum E-selectin levels and soluble interleukin-2 receptors with relation to disease activity in localized scleroderma. Postepy Dermatol Alergol 2018; 35:614-619. [PMID: 30618531 PMCID: PMC6320493 DOI: 10.5114/ada.2018.77613] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/02/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Scleroderma is a chronic connective tissue disease resulting in fibrosis. Aim The aim of the study was to determine the connection between sE-selectin and sIL-2R and the severity of skin lesions in various subtypes of LoS. Evaluation of disease severity, the location of skin lesions, the duration of symptoms and disease activity were assessed in relation to the three different LoS subtypes in patients with localized scleroderma. Material and methods The study included 42 patients with localized scleroderma and the control group consisted of 41 healthy subjects. All patients in the LoS study group had a confirmed diagnosis via skin biopsy and underwent serology testing for sE-selectin and sIL-2R concentrations by enzyme-linked immunosorbent assay (ELISA). Results Significantly higher levels of sE-selectin and sIL-2R were observed in the LoS study group when compared with the control group (p < 0.001). The analysis showed a result close to statistical significance (p = 0.058) between sE-selectin concentration during the time of active disease in the LoS study group. The highest concentrations of sE-selectin and sIL-2R were observed in patients with the generalized subtype of LoS. A positive, statistically significant, curvilinear relationship was shown amid the modified Localized Skin Severity Index (mLoSSI) and sE-selectin and sIL-2R concentrations in the LoS study group. Conclusions Concentrations of the circulating form of sE-selectin appear to be an adequate marker of the endothelial function, positively correlating with the severity of the disease. The proven correlation of sIL-2R concentrations with the severity of the disease indicates that it is a valuable prognostic factor for predicting the impending course of the disease.
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18
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Harrach S, Barz V, Pap T, Pavenstädt H, Schlatter E, Edemir B, Distler J, Ciarimboli G, Bertrand J. Notch Signaling Activity Determines Uptake and Biological Effect of Imatinib in Systemic Sclerosis Dermal Fibroblasts. J Invest Dermatol 2018; 139:439-447. [PMID: 30273596 DOI: 10.1016/j.jid.2018.08.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 08/14/2018] [Accepted: 08/21/2018] [Indexed: 02/08/2023]
Abstract
Tyrosine kinase inhibitors have emerged as a therapeutic option for rheumatic diseases such as systemic sclerosis (SSc). Because tyrosine kinases like c-Abl kinase are important for fibroblast activation and fibrosis development in SSc, the c-Abl inhibitor imatinib was proposed for SSc treatment. Transporters for organic cations have become increasingly recognized as an important determinant for uptake and efficacy of tyrosine kinase inhibitors. Therefore, we investigated the role of organic cation transporters in the uptake of imatinib. Moreover, the influence of important SSc pathogenetic factors, like PDGF and Notch pathway activation on these uptake processes, has been studied. We showed that organic cation transporters OCT1-3, novel organic cation transporters OCTN1/2, and the multidrug and toxin extrusion protein MATE1 are expressed in healthy dermal and SSc fibroblasts. Decreased expression levels of MATE1 and decreased imatinib uptake were measured in SSc fibroblasts. In small interfering RNA experiments, MATE1 was identified as key transporter for imatinib uptake and biological effect in dermal fibroblasts. Furthermore, PDGF reduced imatinib uptake by decreasing MATE1 expression in SSc fibroblasts, but not in healthy fibroblasts. Blocking the Notch pathway in SSc fibroblasts increased MATE1 transporter expression and imatinib uptake. In conclusion, MATE1-mediated transport governs therapeutic efficacy of imatinib in SSc.
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Affiliation(s)
- Saliha Harrach
- Institute of Experimental Musculoskeletal Medicine, Department of Internal Medicine D, University Hospital Muenster, Germany; Experimental Nephrology, Department of Internal Medicine D, University Hospital Muenster, Germany
| | - Vivien Barz
- Experimental Nephrology, Department of Internal Medicine D, University Hospital Muenster, Germany
| | - Thomas Pap
- Institute of Experimental Musculoskeletal Medicine, Department of Internal Medicine D, University Hospital Muenster, Germany
| | - Hermann Pavenstädt
- Experimental Nephrology, Department of Internal Medicine D, University Hospital Muenster, Germany
| | - Eberhard Schlatter
- Experimental Nephrology, Department of Internal Medicine D, University Hospital Muenster, Germany
| | - Bayram Edemir
- Department of Internal Medicine IV, Hematology and Oncology, University Hospital Halle (Saale), Germany
| | - Jörg Distler
- Rheumatology and Immunology, Medical Clinic 3, University Hospital Erlangen, Erlangen, Germany
| | - Giuliano Ciarimboli
- Experimental Nephrology, Department of Internal Medicine D, University Hospital Muenster, Germany
| | - Jessica Bertrand
- Department of Orthopaedic Surgery, Otto-von-Guericke University Magdeburg, Germany.
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Asano Y, Fujimoto M, Ishikawa O, Sato S, Jinnin M, Takehara K, Hasegawa M, Yamamoto T, Ihn H. Diagnostic criteria, severity classification and guidelines of localized scleroderma. J Dermatol 2018; 45:755-780. [PMID: 29687475 DOI: 10.1111/1346-8138.14161] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 11/26/2022]
Abstract
We established diagnostic criteria and severity classification of localized scleroderma because there is no established diagnostic criteria or widely accepted severity classification of the disease. Also, there has been no clinical guideline for localized scleroderma, so we established its clinical guideline ahead of all over the world. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of localized scleroderma.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Osamu Ishikawa
- Department of Dermatology, Graduate School of Medicine, Gunma University, Gunma, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Toshiyuki Yamamoto
- Department of Dermatology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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20
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21
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Resorlu H, Kılıc S, Isık S, Gokmen F. Successful infliximab therapy in a patient with comorbid spondyloarthritis, primary biliary cirrhosis and generalized morphea. Acta Clin Belg 2017; 72:365-368. [PMID: 28229620 DOI: 10.1080/17843286.2017.1290567] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The patient in this report was diagnosed simultaneously with primary biliary cirrhosis (PBC), spondyloarthritis, and generalized morphea and was started on infliximab therapy. In addition to an improvement in clinical symptoms with this therapy, an improvement was also observed in laboratory parameters such as cholestatic enzymes, C-reactive protein, and erythrocyte sedimentation rate. Infliximab was well tolerated in this 56-year-old patient. However, further studies must be performed in order to clarify the therapeutic role of TNF-α blockers in, PBC and generalized morphea.
