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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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Papara C, De Luca DA, Bieber K, Vorobyev A, Ludwig RJ. Morphea: The 2023 update. Front Med (Lausanne) 2023; 10:1108623. [PMID: 36860340 PMCID: PMC9969991 DOI: 10.3389/fmed.2023.1108623] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/18/2023] [Indexed: 02/15/2023] Open
Abstract
Morphea, also known as localized scleroderma, is a chronic inflammatory connective tissue disorder with variable clinical presentations, that affects both adults and children. It is characterized by inflammation and fibrosis of the skin and underlying soft tissue, in certain cases even of the surrounding structures such as fascia, muscle, bone and central nervous system. While the etiology is still unknown, many factors may contribute to disease development, including genetic predisposition, vascular dysregulation, TH1/TH2 imbalance with chemokines and cytokines associated with interferon-γ and profibrotic pathways as well as certain environmental factors. Since the disease may progress to permanent cosmetic and functional sequelae, it is crucial to properly assess the disease activity and to initiate promptly the adequate treatment, thus preventing subsequent damage. The mainstay of treatment is based on corticosteroids and methotrexate. These, however, are limited by their toxicity, especially if applied long-term. Furthermore, corticosteroids and methotrexate often do not sufficiently control the disease and/or the frequent relapses of morphea. This review presents the current understanding of morphea by discussing its epidemiology, diagnosis, management and prognosis. In addition, it will describe recent pathogenetic findings, thus proposing potential novel targets for therapeutic development in morphea.
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Affiliation(s)
- Cristian Papara
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany,*Correspondence: Cristian Papara, ✉
| | - David A. De Luca
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Artem Vorobyev
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Ralf J. Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Xie C, Mondal DK, Ulas M, Neill T, Iozzo RV. Oncosuppressive roles of decorin through regulation of multiple receptors and diverse signaling pathways. Am J Physiol Cell Physiol 2022; 322:C554-C566. [PMID: 35171698 PMCID: PMC8917911 DOI: 10.1152/ajpcell.00016.2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Decorin is a stromal-derived prototype member of the small leucine-rich proteoglycan gene family. In addition to its functions as a regulator of collagen fibrillogenesis and TGF-β activity soluble decorin acts as a pan-receptor tyrosine kinase (RTK) inhibitor. Decorin binds to various RTKs including EGFR HER2 HGFR/Met VEGFR2 TLR and IGFR. Although the molecular mechanism for the action of decorin on these receptors is not entirely elucidated overall decorin evokes transient activation of these receptors with suppression of downstream signaling cascades culminating in growth inhibition followed by their physical downregulation via caveosomal internalization and degradation. In the case of Met decorin leads to decreased β-catenin signaling pathway and growth suppression. As most of these RTKs are responsible for providing a growth advantage to cancer cells the result of decorin treatment is oncosuppression. Another decorin-driven mechanism to restrict cancer growth and dissemination is by impeding angiogenesis via vascular endothelial growth factor receptor 2 (VEGFR2) and the concurrent activation of protracted endothelial cell autophagy. In this review we will dissect the multiple roles of decorin in cancer biology and its potential use as a next-generation protein-based adjuvant therapy to combat cancer.
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Affiliation(s)
- Christopher Xie
- Department of Pathology, Anatomy and Cell Biology and the Translational Cellular Oncology Program, Sidney Kimmel Cancer Center, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Dipon K. Mondal
- Department of Pathology, Anatomy and Cell Biology and the Translational Cellular Oncology Program, Sidney Kimmel Cancer Center, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mikdat Ulas
- Department of Pathology, Anatomy and Cell Biology and the Translational Cellular Oncology Program, Sidney Kimmel Cancer Center, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Thomas Neill
- Department of Pathology, Anatomy and Cell Biology and the Translational Cellular Oncology Program, Sidney Kimmel Cancer Center, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Renato V. Iozzo
- Department of Pathology, Anatomy and Cell Biology and the Translational Cellular Oncology Program, Sidney Kimmel Cancer Center, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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Abstract
Morphea, also known as localized scleroderma, is a chronic, autoimmune disease of connective tissue. It is characterized by a typical clinical feature. In morphea, there is no Raynaud’s phenomenon, no sclerodactyly or no ulcerations on the fingertips. Although morphea and systemic sclerosis have been perceived as separate disease entities for years, they are still confused both by patients (which is a source of unnecessary stress) and doctors. This may be due to, in part, misunderstood terminology. The controversy around morphea also concerns the division of this disease entity, including its less common subtypes, such as eosinophilic fasciitis. Discussions also revolve around the diagnostic aspects and possible treatment options. The paper attempts to present the debatable aspects regarding nomenclature, classification, diagnosis and treatment of morphea.
