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Al-Nasrawi AN, Abdulkareem AS, Mohammed Ali MN. The Serological Evidence of Positive Rheumatoid Factor in Morphea Patients and Its Relation to Disease Severity. Cureus 2024; 16:e61105. [PMID: 38919251 PMCID: PMC11197628 DOI: 10.7759/cureus.61105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2024] [Indexed: 06/27/2024] Open
Abstract
Background and objective Morphea, or localized scleroderma (LS), is an autoimmune skin disorder characterized by inflammation and sclerosis. Its potential causes include infections, genetic predisposition, and trauma. The disease involves cycles of inflammation and fibrosis, leading to skin hardening and scarring, which can cause deformities if untreated. Research exploring the link between morphea and rheumatoid factor (RF), a marker associated with other autoimmune conditions, is ongoing. This study aimed to examine the less-explored role of RF, a marker typically linked to rheumatoid arthritis (RA), in the severity of morphea. It focused on assessing the levels of RF among morphea patients and its correlation with disease severity, intending to provide deeper insights into the condition and its management. Methods This study involved a simple randomized cross-sectional analysis to evaluate the role of the RF in measuring morphea severity among patients at the Dermatology and Venereology Department of Al-Sader Teaching Hospital from October 2022 to December 2023. We included participants with clinically and laboratory-confirmed morphea while excluding those with other autoimmune dermatological diseases, recent systemic steroid or immunosuppressive therapy, and pregnant women. The assessment of disease severity was done by utilizing the Localized Scleroderma Cutaneous Assessment Tool (LoSCAT). Statistical analyses were performed using SPSS Statistics version 27 (IBM Corp., Armonk, NY), with a significance threshold of p<0.05. Results Elevated RF levels were significantly associated with increased morphea severity, with severe cases showing higher RF levels (mean: 30.34 U/mL) compared to moderate (25.83 U/mL) and mild cases (21.56 U/mL) (p = 0.028). However, no significant correlation was found between RF levels and demographic factors such as age, gender, or occupation. Patients with high RF levels had a longer disease duration (mean: 57.15 years) compared to those with normal levels (25.83 years, p = 0.020). Significant differences were observed in lesion distribution on the back (p = 0.002). Logistic regression indicated that severe morphea patients were more likely to have elevated RF levels [odds ratio (OR): 1.158, p = 0.014]. Conclusions This study enriches our understanding of RF's role in morphea, revealing no significant correlation with demographic factors but suggesting its potential role in disease chronicity and severity.
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Cotton CH. JAAD Game Changers∗: Inflammatory arthritis in pediatric patients with morphea. J Am Acad Dermatol 2022; 87:1237. [PMID: 35934212 DOI: 10.1016/j.jaad.2022.07.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Colleen H Cotton
- Division of Dermatology, Children's National Hospital, Washington, DC.
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Treatment of juvenile localized scleroderma: current recommendations, response factors, and potential alternative treatments. Curr Opin Rheumatol 2022; 34:245-254. [PMID: 35880663 DOI: 10.1097/bor.0000000000000886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Juvenile localized scleroderma (jLS) is a chronic autoimmune and fibrosing disease associated with a high risk for functional impairment. Antifibrotic options are limited, so current treatment strategies are focused on disease activity control. Pediatric rheumatologists are in consensus on the need to treat with systemic immunosuppressants, in particular, methotrexate. However, more than 30% of patients fail initial methotrexate treatment. This review provides an update on current management and reviews reports on potential alternative treatments. RECENT FINDINGS An overview of current treatment recommendations and its efficacy are discussed. Recent studies have identified several factors associated with likelihood of treatment response. These include time to initiation of treatment, certain subtypes, and extracutaneous involvement. Findings from recent reports of alternative systemic immunomodulators, including biologic medications, will be summarized. SUMMARY Methotrexate treatment has greatly improved outcome for most jLS patients but a substantial portion have refractory cutaneous and/or extracutaneous disease. Treatment response factors are being identified, which could lead to improved management strategies. Recent studies provide further support on mycophenolate mofetil as an alternative treatment. Data on biologic therapies is encouraging, with data suggesting efficacy for many extracutaneous manifestations but more studies are needed to evaluate these and other options for jLS.