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Affiliation(s)
- Hatice Resorlu
- Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Sevilay Kılıc
- Faculty of Medicine, Department of Dermatology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Selda Isık
- Faculty of Medicine, Department of Dermatology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Ferhat Gokmen
- Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Canakkale Onsekiz Mart University, Canakkale, Turkey
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22
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Knobler R, Moinzadeh P, Hunzelmann N, Kreuter A, Cozzio A, Mouthon L, Cutolo M, Rongioletti F, Denton CP, Rudnicka L, Frasin LA, Smith V, Gabrielli A, Aberer E, Bagot M, Bali G, Bouaziz J, Braae Olesen A, Foeldvari I, Frances C, Jalili A, Just U, Kähäri V, Kárpáti S, Kofoed K, Krasowska D, Olszewska M, Orteu C, Panelius J, Parodi A, Petit A, Quaglino P, Ranki A, Sanchez Schmidt JM, Seneschal J, Skrok A, Sticherling M, Sunderkötter C, Taieb A, Tanew A, Wolf P, Worm M, Wutte NJ, Krieg T. European Dermatology Forum S1-guideline on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: localized scleroderma, systemic sclerosis and overlap syndromes. J Eur Acad Dermatol Venereol 2017; 31:1401-1424. [PMID: 28792092 DOI: 10.1111/jdv.14458] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 06/26/2017] [Indexed: 12/13/2022]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present guideline focuses on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, current strategies in the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this guideline provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes of systemic sclerosis with diseases of the rheumatological spectrum.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Moinzadeh
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - A Cozzio
- Department of Dermatology, Venereology and Allergology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - L Mouthon
- Service de Médecine Interne, Centre de référence maladies rares: vascularites et sclérodermie systémique, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - M Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - F Rongioletti
- Dermatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - C P Denton
- Division of Medicine, Centre for Rheumatology, University College London, London, UK
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L A Frasin
- Dermatology Unit, Hospital of Lecco, Lecco, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - A Gabrielli
- Department of Clinical and Molecular Science, Università Politecnica delle Marche, Ancona, Italy
| | - E Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - G Bali
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - J Bouaziz
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - A Braae Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - I Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - C Frances
- Department of Dermatology and Allergology, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - A Jalili
- Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - U Just
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - V Kähäri
- Department of Dermatology and Venereology, Turku University Hospital and University of Turku, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- Department of Dermato-Allergology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - D Krasowska
- Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Lublin, Poland
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - C Orteu
- Department of Dermatology, Connective Tissue Diseases Service, Royal Free Hospital, London, UK
| | - J Panelius
- Department of Dermatology, Allergology and Venereology, University of Helsinki, and Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - A Parodi
- Department of Dermatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - A Petit
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - P Quaglino
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - A Ranki
- Department of Dermatology, Allergology and Venereology, Inflammation Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J M Sanchez Schmidt
- Department of Dermatology, Hospital del Mar-Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - M Sticherling
- Department of Dermatology, University Hospital of Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Taieb
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Tanew
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Wolf
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Worm
- Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - N J Wutte
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - T Krieg
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
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Platsidaki E, Tzanetakou V, Kouris A, Stavropoulos PG. Methotrexate: an effective monotherapy for refractory generalized morphea. Clin Cosmet Investig Dermatol 2017; 10:165-169. [PMID: 28507446 PMCID: PMC5428760 DOI: 10.2147/ccid.s134879] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Introduction Morphea is an inflammatory skin disorder characterized by excessive collagen deposition. Although treatment algorithms for morphea subtypes have been suggested, no consistent recommendations are available. This study attempts to evaluate the clinical efficacy of methotrexate (MTX) as monotherapy in refractory generalized morphea. Methods It is a retrospective study, including 20 patients who had already been treated with various topical and systemic therapies with minimal clinical improvement. Patients received orally MTX at a of dosage 15 mg once weekly. Duration of the use, dosage of MTX, and adverse events were recorded. Clinical assessment of skin lesions was performed and documented. Results The mean disease duration was 27 months before the initiation of MTX treatment. After 12 months of therapy, very good response was achieved in 6 patients (30%), good response in 10 patients (50%), and fair response in 2 patients (10%), while 2 patients (10%) had failed treatment. Patients were followed up for a mean time interval of 21 months. No serious adverse event was recorded. Conclusion MTX has been already proved to be an effective and well-tolerated treatment in pediatric patients with morphea. The majority of the group of adult patients showed very good and good improvement when treated with MTX. Although this is an uncontrolled study, MTX monotherapy was considered a safe and effective treatment for the management of this specific clinical subset of morphea in adults.