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Therapeutic and Reconstructive Management Options in Scleroderma (Morphea) en Coup de Sabre in Children and Adults. A Systematic Literature Review. J Clin Med 2021; 10:jcm10194517. [PMID: 34640533 PMCID: PMC8509267 DOI: 10.3390/jcm10194517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 01/15/2023] Open
Abstract
Scleroderma (morphea) en coup de sabre is a localized subtype restricted to the frontoparietal region of the head. Current treatment paradigms rely on low levels of evidence, primarily case reports and case series-supported by expert opinions. The aim of this article was to systematically analyze current data related to the treatment of localized scleroderma en coup de sabre. The databases Scopus, PubMed, and EBSCO were searched for all reports discussing the treatment of localized scleroderma en coup de sabre. The keywords en coup de sabre, “facial linear scleroderma”, and “morphea linearis”, combined with “treatment” or “therapy” were used as search terms. A total of 34 articles analyzed treatment outcomes for patients with localized scleroderma en coup de sabre including 4 retrospective cohort studies, 2 prospective cohort studies, 4 case series, and 24 case reports, representing a total of 69 patients (38 children and 31 adults). Methotrexate was the most commonly investigated treatment (26 patients) with a highest response rate (26/26, 100%). Other treatments included systemic glucocorticosteroids (nine patients), followed by UVA1 (four patients), mycophenolate mofetil (two patients), hydroxychloroquine (five patients), abatacept (two patients), tocilizumab (three patients), cyclosporine (one patient), interferon gamma (one patient), PUVA therapy (two patients), NB-UVB therapy (one patient), and pulsed dye laser (one patient). Reconstructive and surgery treatment was successfully used for lesions with settled disease activity to improve the cosmetic aspect of the lesions. Conclusion: methotrexate is the most often-studied treatment and reported good clinical outcomes in children and adults with localized scleroderma en coup de sabre.
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Albuquerque JVD, Andriolo BNG, Vasconcellos MRA, Civile VT, Lyddiatt A, Trevisani VFM. Interventions for morphea. Cochrane Database Syst Rev 2019; 7:CD005027. [PMID: 31309547 PMCID: PMC6630193 DOI: 10.1002/14651858.cd005027.pub5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Morphea (morphoea) is an immune-mediated disease in which excess synthesis and deposition of collagen in the skin and underlying connective tissues results in hardened cutaneous areas. Morphea has different clinical features according to the subtype and stage of evolution of the disease. There is currently no consensus on optimal interventions for morphea. OBJECTIVES To assess the effects of treatments for people with any form of morphea. SEARCH METHODS We searched the following databases up to July 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, and five trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials. SELECTION CRITERIA Randomised controlled trials of topical, intralesional, or systemic treatments (isolated or combined) in anyone who has been clinically diagnosed by a medical practitioner with any form of morphea. Eligible controls were placebo, no intervention, any other treatment, or different doses or duration of a treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcomes were global improvement of disease activity or damage assessed by a medical practitioner or by participants, and adverse effects. Secondary outcomes were improvement of disease activity and improvement of disease damage. We used GRADE to assess the quality of the evidence for each outcome. MAIN RESULTS We included 14 trials, with a total of 429 randomised participants, aged between 3 and 76 years. There were juvenile and adult participants; over half were female, and the majority had circumscribed morphea, followed by linear scleroderma. The settings of the studies (where described) included a dermatologic centre, a national laboratory centre, paediatric rheumatology and dermatology centres, and a university hospital or medical centre.The studies evaluated heterogenous therapies for different types of morphea, covering a wide range of comparisons. We were unable to conduct any meta-analyses. Seven studies investigated topical medications, two evaluated intralesional medications, and five investigated systemic medications. The study duration ranged from seven weeks to 15 months from baseline.We present here results for our primary outcomes for our four key comparisons. All of these results are based on low-quality evidence.The included studies were at high risk of performance, detection, attrition, and reporting bias.Global improvement of disease activity or damage after treatment may be higher with oral methotrexate (15 mg/m², maximum 20 mg, once a week, for 12 months or until disease flare) plus oral prednisone (1 mg/kg a day, maximum of 50 mg, in a single morning dose, for three months, and one month with gradually decreased dose until discontinuation) than with placebo plus oral prednisone in children and adolescents with active morphea (linear scleroderma, generalised morphea or mixed morphea: linear and circumscribed) (risk ratio (RR) 2.31, 95% confidence interval (CI) 1.20 to 4.45; number needed to treat for an additional beneficial outcome (NNTB) 3; 1 randomised controlled trial (RCT); 70 participants, all juvenile). This outcome was measured 12 months from the start of treatment or until flare of the disease. Data were not available separately for each morphea type. There may be little or no difference in the number of participants experiencing at least one adverse event with oral methotrexate (26/46) or placebo (11/24) (RR 1.23, 95% CI 0.75 to 2.04; 1 RCT; 70 participants assessed during the 12-month follow-up). Adverse events related to methotrexate included alopecia, nausea, headache, fatigue and hepatotoxicity, whilst adverse events related to prednisone (given in both groups) included weight gain (more than 5% of body weight) and striae rubrae.One three-armed RCT compared the following treatments: medium-dose (50 J/cm²) UVA-1; low-dose (20 J/cm²) UVA-1; and narrowband UVB phototherapy. There may be little or no difference between treatments in global improvement of disease activity or damage, as assessed through the modified skin score (where high values represent a worse outcome): medium-dose UVA-1 phototherapy versus low-dose UVA-1 group: MD 1.60, 95% CI -1.70 to 4.90 (44 participants); narrowband UVB phototherapy versus medium-dose UVA-1 group: MD -1.70, 95% CI -5.27 to 1.87 (35 participants); and narrowband UVB versus low-dose UVA-1 group: MD -0.10, 95% CI -2.49 to 2.29 (45 participants). This RCT included children and adults with active morphea (circumscribed morphea, linear scleroderma (with trunk/limb variant and head variant), generalised morphea, or mixed morphea), who received phototherapy five times a week, for eight weeks. Outcomes were measured at eight weeks from the start of treatment.Safety data, measured throughout treatment, from the same RCT (62 participants) showed that treatment with UVA-1 phototherapy may cause mild tanning compared to narrowband UVB: narrowband UVB versus medium-dose UVA-1: RR 0.03, 95% CI 0.00 to 0.42; 35 participants; narrowband UVB versus low-dose UVA-1: RR 0.03, 95% CI 0.00 to 0.41; 45 participants. However, there may be no difference in the number of participants reporting mild tanning when comparing medium and low dose UVA-1 phototherapy (RR 1.00, 95% CI 0.91 to 1.10; 44 participants). Transient erythema was reported in three participants with narrowband UVB and no participants in the low- or medium-dose UVA-1 groups. AUTHORS' CONCLUSIONS Compared to placebo plus oral prednisone, oral methotrexate plus oral prednisone may improve disease activity or damage in juvenile active morphea (linear scleroderma, generalised morphea or mixed morphea: linear and circumscribed), but there may be a slightly increased chance of experiencing at least one adverse event.When medium-dose UVA-1 (50 J/cm²), low-dose UVA-1 (20 J/cm²), and narrowband UVB were compared against each other in treating children and adults with active morphea (circumscribed morphea, linear scleroderma, generalised morphea and mixed morphea), there may be little or no difference between these treatments on global improvement of disease activity or damage. UVA-1 phototherapy may cause more mild tanning than narrowband UVB, but there may be no difference between medium- and low-dose UVA-1 phototherapy. These results are based on low-quality evidence.Limitations of data and analyses include risk of bias and imprecision (small number of participants or events and wide confidence intervals). We encourage multicentre RCTs to increase sample size and evaluate, with validated tools, different treatment responses according to the subtypes of morphea and age groups.