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Vasquez-Canizares N, Li SC. Juvenile Localized Scleroderma: Updates and Differences from Adult-Onset Disease. Rheum Dis Clin North Am 2021; 47:737-755. [PMID: 34635302 DOI: 10.1016/j.rdc.2021.07.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Children and adolescents with localized scleroderma (LS) are at high risk for extracutaneous-related functional impairment including hemiatrophy, arthropathy, seizures, and vision impairment. Compared with adult-onset LS, pediatric disease has a higher likelihood for poor outcome, with extracutaneous involvement twice as prevalent in linear scleroderma, disease relapses more common, and disease duration more than double. Consensus among pediatric rheumatologists on treating patients at risk for significant morbidity with systemic immunosuppressants has led to major improvements in outcome. This review discusses recent progress in assessment and treatment strategies and in our understanding of key disease pathways.
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Affiliation(s)
- Natalia Vasquez-Canizares
- Department of Pediatrics, Division of Pediatric Rheumatology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA
| | - Suzanne C Li
- Department of Pediatrics, Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack Meridian School of Medicine, 30 Prospect Avenue, WFAN PC337, Hackensack, NJ 07601, USA.
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Sink JR, Chiu YE. Pediatric morphea state-of-the-art literature review: Reframing morphea as a systemic disease. Pediatr Dermatol 2021; 38:1020-1031. [PMID: 34272748 DOI: 10.1111/pde.14688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric morphea is an inflammatory, fibrosing dermatologic disorder. Although morphea may be localized to the skin and subcutaneous tissues, differentiating it from systemic sclerosis, there is increasing evidence that morphea is a manifestation of a systemic inflammatory process, with the potential to involve many organ systems. Given the potential risk for irreversible sequelae, pediatric morphea should be treated early and aggressively. Long-term disease monitoring is essential.
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Affiliation(s)
- Jacquelyn R Sink
- Department of Dermatology, Northwestern Medicine Regional Medical Group, Winfield, IL, USA
| | - Yvonne E Chiu
- Departments of Dermatology (Section of Pediatric Dermatology) and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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Oh YH, Lee SH. Frontal Linear Scleroderma (en coup de sabre): A Case Report. Cleft Palate Craniofac J 2021; 59:538-542. [PMID: 33966485 DOI: 10.1177/10556656211013168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
En coup de sabre is an unusual variant of localized scleroderma characterized by its distinct location involving the frontoparietal region of the forehead and scalp. The authors describe a rare case of en coup de sabre in a 3-year-old boy whose disease onset was at 12 months of age. This article presents the clinical manifestations of continuous changes in the lesion photographed over time. The clinical presentation, laboratory results, and radiological findings together with a brief discussion of the management of the disease are discussed.
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Affiliation(s)
- Yo Han Oh
- Department of Plastic and Reconstructive Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang-si, Republic of Korea
| | - Soo Hyang Lee
- Department of Plastic and Reconstructive Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang-si, Republic of Korea
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Glaser D, Torok KS. Evaluation and Treatment of Pediatric Localized Scleroderma: Pearls and Updates. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00170-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rustad AM, Nolan BE, Ollech A, Boctor MJ, Paller AS. Incorporating joint pain screening into the pediatric dermatologic examination. Pediatr Dermatol 2021; 38:92-97. [PMID: 33275304 DOI: 10.1111/pde.14454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Joint manifestations are a feature of many pediatric skin disorders, among them psoriasis, autoimmune and autoinflammatory diseases, hypermobility disorders, and as an adverse effect of certain medications. Identifying joint disease early is important for intervention and prevention of chronic damage. However, pediatric musculoskeletal complaints are common and determining whether symptoms warrant a rheumatology referral for arthritis can be challenging. METHODS Pediatric dermatologists were surveyed for their comfort in screening for joint disease. Through literature review and interviews with three pediatric rheumatologists, key joints involved in disorders with skin manifestations and arthritis were identified and the essential evaluations were determined. RESULTS Of 100 surveyed practicing board-certified pediatric dermatologists, 79% did not feel confident in their ability to perform a joint-focused physical examination, a key step in screening for joint disease. A rapid joint examination technique (R-JET) was developed, along with an accompanying three-question survey and body diagram for patient self-report of symptoms. A video demonstration of the R-JET was created as a teaching tool. CONCLUSIONS Teaching and incorporation of a rapid screening examination for arthritis by pediatric dermatologists has the potential to identify pediatric arthritis earlier, facilitate referral, and reduce the risk of progressive joint disease. These instruments can easily be incorporated into a pediatric dermatology office visit.