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Affiliation(s)
- Eftychia Platsidaki
- Department of Dermatology and Venereology, Andreas Syggros Hospital, University of Athens, Athens, Greece
| | - Vassiliki Tzanetakou
- Department of Dermatology and Venereology, Andreas Syggros Hospital, University of Athens, Athens, Greece
| | - Anargyros Kouris
- Department of Dermatology and Venereology, Andreas Syggros Hospital, University of Athens, Athens, Greece
| | - Panagiotis G Stavropoulos
- Department of Dermatology and Venereology, Andreas Syggros Hospital, University of Athens, Athens, Greece
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Abreu C, Rodrigues M, Medeiros J, Costa D, Melo I, Souza F, Ferreira J, Nascimento M, Rodrigues E, Menezes D. ESCLERODERMIA EM PACIENTE INDÍGENA MASCULINO DA TRIBO YANOMAMI: RELATO DE CASO. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Marangon Júnior H, Souza PEA, Soares RV, Gomez RS, Pereira GHDM, Horta MCR. Oral Lichen Sclerosus: A Rare Case Report and Review of the Literature. Head Neck Pathol 2016; 11:212-218. [PMID: 27807761 PMCID: PMC5429284 DOI: 10.1007/s12105-016-0766-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
Lichen sclerosus (LS) is a chronic inflammatory mucocutaneous disease that often affects the anogenital area and causes significant discomfort and morbidity. Oral mucosal lesions in LS are extremely rare and might be associated with genital and/or skin manifestations. As a unique manifestation of LS, oral lesions are even more rare, with only 20 cases reported in English-language literature. In reviewing that literature in this paper, we present the case of a 44-year-old white man who sought dental assistance with a complaint of a white spot on his upper lip. Extraoral clinical examination revealed a slight white macule on the left upper lip vermilion next to the labial commissure. Intraoral examination revealed that the macule was approximately 3.5 × 2.0 cm, extended to the upper left labial mucosa, and presented an ivory-white color. Following an incisional biopsy and microscopy, the lesion was shown to be covered by a stratified squamous epithelium showing hyperkeratosis and atrophy. The superficial lamina propria revealed a well-marked band of subepithelial hyalinization and, below it, a band-like mononuclear inflammatory infiltrate. Sections stained by Verhoeff's technique revealed a scantiness of elastic fibers in the superficial lamina propria. The diagnosis of LS was then established. The patient was referred for dermatologic evaluation, which identified no skin or genital lesions, and no treatment was employed. After 6 years, no significant changes in clinical features were observed. Altogether, this rare case makes an important contribution to knowledge on this uncommon condition.
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Affiliation(s)
- Helvécio Marangon Júnior
- 0000 0001 2155 6671grid.412520.0Oral Pathology Division, School of Dentistry, Pontifical Catholic University of Minas Gerais, Avenida Dom José Gaspar, 500, Prédio 46, Sala 101, Coração Eucarístico, Belo Horizonte, MG 30535-901 Brazil
| | - Paulo Eduardo Alencar Souza
- 0000 0001 2155 6671grid.412520.0Oral Pathology Division, School of Dentistry, Pontifical Catholic University of Minas Gerais, Avenida Dom José Gaspar, 500, Prédio 46, Sala 101, Coração Eucarístico, Belo Horizonte, MG 30535-901 Brazil
| | - Rodrigo Villamarim Soares
- 0000 0001 2155 6671grid.412520.0Periodontology Division, School of Dentistry, Pontifical Catholic University of Minas Gerais, Belo Horizonte, MG Brazil
| | - Ricardo Santiago Gomez
- 0000 0001 2181 4888grid.8430.fDepartment of Oral Surgery and Pathology, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG Brazil
| | | | - Martinho Campolina Rebello Horta
- 0000 0001 2155 6671grid.412520.0Oral Pathology Division, School of Dentistry, Pontifical Catholic University of Minas Gerais, Avenida Dom José Gaspar, 500, Prédio 46, Sala 101, Coração Eucarístico, Belo Horizonte, MG 30535-901 Brazil
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Kreuter A, Krieg T, Worm M, Wenzel J, Moinzadeh P, Kuhn A, Aberer E, Scharffetter-Kochanek K, Horneff G, Reil E, Weberschock T, Hunzelmann N. German guidelines for the diagnosis and therapy of localized scleroderma. J Dtsch Dermatol Ges 2016; 14:199-216. [PMID: 26819124 DOI: 10.1111/ddg.12724] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Localized scleroderma designates a heterogeneous group of sclerotic skin disorders. Depending on the subtype, severity, and site affected, adjacent structures such as adipose tissue, muscles, joints, and bones may be involved. This is an update of the existing German AWMF (Association of the Scientific Medical Societies in Germany) guidelines (classification: S2k). These guidelines provide an overview of the definition, epidemiology, classification, pathogenesis, laboratory workup, histopathology, clinical scoring systems, as well as imaging and device-based workup of localized scleroderma. Moreover, consensus-based recommendations are given on the management of localized scleroderma depending on its clinical subtype. Treatment recommendations are presented in a therapeutic algorithm. No financial support was given by any pharmaceutical company. The guidelines are valid until July 2019.