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Affiliation(s)
- Julia V de Albuquerque
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Brenda NG Andriolo
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Monica RA Vasconcellos
- Universidade Federal de São PauloDepartment of DermatologyPedro de Toledo St. 508São PauloBrazil04039‐001
| | - Vinicius T Civile
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Anne Lyddiatt
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Virginia FM Trevisani
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
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Magnetic Resonance Imaging Evaluation in Patients with Linear Morphea Treated with Methotrexate and High-Dose Corticosteroid. Dermatol Res Pract 2018; 2018:8391218. [PMID: 30057597 PMCID: PMC6051098 DOI: 10.1155/2018/8391218] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 05/04/2018] [Accepted: 05/30/2018] [Indexed: 11/25/2022] Open
Abstract
Background Morphea is an inflammatory disease of the connective tissue that may lead to thickening and hardening of the skin due to fibrosis. The aim of this study was to document magnetic resonance imaging (MRI) changes in patients with linear morphea who were treated with methotrexate (MTX) and high-dose corticosteroid. Methods This study was conducted on 33 patients from the outpatient's dermatology clinic of our institute, who fulfilled the inclusion criteria. Patients received 15 mg/week of MTX and monthly pulses of methylprednisolone for three days in six months. The effectiveness of the treatment was evaluated by MRI, modified LS skin severity index (mLoSSI), and localized scleroderma damage index (LoSDI). Results All parameters of mLoSSI and LoSDI including erythema, skin thickness, new lesion/lesion extension, dermal atrophy, subcutaneous atrophy, and dyspigmentation were also noticeably improved after treatment. Subcutaneous fat enhancement was the most common finding in MRI. MRI scores were significantly associated with clinical markers both before and after the treatment with the exception of skin thickness and new lesion/lesion extension which were not associated with MRI scores before and after the treatment, respectively. Limitations The lack of correlative laboratory disease activity markers, control group, and clearly defined criteria to judge the MRI changes. Conclusion MRI could be a promising tool for the assessment of musculoskeletal and dermal involvement and also monitoring treatment response in patients with morphea.
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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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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: 105] [Impact Index Per Article: 15.0] [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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Early- and late-stage morphea subtypes with deep tissue involvement is treatable with Abatacept (Orencia). Semin Arthritis Rheum 2017; 46:775-781. [DOI: 10.1016/j.semarthrit.2016.08.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 08/22/2016] [Accepted: 08/30/2016] [Indexed: 11/21/2022]
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Morphea - selected local treatment methods and their effectiveness. Reumatologia 2017; 55:305-313. [PMID: 29491539 PMCID: PMC5825969 DOI: 10.5114/reum.2017.72628] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/30/2017] [Indexed: 01/15/2023] Open
Abstract
Localised scleroderma is an uncommon connective tissue disease of multifactorial aetiology occurring in the paediatric and adult population. It is relatively difficult to conduct any research on the subject of this disease entity treatment due to the low number of patients suffering from morphea, a tendency of the disease to remit spontaneously, and not yet well recognised aetiology. Hence, there has been developed no causal treatment of well-proven effectiveness, and schedules of symptomatic therapy are not yet clearly determined. The paper depicts most widely used topical treatment methods in morphea therapy, which due to minor risk of systemic adverse effects seem to be a beneficial therapeutic alternative. The main aim of this article was to analyse different topical treatment options used in localised scleroderma therapy and to indicate the most appropriate, safe, and effective one.
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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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Timpane S, Brandling-Bennett H, Kristjansson AK. Autoimmune collagen vascular diseases: Kids are not just little people. Clin Dermatol 2016; 34:678-689. [PMID: 27968927 DOI: 10.1016/j.clindermatol.2016.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Morphea, dermatomyositis (DM), and discoid lupus erythematosus (DLE) are autoimmune collagen vascular diseases that can present at any age. In all three of these diseases, the tenants of diagnosis and treatment are largely the same in both children and adults, with a few notable differences. Children with morphea are more likely to present with the linear subtype and have a higher incidence of extracutaneous manifestations. Children often need early aggressive systemic treatment to try to prevent long-term sequelae of morphea. In DM, adult disease has a clear association with malignancy that is not seen in children. Adults have a higher rate of pulmonary involvement and increased mortality, whereas calcinosis is more common in juvenile DM. DLE in adults is generally considered to have a low rate of progression from discoid lesions alone to systemic lupus erythematosus (SLE). DLE is less common in children, but several studies have suggested a higher rate of progression from DLE to SLE in children compared with adults.