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Affiliation(s)
- Andrea M Rustad
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brian E Nolan
- Departments of Pediatrics/Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ayelet Ollech
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Departments of Pediatrics/Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael J Boctor
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy S Paller
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Departments of Pediatrics/Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Flores Quispe SKJ, Cavaliere A, Weber M, Stramare R, Zuliani M, Quaia E, Zulian F, Giraudo C. Sarcopenia in juvenile localized scleroderma: new insights on deep involvement. Eur Radiol 2020; 30:4091-4097. [PMID: 32144460 DOI: 10.1007/s00330-020-06764-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Juvenile localized scleroderma (JLS) is a rare chronic autoimmune disease which can also affect bones and muscles. Nevertheless, muscle loss was not previously investigated in patients with JLS. Thus, the aim of this study was to retrospectively evaluate deep involvement and assess and quantify sarcopenia in JLS patients using magnetic resonance imaging (MRI). METHODS Fourteen children with JLS (nine females, mean age ± SD, 7.1 ± 3.6 years) referring to our tertiary center from January 2012 to January 2018 who underwent at least one MRI examination including axial T1-weighted and short tau inversion recovery images were included. Two readers assessed in consensus superficial and deep involvement. Muscle edema, muscle fatty infiltration, and sarcopenia were independently scored (absent, moderate, or severe) and the Cohen's kappa coefficient computed. Skin perimeter, subcutaneous area, muscle area, and muscle volume were independently measured using the contralateral unaffected extremity as reference (paired Student's t test, p < 0.05). The intraclass correlation coefficient (ICC) was used to investigate the reliability of the measurements. RESULTS All patients showed superficial involvement with subcutaneous fat atrophy being the most common finding (13 patients). Bone marrow edema occurred in five patients. Muscle edema affected ten children (moderate in seven, severe in three; k = 0.89), muscle fatty replacement occurred in one case (severe; k = 1.00), and sarcopenia was detected in eight patients (severe in two; k = 0.78). All quantitative parameters were lower on the affected side than on the unaffected contralateral limb (p < 0.05, each) and all measurements showed a high reliability (ICC > 0.750, each). CONCLUSION Patients with JLS can be affected by sarcopenia and quantitative analyses allow a robust characterization of such finding. KEY POINTS • Deep involvement in juvenile localized scleroderma is frequently characterized by sarcopenia. • In juvenile localized scleroderma, muscle edema and sarcopenia are mostly moderate while fatty infiltration, even if rare, can be severe. • Sarcopenia can be reliably quantified in children with juvenile localized scleroderma using MRI.
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Affiliation(s)
| | - Annachiara Cavaliere
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Roberto Stramare
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Monica Zuliani
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Emilio Quaia
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | | | - Chiara Giraudo
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy.
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Reiff D, Crayne CB, Mannion ML, Cron RQ. Characteristics of coexisting localized scleroderma and inflammatory arthritis. Eur J Rheumatol 2020; 7:S67-S71. [PMID: 31804172 PMCID: PMC7004265 DOI: 10.5152/eurjrheum.2019.19147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/07/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Localized scleroderma (LS), including morphea and linear scleroderma, is an autoimmune disease where excessive subcutaneous collagen deposits lead to thickening, scarring, and fibrosis of the tissues. LS coexisting with inflammatory arthritis is less well-described but has been reported in as many as 20% of 53 LS patients in a recent cohort. Herein, we describe a cohort of 8 children with both LS and inflammatory arthritis. The objective of this study is to determine the characteristics of inflammatory arthritis in children with LS and their response to treatment regimens. METHODS A retrospective chart review was completed on patients less than 19 years of age who were diagnosed with either morphea or linear scleroderma at the Children of Alabama center from 2004-2018. Patients were identified using ICD-9 and ICD-10 diagnostic codes. Records were reviewed for additional diagnostic codes, exams, and laboratory findings confirming coexisting inflammatory arthritis and LS. RESULTS A total of 87 patients with a diagnosis of either morphea or linear scleroderma were identified. Eight (9%) had coexisting inflammatory arthritis according to the diagnostic codes with documented active arthritis. Median age of initial rheumatic disease diagnosis was 7.5 years. A majority of patients with both LS and inflammatory arthritis were female (62.5%). Half of the patients (n=4, 50%) had LS lesions over arthritic joints. All of the identified patients were diagnosed with a form of juvenile idiopathic arthritis (JIA). The JIA diagnoses varied widely in 3 (37.5%) patients with rheumatoid factor (RF) negative polyarticular JIA, 2 (25%) with oligoarticular JIA, 2 (25%) with psoriatic JIA, and 1 (12.5%) with enthesitis-related JIA. The timing of onset of LS and inflammatory arthritis varied widely. Three (37.5%) patients had LS lesions preceding clinical arthritis, and three (37.5%) had arthritis before the appearance of LS. Two (25%) patients had both LS and arthritis at the time of diagnosis. All patients received methotrexate (MTX) during their disease course with only 3 (37.5%) receiving systemic steroids during treatment. All 8 patients showed resolution of LS lesions. However, 6 of the 8 patients demonstrated active arthritis on combination MTX and TNFi therapy. CONCLUSION In this cohort of pediatric LS, 9% of patients had coexisting inflammatory arthritis. The characteristics of this cohort varied widely. All patients received MTX initially and showed a resolution of LS lesions. However, in the majority of patients, the arthritis failed to respond to MTX and TNFi combination therapy. These results suggest that inflammatory arthritis coexisting with LS may be less likely to respond to traditional inflammatory arthritis or JIA therapies.