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Affiliation(s)
- Alexander Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, Oberhausen, Germany
| | - Thomas Krieg
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology, and Allergology, Charité - University Medical Center Berlin, Berlin, Germany
| | - Jörg Wenzel
- Department of Dermatology and Allergology, University Hospital Bonn, Bonn, Germany
| | - Pia Moinzadeh
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Annegret Kuhn
- Interdisciplinary Center for Clinical Studies (IZKS), University Medical Center Mainz, Mainz, Germany
| | - Elisabeth Aberer
- Department of Dermatology and Venereology, University Hospital Graz, Graz, Austria
| | | | - Gerd Horneff
- Department of General Pediatrics, Asklepios Hospital, St. Augustin, Germany
| | - Emma Reil
- Emma Reil, Scleroderma Support Group, Heilbronn, Germany
| | - Tobias Weberschock
- Department of Dermatology, Venereology, und Allergology, University Hospital Frankfurt and Work Group EbM Frankfurt, Institute for General Medicine, Johann Wolfgang Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Nicolas Hunzelmann
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
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Abstract
Localized scleroderma (LoS) comprises a heterogeneous spectrum of fibrotic diseases that primarily affect the skin with inflammation and skin thickening. The extent of skin involvement and manifestation at extra-cutaneous structures characterizes the specific subset. Fat tissue, fascia, and sometimes muscle, and bones might be involved, and in rare cases the central nervous or ocular system. A worldwide accepted classification system for LoS is still lacking. The latest guidelines have proposed a distinction of limited, generalized, linear, deep, and mixed types. The exact pathophysiology of LoS is not fully understood yet, but it is thought that an externally triggered release of pro-inflammatory cytokines leads to a dysregulation of the connective tissue metabolism. LoS is diagnosed according to typical clinical features. Further diagnostic procedures are helpful to characterize the subtype and to define the extent of inflammation and fibrosis. Due to the heterogeneity of LoS, therapeutic strategies should always be selected depending on the respective subtype. The stage of tissue inflammation and sclerosis has to be considered. Treatment options such as topical corticosteroids, calcipotriol, and calcineurin inhibitors as well as phototherapy are well established. In subsets with severe wide-spread skin manifestation and/or extra-cutaneous involvement, methotrexate monotherapy or a combination of methotrexate and systemic corticosteroids need to be considered. Physical treatment should always be added to the topical and systemic treatment to prevent significant disabilities due to LoS. This article provides an updated review on the epidemiology, pathophysiology, clinical classification and treatment options for patients suffering from LoS.
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Orofacial Manifestations and Temporomandibular Disorders of Systemic Scleroderma: An Observational Study. Int J Mol Sci 2016; 17:ijms17071189. [PMID: 27455250 PMCID: PMC4964558 DOI: 10.3390/ijms17071189] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/08/2016] [Accepted: 07/19/2016] [Indexed: 12/22/2022] Open
Abstract
Scleroderma is a disorder involving oral and facial tissues, with skin hardening, thin lips, deep wrinkles, xerostomia, tongue rigidity, and microstomia. The aim of this study was to investigate the prevalence of oral manifestations and temporomandibular disorders (TMD) in Systemic Sclerosis (SSc) patients compared with healthy people. Eighty patients (6 men, 74 women) fulfilling ACR/EULAR SSc Criteria were enrolled. A randomly selected group of 80 patients, matched by sex and age served as control group. The examination for TMD signs and symptoms was based on the standardized Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) through a questionnaire and clinical examination. SSc patients complained more frequently (78.8%) of oral symptoms (Xerostomia, dysgeusia, dysphagia and stomatodynia) than controls (28.7%) (χ2 = 40.23 p = 0.001). TMD symptoms (muscle pain on chewing, difficulty in mouth opening, headaches) were complained by 92.5% of SSc patients and by 76.2% of controls (χ2 = 8.012 p = 0.005). At the clinical examination, 85% of SSc patients showed restricted opening versus 20.0% of controls (χ2 = 67.77 p = 0.001), 81.2% of SSc showed reduced right lateral excursion versus 50% of controls (χ2 = 17.316 p = 0.001); 73.8% of SSc showed limited left lateral excursion versus 53.8% of controls (χ2 = 6.924 p = 0.009); and 73.8% of SSc had narrow protrusion versus 56.2% of controls (χ2 = 5.385 p = 0.02).
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29
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Wollina U, Buslau M, Heinig B, Petrov I, Unger E, Kyriopoulou E, Koch A, Köstler E, Schönlebe J, Haroske G, Doede T, Pramatarov K. Disabling Pansclerotic Morphea of Childhood Poses a High Risk of Chronic Ulceration of the Skin and Squamous Cell Carcinoma. INT J LOW EXTR WOUND 2016; 6:291-8. [DOI: 10.1177/1534734607308731] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Disabling pansclerotic morphea of childhood (DPMC) is a rare and severe variant of scleroderma. This report presents 3 cases that presented to the authors and studies 25 patients from the literature (English language only) for the presence of chronic nonhealing ulcers of skin and skin cancer. The authors identified a total of 30 patients (9 male and 21 female) aged between 1 and 37 years at time of presentation. All cases were less than 14 years old when the disease started. The majority of patients had an aggressive course with deep sclerotic lesions leading to joint contractures and immobility. Five patients suffered from chronic nonhealing leg ulcers (17%), but ulcers were present on other parts of the body (upper limbs, trunk, head) as well (n = 6). Four patients died because of complications of the disease such as sepsis or gangrene. Two patients developed a squamous cell carcinoma at the age of 16 years and 19 years, respectively (6.7%). The available treatment of DMPC-associated ulcers is unsatisfying. Only temporary improvements have been seen in a minority of patients. We report on marked improvement of chronic leg ulcers by a combination of sildenafil 3 × 20 mg/day and repeated application of a porcine small intestinal submucosal acellular matrix.
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Affiliation(s)
| | | | | | - Ivailo Petrov
- Department of Dermatology, Medical University of Sofia,
Sofia, Bulgaria
| | | | | | - André Koch
- Department of Dermatology and Allergology
| | | | - Jaqueline Schönlebe
- Institute of Pathology “Georg Schmorl," Hospital
Dresden-Friedrichstadt, Dresden, Germany
| | - Gunther Haroske
- Institute of Pathology “Georg Schmorl," Hospital
Dresden-Friedrichstadt, Dresden, Germany
| | - Thorsten Doede
- Department of Pediatric Surgery, Medical School-Freidrich
Schiller University of Jena, Jena, Germany
| | - Kyrill Pramatarov
- Department of Dermatology, Medical University of Sofia,
Sofia, Bulgaria
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30
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Bakulev AL, Galkina EM, Karakaeva AV, Litvinenko MV. A case of localized bullous scleroderma. VESTNIK DERMATOLOGII I VENEROLOGII 2016. [DOI: 10.25208/0042-4609-2016-92-3-97-101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Bullous scleroderma is a rare type of the focal form of the disease mainly affecting the skin and characterized by induration and sclerosis foci as well as subepidermal blisters containing a transparent matter. The article describes a case study of bullous scleroderma in an adult woman with localized skin eruptions in the area of the left breast, which were completely regressed after a standard therapy with the use of drugs having an effect on collagen synthesis.