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Affiliation(s)
- Sean Timpane
- Resident, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Heather Brandling-Bennett
- Assistant Professor, Department of Pediatrics, Division of Dermatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Arni K Kristjansson
- Assistant Professor of Dermatology, University of Connecticut School of Medicine, Farmington, CT
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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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Acquired facial lipoatrophy: pathogenesis and therapeutic options. Postepy Dermatol Alergol 2015; 32:127-33. [PMID: 26015783 PMCID: PMC4436232 DOI: 10.5114/pdia.2014.40971] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 12/15/2013] [Accepted: 01/06/2014] [Indexed: 01/18/2023] Open
Abstract
Facial lipoatrophy refers to the loss of subcutaneous fat tissue presenting by flattening or indentation of convex contour of the face. Facial lipoatrophy is a feature of the normal ageing process. It may be also a manifestation of chronic diseases, most frequently it affects HIV-infected individuals treated with highly active antiretroviral therapy (HAART) and may constitute a complication of connective tissue diseases, like lupus erythematosus profundus or morphea. Early recognition and treatment of the active stage of connective tissue diseases is of essential significance in prevention of subsequent scarring and atrophy lesions. In HIV-positive patients undergoing HAART therapy, the attempt to modify thetreatment scheme so it has a less lipemic effect seems to be justified. Esthetic correction of facial lipoatrophy in chronic diseases is a great challenge. Improvement of appearance is very important for affected individuals, because it diminishes their stigmatization and psychosocial dysfunction. Facial volumetric correction includes surgical and dermatological procedures such as adipose transfer and injectable dermal fillers.
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Dytoc M, Wat H, Cheung-Lee M, Sawyer D, Ackerman T, Fiorillo L. Evaluation of the efficacy and safety of topical imiquimod 5% for plaque-type morphea: a multicenter, prospective, vehicle-controlled trial. J Cutan Med Surg 2015; 19:132-9. [PMID: 25775634 DOI: 10.2310/7750.2014.14072] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is currently a lack of evidence-based therapies that are safe and effective for plaque-type morphea. We aimed to evaluate the therapeutic potential and safety profile of imiquimod 5% cream in plaque-type morphea. METHODS We enrolled 25 adult patients from two Canadian centers with histologically confirmed plaque-type morphea. Imiquimod 5% was applied to a representative plaque, and vehicle was applied to a control plaque for 9 months. Treatment efficacy was assessed with the Dyspigmentation, Induration, Erythema, and Telangiectasias (DIET) score, histology, and ultrasound evaluation. RESULTS AND CONCLUSIONS Twenty-two patients completed the entire length of the study. Imiquimod 5% was superior to vehicle in reducing DIET scores at 3, 6, 9, and 12 months (p < .05). Induration demonstrated the greatest response. Histologic evaluation showed significant improvement or resolution of disease. However, no ultrasonographic differences were found in dermal and hypodermal thicknesses between the treatment and vehicle groups (p > .05). Adverse effects were minimal and well tolerated.
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Affiliation(s)
- Marlene Dytoc
- Divisions of Dermatology and Cutaneous Sciences and Pediatric Dermatology and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, ABDivision of Anatomical Pathology, University of British Columbia, Victoria, BC
| | - Heidi Wat
- Divisions of Dermatology and Cutaneous Sciences and Pediatric Dermatology and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, ABDivision of Anatomical Pathology, University of British Columbia, Victoria, BC
| | - Melody Cheung-Lee
- Divisions of Dermatology and Cutaneous Sciences and Pediatric Dermatology and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, ABDivision of Anatomical Pathology, University of British Columbia, Victoria, BC
| | - Douglas Sawyer
- Divisions of Dermatology and Cutaneous Sciences and Pediatric Dermatology and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, ABDivision of Anatomical Pathology, University of British Columbia, Victoria, BC
| | - Thomas Ackerman
- Divisions of Dermatology and Cutaneous Sciences and Pediatric Dermatology and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, ABDivision of Anatomical Pathology, University of British Columbia, Victoria, BC
| | - Loretta Fiorillo
- Divisions of Dermatology and Cutaneous Sciences and Pediatric Dermatology and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, ABDivision of Anatomical Pathology, University of British Columbia, Victoria, BC
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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
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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22
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Effect of topical interferon-γ gene therapy using gemini nanoparticles on pathophysiological markers of cutaneous scleroderma in Tsk/+ mice. Gene Ther 2011; 19:978-87. [DOI: 10.1038/gt.2011.159] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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23
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A systematic review of morphea treatments and therapeutic algorithm. J Am Acad Dermatol 2011; 65:925-41. [DOI: 10.1016/j.jaad.2010.09.006] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 07/27/2010] [Accepted: 09/09/2010] [Indexed: 11/23/2022]