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Affiliation(s)
- Daniel Reiff
- Department of Pediatrics, University of Alabama, Birmingham, AL, USA
| | - Courtney B. Crayne
- Division of Rheumatology, Department of Pediatrics, University of Alabama, Birmingham, AL, USA
| | - Melissa L. Mannion
- Division of Rheumatology, Department of Pediatrics, University of Alabama, Birmingham, AL, USA
| | - Randy Q. Cron
- Division of Rheumatology, Department of Pediatrics, University of Alabama, Birmingham, AL, USA
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Giani T, Madera A, Cimaz R. Association of juvenile idiopathic arthritis and morphea: a case series. Clin Rheumatol 2019; 39:1341-1345. [PMID: 31838640 DOI: 10.1007/s10067-019-04850-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/21/2019] [Accepted: 11/08/2019] [Indexed: 11/30/2022]
Abstract
The association of different autoimmune diseases in the same subject is not uncommon, also in the pediatric age. The coexistence of morphea and juvenile idiopathic arthritis (JIA) is however exceptional. We report four such cases. Unlike the few other reported cases, in 3/4 of our patients, morphea appeared well after the onset of JIA, when the articular disease was in full clinical remission. Based on the epidemiology of pediatric morphea in the general population, this association is unlikely to be fortuitous. Pediatric rheumatologists should be aware of this possible association, and follow clinically patients who achieve long-term clinical remission. Key Points ⦁ Morphea is an unusual occurrence in the context of JIA. These conditions have a common autoimmune background, but are very rarely reported together. ⦁ It is important to follow JIA patients even during long-term remission since other autoimmune phenomena can occur.
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Affiliation(s)
- Teresa Giani
- Pediatric Rheumatology, AOU Meyer, Florence, Italy.,Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Anna Madera
- Pediatric Rheumatology, AOU Meyer, Florence, Italy
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy. .,ASST G Pini, Via Pini 9, 20122, Milan, Italy.
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Abstract
PURPOSE OF REVIEW Linear scleroderma is the most common subtype of localized scleroderma (LoS) in children. It can be associated with extracutaneous manifestations and long-term sequelae. Thus, appropriate diagnosis and management are key to improve the prognosis. In this review, we summarize the most relevant recent publications for the diagnosis, evaluation of disease activity and adequate management of patients with linear scleroderma. RECENT FINDINGS There are specific clinical features that indicate activity in LoS; dermoscopy and Wood's lamp may be useful. Summarizing, scoring methods seem to provide the most adequate assessment of LoS; but several biomarkers that correlate with activity have been studied: E-selectin and IL-2 receptor, CD34+ dermal dendritic cells and Th/Th1 immunophenotype with decreased T helper (Th2), T regulatory (Tregs), B and natural killer (NK) cells. Recent studies propose hydroxychloroquine monotherapy and tocilizumab as potential therapeutic options. SUMMARY Clinical evaluation, both physical exam and history, is the most important aspect in diagnosing and assessing activity of linear scleroderma. Clinical scoring methods may be most useful for evaluation of activity; eventually, other biomarkers could be relevant in clinical practice. For most patients with linear scleroderma, the first choice of treatment is methotrexate, but physical therapy, plastic surgery and/or orthopedic management are key to improve residual limitations and quality of life. VIDEO ABSTRACT: http://links.lww.com/MOP/A35.
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