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31
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Kumar MH, Kumar MS, Kumar SH, Kumar KS. A neoteric multidrug combination: novel approach to limited cutaneous systemic scleroderma involving the face. BMJ Case Rep 2016; 2016:bcr-2015-212787. [PMID: 27033280 DOI: 10.1136/bcr-2015-212787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Limited cutaneous scleroderma is a subtype of scleroderma limited to the skin of the face, hands, feet and forearms. We present a case of a 45-year-old woman affected by limited cutaneous systemic scleroderma involving the orofacial region and causing restricted mouth opening. The patient showed noteworthy improvement of the skin lesion by use of a combination of intralesional corticosteroid with hyaluronidase and various multiantioxidants, resulting in amelioration of her mouth opening problem. The patient gave her full informed written consent to this report being published.
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Affiliation(s)
- M Hari Kumar
- Dental Department, Jeba Dental Clinic, Nagercoil, Tamilnadu, India
| | - M Siva Kumar
- Department of Maxillo Facial, Doctor Kamalkanadasan Dental Clinic, Chennai, Tamilnadu, India
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Targeting miR-155 to Treat Experimental Scleroderma. Sci Rep 2016; 6:20314. [PMID: 26828700 PMCID: PMC4734331 DOI: 10.1038/srep20314] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/30/2015] [Indexed: 01/08/2023] Open
Abstract
Scleroderma is a refractory autoimmune skin fibrotic disorder. Alterations of microRNAs in lesional skin could be a new approach to treating the disease. Here, we found that expression of miR-155 was up regulated in lesional skin tissue from patients with either systemic or localized scleroderma, and correlated with fibrosis area. Then we demonstrated the potential of miR-155 as a therapeutic target in pre-clinical scleroderma models. MiR-155−/− mice were resistant to bleomycin induced skin fibrosis. Moreover, topical antagomiR-155 could effectively treat mice primed with subcutaneous bleomycin. In primary skin fibroblast, miR-155 silencing could inhibit collagen synthesis function, as well as signaling intensity of two pro-fibrotic pathways, Wnt/β-catenin and Akt, simultaneously. We further showed that miR-155 could regulate the two pathways via directly targeting casein kinase 1α (CK1α) and Src homology 2-containing inositol phosphatase-1 (SHIP-1), as previous reports. Mice with miR-155 knockout or topical antagomir-155 treatment showed inhibited Wnt/β-catenin and Akt signaling in skin upon bleomycin challenge. Together, our data suggest the potential of miR-155 silencing as a promising treatment for dermal fibrosis, especially in topical applications.
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33
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Kreuter A, Krieg T, Worm M, Wenzel J, Moinzadeh P, Kuhn A, Aberer E, Scharffetter-Kochanek K, Horneff G, Reil E, Weberschock T, Hunzelmann N. Deutsche Leitlinie zur Diagnostik und Therapie der zirkumskripten Sklerodermie. J Dtsch Dermatol Ges 2016. [DOI: 10.1111/ddg.130_12724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alexander Kreuter
- Klinik für Dermatologie; Venerologie und Allergologie; HELIOS St. Elisabeth Hospital Oberhausen
| | - Thomas Krieg
- Klinik und Poliklinik für Dermatologie und Venerologie; Uniklinik Köln
| | - Margitta Worm
- Klinik für Dermatologie; Venerologie und Allergologie; Charité - Universitätsmedizin; Berlin
| | - Jörg Wenzel
- Klinik und Poliklinik für Dermatologie und Allergologie; Universität Bonn
| | - Pia Moinzadeh
- Klinik und Poliklinik für Dermatologie und Venerologie; Uniklinik Köln
| | - Annegret Kuhn
- Interdisziplinäres Zentrum Klinische Studien (IZKS); Universitätsmedizin Mainz
| | - Elisabeth Aberer
- Universitätsklinik für Dermatologie und Venerologie; Medizinische Universität Graz
| | | | - Gerd Horneff
- Allgemeine Kinder- und Jugendmedizin; Asklepios Klinik; St. Augustin
| | - Emma Reil
- Emma Reil; Sklerodermie Selbsthilfe e.V.; Heilbronn
| | - Tobias Weberschock
- Klinik für Dermatologie; Venerologie und Allergologie; Universitätsklinikum Frankfurt und Arbeitsgruppe EbM Frankfurt; Institut für Allgemeinmedizin; Johann Wolfgang Goethe-Universität; Frankfurt am Main
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34
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Panchbhai A, Pawar S, Barad A, Kazi Z. Review of orofacial considerations of systemic sclerosis or scleroderma with report of analysis of 3 cases. Indian J Dent 2016; 7:134-139. [PMID: 27795648 PMCID: PMC5015564 DOI: 10.4103/0975-962x.186702] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Scleroderma (skleros; hard, and derma; skin), is currently known as systemic sclerosis due to its progressive nature and widespread tissue involvement. It is a rare connective tissue disorder with a wide range of oral manifestations. Thickening of the skin is the hallmark of the disease. The patient education for self-care and multidisciplinary approach would be needed to manage the condition. The article presents the review of orofacial considerations in scleroderma with a report of analysis of orofacial manifestations 3 cases.