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Zulian F, Martini G, Vallongo C, Vittadello F, Falcini F, Patrizi A, Alessio M, La Torre F, Podda RA, Gerloni V, Cutrone M, Belloni-Fortina A, Paradisi M, Martino S, Perilongo G. Methotrexate treatment in juvenile localized scleroderma: a randomized, double-blind, placebo-controlled trial. ACTA ACUST UNITED AC 2011; 63:1998-2006. [PMID: 21305525 DOI: 10.1002/art.30264] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Juvenile localized scleroderma is a chronic progressive fibrotic disorder of the skin that causes permanent disability and aesthetic damage. This study was undertaken to assess the safety and efficacy of methotrexate (MTX) in the treatment of juvenile localized scleroderma. METHODS In this double-blind study, patients with active juvenile localized scleroderma were randomized (2:1) to receive oral MTX (15 mg/m², maximum 20 mg) or placebo once weekly, for 12 months or until treatment failure. Both groups received oral prednisone (1 mg/kg/day, maximum 50 mg) for the first 3 months. A target lesion was evaluated clinically, with infrared thermography and using a computerized scoring system with skin score rate (SSR) evaluation. Response to treatment was defined as the absence of new lesions, SSR ≤ 1, and a decrease in lesion temperature of at least 10% compared to baseline. Treatment failure was defined as the occurrence of new lesions, SSR > 1, or increased lesion temperature. All analyses were done on the intent-to-treat population. RESULTS Of the 85 patients screened, 70 (ages 6-17 years) were randomized (46 to the MTX group, 24 to the placebo group). The mean disease duration was 2.3 years. After an initial response in all patients, disease relapsed in 15 MTX-treated patients (32.6%) and 17 placebo-treated patients (70.8%) (P < 0.005). New lesions appeared in 3 MTX-treated patients (6.5%) versus 4 placebo-treated patients (16.7%). The mean SSR decreased from 1 to 0.79 in the MTX group and increased from 1 to 1.1 in the placebo group, and the mean target lesion temperature decreased by 44.4% in the MTX group versus 12.1% in the placebo group. Twenty-six patients in the MTX group (56.5%) and 11 patients in the placebo group (45.8%) developed mild side effects related to treatment. None of the side effects were severe enough to necessitate treatment discontinuation. CONCLUSION Our findings indicate that MTX is efficacious in the treatment of juvenile localized scleroderma and is well tolerated.
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Fett N, Werth VP. Update on morphea: part II. Outcome measures and treatment. J Am Acad Dermatol 2011; 64:231-42; quiz 243-4. [PMID: 21238824 DOI: 10.1016/j.jaad.2010.05.046] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 05/19/2010] [Accepted: 05/25/2010] [Indexed: 10/18/2022]
Abstract
Morphea is a rare fibrosing disorder of the skin and underlying tissues. The underlying pathogenesis of morphea is not completely understood at this time, but ultimately results in an imbalance of collagen production and destruction. Evidence-based treatment options of morphea are limited secondary to the rarity of the disease, and the lack of universally used validated outcome measures. The most commonly used outcome measures are skin scores, computerized surface area measurement, durometer, cutometer, thermography, and ultrasound measurements. The Localized Scleroderma Cutaneous Assessment Tool is a promising recently validated skin scoring tool that allows differentiation between activity and damage, is sensitive to change, and requires no additional equipment. The most robust data in the treatment of morphea exists for methotrexate in combination with systemic steroids and ultraviolet A1.
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Affiliation(s)
- Nicole Fett
- Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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26
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New alternative therapy for orofacial localized scleroderma. ACTA ACUST UNITED AC 2010; 110:e15-9. [PMID: 20634110 DOI: 10.1016/j.tripleo.2010.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 03/29/2010] [Accepted: 04/02/2010] [Indexed: 11/22/2022]
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27
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Kreuter A, Krieg T, Worm M, Wenzel J, Gambichler T, Kuhn A, Aberer E, Scharffetter-Kochanek K, Hunzelmann N. [AWMF Guideline no. 013/066. Diagnosis and therapy of circumscribed scleroderma]. J Dtsch Dermatol Ges 2009; 7 Suppl 6:S1-14. [PMID: 19660073 DOI: 10.1111/j.1610-0387.2009.07178.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Localized scleroderma is a rare autoimmune disease with primary affection of the skin, and occasional involvement of the fat tissue, muscle, fascia, and bone. Depending on the clinical subtype, the spectrum of skin lesions ranges from singular plaque lesions to severe generalized or linear subtypes which may lead to movement restrictions and permanent disability. This German S1-guideline proposes a classification of localized scleroderma that, considering the extent and depth of fibrosis, distinguishes limited, generalized, linear, and deep forms of localized scleroderma, together with its associated subtypes. The guideline includes a description of the pathogenesis, of differential diagnoses, and particular aspects of juvenile localized scleroderma, as well as recommendations for histopathologic, serologic, and biometric diagnostic procedures. Based on studies of topical and systemic treatments as well as phototherapy for localized scleroderma published in international literature, a treatment algorithm was developed which takes account of the different subtypes and the extent of disease.
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Kroft EBM, Groeneveld TJ, Seyger MMB, de Jong EMGJ. Efficacy of topical tacrolimus 0.1% in active plaque morphea: randomized, double-blind, emollient-controlled pilot study. Am J Clin Dermatol 2009; 10:181-7. [PMID: 19354332 DOI: 10.2165/00128071-200910030-00004] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Tacrolimus, a calcineurin inhibitor, is an immunomodulating and anti-inflammatory drug that inhibits T-cell activation and production of cytokines. The elevated level of cytokines in morphea causes fibroblast proliferation and subsequent overproduction of collagen. Theoretically, tacrolimus could inhibit the pathophysiologic process of morphea. OBJECTIVE To assess whether tacrolimus 0.1% ointment is an effective treatment for active plaque morphea in a double-blind, placebo (petroleum emollient)-controlled pilot study. METHODS Ten patients with active plaque morphea were included. All patients were treated with tacrolimus 0.1% ointment and with an emollient (petrolatum) on two selected morphea plaques, applied twice daily for 12 weeks. Initial and final assessment included surface area measurements, photography, durometer scores, and clinical feature scores. Adverse reactions were recorded. RESULTS The scleroderma plaques treated with topical tacrolimus 0.1% improved, resulting in a significant reduction in durometer and clinical feature scores. Overall, a significant difference could be found between topical tacrolimus and petrolatum with regard to durometer score (p < 0.005) and the clinical feature score (p = 0.019). CONCLUSION In this first double-blind, placebo-controlled pilot study comparing tacrolimus 0.1% ointment with petrolatum in active plaque morphea, tacrolimus 0.1% ointment was shown to be an effective treatment for this condition.