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Affiliation(s)
- Arati Panchbhai
- Department of Oral Medicine and Radiology, SP Dental College and Hospital, DMIMS University, Wardha, Maharashtra, India
| | - Sangita Pawar
- Department of Oral Pathology, HSRSM, Hingoli, Maharashtra, India
| | - Anuradha Barad
- Department of Oral Pathology, HSRSM, Hingoli, Maharashtra, India
| | - Zamzam Kazi
- Department of Oral Medicine and Radiology, SP Dental College, Wardha, Maharashtra, India
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35
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Gorkiewicz-Petkow A, Kalinska-Bienias A. Systemic involvement in localized scleroderma/morphea. Clin Dermatol 2015; 33:556-62. [DOI: 10.1016/j.clindermatol.2015.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Careta MF, Romiti R. Localized scleroderma: clinical spectrum and therapeutic update. An Bras Dermatol 2015; 90:62-73. [PMID: 25672301 PMCID: PMC4323700 DOI: 10.1590/abd1806-4841.20152890] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 10/11/2013] [Indexed: 12/31/2022] Open
Abstract
Scleroderma is a rare connective tissue disease that is manifested by cutaneous
sclerosis and variable systemic involvement. Two categories of scleroderma are known:
systemic sclerosis, characterized by cutaneous sclerosis and visceral involvement,
and localized scleroderma or morphea which classically presents benign and
self-limited evolution and is confined to the skin and/or underlying tissues.
Localized scleroderma is a rare disease of unknown etiology. Recent studies show that
the localized form may affect internal organs and have variable morbidity. Treatment
should be started very early, before complications occur due to the high morbidity of
localized scleroderma. In this review, we report the most important aspects and
particularities in the treatment of patients diagnosed with localized
scleroderma.
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37
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Borghini A, Manetti M, Nacci F, Bellando-Randone S, Guiducci S, Matucci-Cerinic M, Ibba-Manneschi L, Weber E. Systemic Sclerosis Sera Impair Angiogenic Performance of Dermal Microvascular Endothelial Cells: Therapeutic Implications of Cyclophosphamide. PLoS One 2015; 10:e0130166. [PMID: 26076019 PMCID: PMC4468204 DOI: 10.1371/journal.pone.0130166] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/18/2015] [Indexed: 11/19/2022] Open
Abstract
In systemic sclerosis (SSc), dermal capillaries are progressively lost with consequent chronic tissue hypoxia insufficiently compensated by angiogenesis. Clinical studies reported that intravenous cyclophosphamide (CYC) may improve SSc-related peripheral microvascular damage. Recently, we showed that CYC treatment may normalize SSc sera-induced abnormalities in endothelial cell-matrix interactions. Our objective was to evaluate in vitro the effects of sera from treatment-naïve or CYC-treated SSc patients on dermal blood microvascular endothelial cell (dMVEC) angiogenesis, migration, proliferation and apoptosis. dMVECs were challenged with sera from 21 SSc patients, treatment-naïve (n = 8) or under CYC treatment (n = 13), and 8 healthy controls. Capillary morphogenesis on Geltrex matrix was significantly reduced upon challenge with sera from naïve SSc patients compared with healthy controls. When dMVECs were challenged with sera from CYC-treated SSc patients, their angiogenic capacity was comparable to that of cells treated with healthy sera. Wound healing capacity and chemotaxis in Boyden chamber were both significantly decreased in the presence either of naïve or CYC-treated SSc sera compared with healthy sera. WST-1 assay revealed that cell proliferation was significantly decreased in dMVECs challenged with sera from naïve SSc patients compared with healthy sera. Conversely, dMVEC proliferation was not impaired in the presence of sera from CYC-treated SSc patients. Accordingly, the percentage of TUNEL-positive apoptotic dMVECs was significantly higher in the presence of sera from naïve SSc patients than healthy controls, while CYC-treated SSc sera did not induce dMVEC apoptosis. Levels of the angiostatic mediators endostatin, pentraxin 3, angiostatin and matrix metalloproteinase-12 were all significantly elevated in sera from naïve SSc patients compared with sera from both healthy controls and CYC-treated SSc patients. In SSc, CYC treatment might boost angiogenesis and consequently improve peripheral microangiopathy through the normalization of the endothelial cell-matrix interactions, reduction of endothelial cell apoptosis and rebalance of dysregulated angiostatic factors.
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MESH Headings
- Antineoplastic Agents, Alkylating/pharmacology
- Apoptosis/drug effects
- Blotting, Western
- Case-Control Studies
- Cell Adhesion/drug effects
- Cell Movement/drug effects
- Cell Proliferation/drug effects
- Cells, Cultured
- Cyclophosphamide/pharmacology
- Dermis/drug effects
- Dermis/metabolism
- Dermis/pathology
- Endothelium, Vascular/drug effects
- Endothelium, Vascular/metabolism
- Endothelium, Vascular/pathology
- Female
- Follow-Up Studies
- Humans
- Male
- Middle Aged
- Neovascularization, Pathologic/drug therapy
- Neovascularization, Pathologic/metabolism
- Neovascularization, Pathologic/pathology
- Prognosis
- Scleroderma, Systemic/blood
- Scleroderma, Systemic/drug therapy
- Scleroderma, Systemic/pathology
- Wound Healing
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Affiliation(s)
- Annalisa Borghini
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Mirko Manetti
- Department of Experimental and Clinical Medicine, Section of Anatomy and Histology, University of Florence, Florence, Italy
- * E-mail:
| | - Francesca Nacci
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Azienda Ospedaliero-Universitaria Careggi (AOUC), University of Florence, Florence, Italy
| | - Silvia Bellando-Randone
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Azienda Ospedaliero-Universitaria Careggi (AOUC), University of Florence, Florence, Italy
| | - Serena Guiducci
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Azienda Ospedaliero-Universitaria Careggi (AOUC), University of Florence, Florence, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Azienda Ospedaliero-Universitaria Careggi (AOUC), University of Florence, Florence, Italy
| | - Lidia Ibba-Manneschi
- Department of Experimental and Clinical Medicine, Section of Anatomy and Histology, University of Florence, Florence, Italy
| | - Elisabetta Weber
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
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38
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Huang YC, Huang CT, Hu C, Wong TW. Portable ultraviolet light A1 light source to treat hypertrophic scar. DERMATOL SIN 2015. [DOI: 10.1016/j.dsi.2014.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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40
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High IL-17E and low IL-17C dermal expression identifies a fibrosis-specific motif common to morphea and systemic sclerosis. PLoS One 2014; 9:e105008. [PMID: 25136988 PMCID: PMC4138152 DOI: 10.1371/journal.pone.0105008] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/16/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND High interleukin (IL)-17A levels are characteristically found in the skin of systemic sclerosis (SSc) individuals. Our aim was to investigate whether the dermal expression of IL-17A and related IL-17 family members (i.e. IL-17C, IL-17E and IL-17F) could distinguish fibrotic from healthy skin and could show similarities in SSc and morphea, two disorders with presumed distinct pathogenesis, but characterized by skin fibrosis. METHODS Biopsies were obtained from the involved skin of 14 SSc, 5 morphea and 8 healthy donors (HD) undergoing plastic surgery. Immunohistochemistry/immunofluorescence techniques were coupled to a semi-automated imaging quantification approach to determine the presence of the IL-17 family members in the skin. The in vitro effects induced by the IL-17 family members on fibroblasts from normal and SSc individuals were assessed by ELISA and RIA. RESULTS Positive cells for each of the IL-17 isoforms investigated were present in the dermis of all the individuals tested, though with variable frequencies. SSc individuals had increased frequency of IL-17A+ (p = 0.0237) and decreased frequency of IL-17F+ (p = 0.0127) and IL-17C+ cells (p = 0.0008) when compared to HD. Similarly, morphea individuals had less frequent IL-17C+ cells (p = 0.0186) in their skin but showed similar number of IL-17A+ and IL-17F+ cells when compared to HD. Finally, IL-17E+ cells were more numerous in morphea (p = 0.0109) and tended to be more frequent in SSc than in HD. Fibroblast production of IL-6, MMP-1 and MCP-1 was enhanced in a dose-dependent manner in the presence of IL-17E and IL-17F, but not in the presence of IL-17C. None of the cytokine tested had significant effect on type I collagen production. Of interest, in SSc the frequency of both IL-17A and IL-17F positive cells increased with disease duration. CONCLUSIONS The frequency of IL-17A and IL-17F distinguish SSc to morphea individuals while dermal expression of IL-17C (low) and IL-17E (high) identifies a fibrosis-specific motif. The specific IL-17C/IL-17E cytokine combination may thus play a role in the development of fibrosis.
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41
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Saad Magalhães C, Fernandes TDAP, Fernandes TD, Resende LADL. A cross-sectional electromyography assessment in linear scleroderma patients. Pediatr Rheumatol Online J 2014; 12:27. [PMID: 25053924 PMCID: PMC4105867 DOI: 10.1186/1546-0096-12-27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/07/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Muscle atrophy and asymmetric extremity growth is a common feature of linear scleroderma (LS). Extra-cutaneous features are also common and primary neurologic involvement, with sympathetic dysfunction, may have a pathogenic role in subcutaneous and muscle atrophy. The aim was investigate nerve conduction and muscle involvement by electromyography in pediatric patients with LS. METHODS We conducted a retrospective review of LS pediatric patients who had regular follow up at a single pediatric center from 1997-2013. We selected participants if they had consistently good follow up and enrolled consecutive patients in the study. We examined LS photos as well as clinical, serological and imaging findings. Electromyograms (EMG) were performed with bilateral symmetric technique, using surface and needle electrodes, comparing the affected side with the contralateral side. Abnormal muscle activity was categorized as a myopathic or neurogenic pattern. RESULTS Nine LS subjects were selected for EMG, 2 with Parry-Romberg/Hemifacial Atrophy Syndrome, 7 linear scleroderma of an extremity and 2 with mixed forms (linear and morphea). Electromyogram analysis indicated that all but one had asymmetric myopathic pattern in muscles underlying the linear streaks. Motor and sensory nerve conduction was also evaluated in upper and lower limbs and one presented a neurogenic pattern. Masticatory muscle testing showed a myopathic pattern in the atrophic face of 2 cases with head and face involvement. CONCLUSION In our small series of LS patients, we found a surprising amount of muscle dysfunction by EMG. The muscle involvement may be possibly related to a secondary peripheral nerve involvement due to LS inflammation and fibrosis. Further collaborative studies to confirm these findings are needed.
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Affiliation(s)
- Claudia Saad Magalhães
- Pediatric Rheumatology Unit, Pediatrics Division, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | | | - Thiago Dias Fernandes
- Electrophysiology Section, Neurology Division, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Luis Antonio de Lima Resende
- Electrophysiology Section, Neurology Division, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
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Wollina U, Buslau M, Petrov I, Pramatarov K. Disabling pansclerotic morphea of childhood. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.2.6.775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bielsa Marsol I. Actualización en la clasificación y el tratamiento de la esclerodermia localizada. ACTAS DERMO-SIFILIOGRAFICAS 2013. [DOI: 10.1016/j.ad.2012.10.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Bielsa Marsol I. Update on the classification and treatment of localized scleroderma. ACTAS DERMO-SIFILIOGRAFICAS 2013; 104:654-66. [PMID: 23948159 DOI: 10.1016/j.adengl.2012.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/07/2012] [Indexed: 01/26/2023] Open
Abstract
Morphea or localized scleroderma is a distinctive inflammatory disease that leads to sclerosis of the skin and subcutaneous tissues. It comprises a number of subtypes differentiated according to their clinical presentation and the structure of the skin and underlying tissues involved in the fibrotic process. However, classification is difficult because the boundaries between the different types of morphea are blurred and different entities frequently overlap. The main subtypes are plaque morphea, linear scleroderma, generalized morphea, and pansclerotic morphea. With certain exceptions, the disorder does not have serious systemic repercussions, but it can cause considerable morbidity. In the case of lesions affecting the head, neurological and ocular complications may occur. There is no really effective and universal treatment so it is important to make a correct assessment of the extent and severity of the disease before deciding on a treatment approach.