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Affiliation(s)
- Elisabeth B M Kroft
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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Badea I, Taylor M, Rosenberg A, Foldvari M. Pathogenesis and therapeutic approaches for improved topical treatment in localized scleroderma and systemic sclerosis. Rheumatology (Oxford) 2008; 48:213-21. [PMID: 19022832 DOI: 10.1093/rheumatology/ken405] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
SSc is a chronic progressive disorder of unknown aetiology characterized by excess synthesis and deposition of collagen and other extracellular matrix components in a variety of tissues and organs. Localized scleroderma (LS) differs from SSc in that with LS only skin and occasionally subcutaneous tissues are involved. Although rarely life threatening, LS can be disfiguring and disabling and, consequently, can adversely affect quality of life. There is no known effective treatment for LS, and various options, including, as examples, corticosteroids and other immunomodulatory agents, ultraviolet radiation and vitamin D analogues, are of unproven efficacy. Clinical trials evaluating combination therapy such as corticosteroids with MTX or UVA1 exposure with psoralens have not been established as consistently effective. New immunomodulators such as tacrolimus and thalidomide are also being evaluated. A better understanding of the molecular and cellular mechanisms of LS has led to evaluation of new treatments that modulate profibrotic cytokines such as TGF-beta and IL-4, regulate assembly and deposition of extracellular matrix components, and restore Th1/Th2 immune balance by administering IL-12 or IFN-gamma. IFN-gamma acts by directly inhibiting collagen synthesis and by restoring immune balance. In this review, we evaluate current and future treatment options for LS and cutaneous involvement in SSc. Recent advances in therapy focus mainly on anti-fibrotic agents. Delivery of these drugs into the skin as the target tissue might be a key factor in developing more effective and safer therapy.
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Affiliation(s)
- I Badea
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
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Kroft EBM, Berkhof NJG, van de Kerkhof PCM, Gerritsen RMJP, de Jong EMGJ. Ultraviolet A phototherapy for sclerotic skin diseases: a systematic review. J Am Acad Dermatol 2008; 59:1017-30. [PMID: 18835066 DOI: 10.1016/j.jaad.2008.07.042] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2008] [Revised: 07/13/2008] [Accepted: 07/24/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ultraviolet (UV) A-1 phototherapy is now available for a variety of skin diseases. Increasingly since 1995, there have been investigations of the efficacy of UVA-1 (340-400 nm) therapy for sclerotic skin diseases. Most studies undertaken treated patients who had localized scleroderma, but UVA-1 phototherapy is currently also used for other sclerotic skin conditions. OBJECTIVE We sought to assess the efficacy, biological effects, and side effects of UVA-1 in a variety of sclerotic skin diseases (localized scleroderma, eosinophilic fasciitis, chronic graft-versus-host disease, lichen sclerosus et atrophicus, scleredema adultorum, necrobiosis lipoidica, POEMS disease, pansclerotic porphyria cutanea tarda, and drug-induced scleroderma-like disorders). METHODS The authors searched for publications dated between January 1996 and November 2007 in the computerized bibliographic database, PubMed. PubMed was searched using medical subject heading terms and open searches to retrieve the latest reports. RESULTS The evidence based on research concerning the effect of full-spectrum UVA (320-400 nm) and UVA-1 on these skin diseases is still growing, and appears promising. Up until now, good results are shown for all different doses (low, medium, and high) UVA-1 and UVA. There are insufficient data regarding use of high-dose UVA-1 and there are no comparative studies to make a clear assessment regarding the superiority of low-, medium-, or high-dose UVA-1 therapy. Although UVA-1 has various effects on, for instance, fibroblasts and inflammatory cells, the precise mode of action remains obscure. The main short-term side effects of UVA-1 therapy are erythema, pruritus, xerosis cutis, tanning, and recrudescence of herpes simplex infection. More studies are warranted to investigate the potential long-term risk of photoaging and skin cancer. Currently, UVA-1 is considered to be less carcinogenic than psoralen plus UVA (PUVA). LIMITATIONS Because of the limited availability of randomized controlled trials and large cohort studies, it is difficult to draw firm conclusions on the long-term efficacy, optimum dose, and best treatment regimens for UVA-1 when administered to patients with sclerosing skin disorders. CONCLUSIONS Full-spectrum UVA and UVA-1 phototherapy seem effective in the treatment of sclerotic skin diseases based on data retrieved from the literature. UVA-1 treatment can shorten the active period of localized scleroderma and pseudoscleroderma and prevent further disease progression, including contractures. Further investigations will be needed to determine any additional biological effects of UVA-1. Although long-term side effects are not yet known, UVA-1 might develop into a promising beneficial and well-tolerated treatment in the therapeutic armamentarium for sclerotic skin diseases. Long-term studies in large groups of patients are clearly needed.