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Affiliation(s)
- I Bielsa Marsol
- Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Barcelona, Spain.
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Abstract
This article outlines the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment of childhood morphea. Also known as localized scleroderma, morphea is a fibrosing disorder of the skin and subcutaneous tissues. Morphea is differentiated from systemic sclerosis (scleroderma) based on the absence of sclerodactyly, Raynaud phenomenon, and nail-fold capillary changes. Confusion may occur because patients with morphea often have systemic symptoms such as malaise, fatigue, arthralgias, myalgias, and positive autoantibodies. Unlike morphea, systemic sclerosis has organ involvement, particularly gastrointestinal, pulmonary, and renal.
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Affiliation(s)
- John C Browning
- Division of Dermatology and Cutaneous Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
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Abstract
Localized scleroderma (also called morphea) is a term encompassing a spectrum of sclerotic autoimmune diseases that primarily affect the skin, but also might involve underlying structures such as the fat, fascia, muscle, and bones. Its exact pathogenesis is still unknown, but several trigger factors in genetically predisposed individuals might initially lead to an immunologically triggered release of pro-inflammatory cytokines, resulting in a profound dysregulation of the connective tissue metabolism and ultimately to induction of fibrosis. To date, there are no specific serological markers available for localized scleroderma. Within the last years, several validated clinical scores have been introduced as potential outcome measures for the disease. Given the rarity of localized scleroderma, only few evidence-based therapeutical treatment options exist. So far, the most robust data is available for ultraviolet A1 phototherapy in disease that is restricted to the skin, and methotrexate alone or in combination with systemic corticosteroids in more severe disease that additionally affects extracutaneous structures. This practical review summarizes relevant information on the epidemiology, pathogenesis, clinical subtypes and classifications, differential diagnoses, clinical scores and outcome measures, and current treatment strategies of localized scleroderma.
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Affiliation(s)
- Alexander Kreuter
- Department of Dermatology, Venerology and Allergology, Ruhr-University Bochum, Bochum, Germany.
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Li SC, Torok KS, Pope E, Dedeoglu F, Hong S, Jacobe HT, Rabinovich CE, Laxer RM, Higgins GC, Ferguson PJ, Lasky A, Baszis K, Becker M, Campillo S, Cartwright V, Cidon M, Inman CJ, Jerath R, O'Neil KM, Vora S, Zeft A, Wallace CA, Ilowite NT, Fuhlbrigge RC. Development of consensus treatment plans for juvenile localized scleroderma: a roadmap toward comparative effectiveness studies in juvenile localized scleroderma. Arthritis Care Res (Hoboken) 2012; 64:1175-85. [PMID: 22505322 DOI: 10.1002/acr.21687] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Juvenile localized scleroderma (LS) is a chronic inflammatory skin disorder associated with substantial morbidity and disability. Although a wide range of therapeutic strategies has been reported in the literature, a lack of agreement on treatment specifics and accepted methods for clinical assessment has made it difficult to compare approaches and identify optimal therapy. Our objective was to develop standardized treatment plans, clinical assessments, and response criteria for active, moderate to high severity juvenile LS. METHODS A core group of pediatric rheumatologists, dermatologists, and a lay advisor was engaged by the Childhood Arthritis and Rheumatology Research Alliance (CARRA) to develop standardized treatment plans and assessment parameters for juvenile LS using consensus methods/nominal group techniques. Recommendations were validated in 2 face-to-face conferences with a larger group of practitioners with expertise in juvenile LS and with the full membership of CARRA, which encompasses the majority of pediatric rheumatologists in the US and Canada. RESULTS Consensus was achieved on standardized treatment plans that reflect the prevailing treatment practices of CARRA members. Standardized clinical assessment methods and provisional treatment response criteria were also developed. Greater than 90% of pediatric rheumatologists responding to a survey (66% of CARRA membership) affirmed the final recommendations and agreed to utilize these consensus plans to treat patients with juvenile LS. CONCLUSION Using consensus methodology, we have developed standardized treatment plans and assessment methods for juvenile LS. The high level of support among pediatric rheumatologists will support future comparative effectiveness studies and enable the development of evidence-based guidelines for the treatment of juvenile LS.
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Affiliation(s)
- Suzanne C Li
- Hackensack University Medical Center, New Jersey, USA
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Anbiaee N, Tafakhori Z. Early diagnosis of progressive systemic sclerosis (scleroderma) from a panoramic view: report of three cases. Dentomaxillofac Radiol 2011; 40:457-62. [PMID: 21960405 DOI: 10.1259/dmfr/64340754] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Systemic sclerosis (scleroderma) is a multisystem disease involving the skin, lungs, heart, kidneys and gastrointestinal tract. It is probably owing to a disorder of the immune system. It may also have some oral manifestations, including limited ability to open the mouth, widening of the periodontal ligament (PDL) space and mandibular bone resorption. We report here on three asymptomatic cases that were referred to our oral and maxillofacial radiology centre for another reason, and in which we suspected scleroderma based on the widening of the PDL in the panoramic view. The early diagnosis was finally confirmed by pathological findings.
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Affiliation(s)
- N Anbiaee
- Department of Oral and Maxillofacial Radiology, Mashhad University of Medical Sciences, Mashhad, Iran
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