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Affiliation(s)
- Elisabeth B M Kroft
- Department of Dermatology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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Kroft EBM, van de Kerkhof PCM, Gerritsen MJP, de Jong EMGJ. Period of remission after treatment with UVA-1 in sclerodermic skin diseases. J Eur Acad Dermatol Venereol 2008; 22:839-44. [DOI: 10.1111/j.1468-3083.2007.02576.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Emmez H, Kardes O, Dogulu F, Kurt G, Memis L, Baykaner MK. ROLE OF ANTIFIBROTIC CYTOKINE INTERFERON-γ IN THE PREVENTION OF POSTLAMINECTOMY PERIDURAL FIBROSIS IN RATS. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000317272.86593.e3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Emmez H, Kardes O, Dogulu F, Kurt G, Memis L, Baykaner MK. ROLE OF ANTIFIBROTIC CYTOKINE INTERFERON-γ IN THE PREVENTION OF POSTLAMINECTOMY PERIDURAL FIBROSIS IN RATS. Neurosurgery 2008; 62:1351-7; discussion 1357-8. [DOI: 10.1227/01.neu.0000333307.02802.04] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Gambichler T, Skrygan M, Tomi NS, Altmeyer P, Kreuter A. Differential expression of decorin in localized scleroderma following ultraviolet-A1 irradiation. J Am Acad Dermatol 2007; 56:956-9. [PMID: 17184878 DOI: 10.1016/j.jaad.2006.10.961] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Revised: 10/18/2006] [Accepted: 10/31/2006] [Indexed: 11/18/2022]
Abstract
Patients with localized scleroderma underwent an 8-week course of ultraviolet A1 phototherapy. At baseline, decorin levels of lesional skin were significantly lower than those of nonlesional skin and healthy control subjects. After ultraviolet A1 phototherapy, decorin levels of lesional skin were significantly higher than baseline. Decorin may be of significance in the pathogenesis of localized scleroderma.
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Affiliation(s)
- Thilo Gambichler
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany.
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Smith DI, Swamy PM, Heffernan MP. Off-label uses of biologics in dermatology: Interferon and intravenous immunoglobulin (Part 1 of 2). J Am Acad Dermatol 2007; 56:e1-54. [PMID: 17190617 DOI: 10.1016/j.jaad.2006.06.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2005] [Revised: 05/04/2006] [Accepted: 06/19/2006] [Indexed: 11/29/2022]
Abstract
The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include interferons, intravenous immunoglobulin, infliximab, adalimumab, etanercept, efalizumab, alefacept, and rituximab. Most dermatologists are familiar with the Food and Drug Administration-approved indications of these medications. However, numerous off-label uses have evolved. As part 1 of a 2-part series, this article will review the literature regarding the off-label uses of the interferons and intravenous immunoglobulin in dermatology.
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Abstract
Sclerosing conditions of the skin are manifested by a full spectrum of presentations that includes skin-limited forms as well as those which can involve internal organs and result in death. At this point, we are just beginning to understand the mechanisms of tissue fibrosis, and it is likely that the fibrotic processes are a heterogeneous group of disorders in which perturbation of multiple molecular pathways, including vascular and immunologically mediated pathways, can lead to fibrosis. We now have some moderately effective therapies for vascular aspects of systemic sclerosis (eg, bosentan for pulmonary arterial hypertension, calcium-channel blockers for Raynaud's, or angiotensin-converting enzyme inhibitors for renal crisis). We also are beginning to find treatments interrupting the immunologic pathways that manifest as systemic sclerosis (eg, methotrexate for the skin or cyclophosphamide for the lungs). The basic process of fibrosis, however, awaits proven, effective therapy.
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Affiliation(s)
- Lorinda Chung
- Department of Dermatology, Stanford University School of Medicine, CA 94305, USA
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Weibel L, Sampaio MC, Visentin MT, Howell KJ, Woo P, Harper JI. Evaluation of methotrexate and corticosteroids for the treatment of localized scleroderma (morphoea) in children. Br J Dermatol 2006; 155:1013-20. [PMID: 17034534 DOI: 10.1111/j.1365-2133.2006.07497.x] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Localized scleroderma (LS) or morphoea is often considered to be a benign self-limiting condition confined to the skin and subcutaneous tissue. However, the course of the disease is unpredictable and severe functional and cosmetic disability may result. Drug treatment with systemic corticosteroids in combination with methotrexate has been reported to be beneficial in LS, but data in children is limited. OBJECTIVES To evaluate the efficacy and tolerability of systemic corticosteroids in combination with methotrexate in children with LS. METHODS Treatment and outcome of 34 patients with LS were retrospectively analysed. Pulsed intravenous methylprednisolone was given, followed by oral prednisolone on a reducing regimen and maintenance treatment with methotrexate. We assessed treatment outcome clinically and by thermography and monitored adverse events. RESULTS From the onset of treatment, the disease stopped progressing in 94% of the patients. All patients demonstrated significant clinical improvement within a mean time of 5.7 +/- 3.9 months. Mean duration of follow-up over the treatment period and beyond was 2.9 +/- 2.0 years. In 16 (47%) patients therapy was discontinued when the disease was considered to be inactive clinically; however, seven (44%) of the 16 developed a relapse, necessitating repeat treatment. At last follow-up (range 0.2-7.0 years), 24 (71%) of the 34 patients had completely inactive disease. Observed adverse events were moderate and transient and no patient had to stop therapy. CONCLUSIONS These data suggest that systemic corticosteroids and methotrexate in combination are beneficial and well tolerated in the treatment of children with LS. Because of the risk of relapse after discontinuing therapy, long-term monitoring is mandatory.
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Affiliation(s)
- L Weibel
- Paediatric Rheumatology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK.
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Yamamoto T. The bleomycin-induced scleroderma model: what have we learned for scleroderma pathogenesis? Arch Dermatol Res 2006; 297:333-44. [PMID: 16402183 DOI: 10.1007/s00403-005-0635-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2005] [Revised: 12/09/2005] [Accepted: 12/13/2005] [Indexed: 10/25/2022]
Abstract
Scleroderma is a fibrotic condition characterized by immunologic abnormalities, vascular injury and increased accumulation of extracellular matrix (ECM) proteins in the skin. Although the etiology of scleroderma has not yet been fully elucidated, a growing body of evidence suggests that ECM overproduction by activated fibroblasts results from complex interactions among endothelial cells, lymphocytes, macrophages and fibroblasts, via a number of mediators, such as cytokines, chemokines and growth factors. For a better understanding of the pathophysiology of scleroderma, animal models are important tools. We established a murine model of cutaneous sclerosis by local treatment of bleomycin. This model reproduces several histological as well as biochemical aspects of human scleroderma. However, it must be emphasized that studying animal models cannot answer all the problems of human scleroderma. In this review, we introduce current insights into the pathogenesis of bleomycin-induced scleroderma, and discuss its contribution to our understanding of the pathogenesis of, and treatments for, human scleroderma.
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Affiliation(s)
- Toshiyuki Yamamoto
- Department of Dermatology, Tokyo Medical University, 6-7-1 Nishi-shinjuku, 160-0023 Tokyo, Japan.
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Abstract
This article discusses the various clinical, laboratory, and therapeutic aspects of systemic sclerosis and localized scleroderma in children. The close collaboration among pediatricians, rheumatologists, and dermatologists represents an important advance in the management of these disabling conditions.
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Affiliation(s)
- Francesco Zulian
- Pediatric Rheumatology Unit, Department of Pediatrics, University of Padova, Via Giustiniani 3 35128, Padua, Italy.
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Abstract
Interferon (IFN)-gamma is considered a key cytokine of innate and adaptive immunity playing pivotal roles in host defence against microbial pathogens and tumours, and exerts profound antiproliferative and antifibrotic effects. In this review we discuss applications and perspectives of IFN-gamma in clinical dermatology, such as papillomavirus and bacterial infections, tumours, atopic dermatitis, and fibrotic conditions such as scleroderma and postradiation fibrosis. Moreover, we give a summary of the pharmacologic properties including main side effects and potential risk factors of IFN-gamma therapy. Although former enthusiasm for IFN-gamma (e.g. in atopic dermatitis) has subsided, this cytokine might remain a promising tool (and target) in clinical dermatology, due to its central immunobiologic functions, better characterization of its kinetics in diseases facilitating optimized treatment schedules, and successful applications in fibrotic conditions such as scleroderma, idiopathic pulmonary and skin postradiation fibrosis.
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El-Mofty M, Mostafa W, Esmat S, Youssef R, Bousseila M, Nagi N, Shaker O, Abouzeid A. Suggested mechanisms of action of UVA phototherapy in morphea: a molecular study. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2004; 20:93-100. [PMID: 15030594 DOI: 10.1111/j.1600-0781.2004.00080.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ultraviolet A (UVA) phototherapy proved to be an efficient line of treatment of scleroderma. The mechanism through which it acts is still not clear. OBJECTIVES To detect the mechanism of action of UVA phototherapy in morphea through measuring its effect on the levels of different parameters related to collagen metabolism. METHODS Twenty-one cases of morphea were treated with low-dose broad-band UVA for 20 sessions. Twelve cases received 20 J/cm(2)/session with a cumulative dose of 400 J/cm(2) and nine cases received 10 J/cm(2)/session with a cumulative dose of 200 J/cm(2). The response was assessed clinically every week. Two skin biopsies were taken from the lesional skin of each patient before starting and after the end of therapy. Paraffin sections were examined for quantitative polymerase chain reaction measurement of collagen I, collagen III, collagenase, transforming growth factor-beta (TGF-beta) and interferon gamma (IFNgamma). RESULTS Eighteen patients reported remarkable softening of the skin lesions, with variable degrees ranging from moderate in 57.1% of them good in 19% to very good response in 9.5%. After treatment, all the studied parameters revealed statistically significant changes. There was a significant decrease in collagen I, collagen III and TGF-beta and a significant increase in collagenase (MMP-1) and IFNgamma. The relative change was found to be greatest in collagenase, followed by IFNgamma then TGF-beta and finally collagen I. The changes in collagen I, collagenase, IFNgamma and TGF-beta were found to increase gradually with the degree of clinical response. In all the parameters studied the relative change was significantly higher in cases treated with 20 J/cm(2)/session in contrast to those treated with 10 J/cm(2)/session although no statistically significant difference could be detected in the clinical response to those doses. CONCLUSIONS The efficacy of low-dose UVA phototherapy in the treatment of localized scleroderma is mainly obtained by the increased production of MMP-1 and IFNgamma, and to a lesser extent by decreasing TGF-beta and collagen production. Concerning the use of 10 or 20 J/cm(2)/session those effects are dose dependent, but the clinical response does not significantly differ.
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Affiliation(s)
- M El-Mofty
- Department of Dermatology, Phototherapy Unit, Faculty of Medicine, Cairo University, Egypt
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Abstract
Pulmonary fibrosis occurs in up to 70% of scleroderma patients and progresses to cause severe restrictive lung disease in about 15% of patients. The mechanisms that cause pulmonary fibrosis in scleroderma remain incompletely understood. Increased amounts of mRNA or protein for multiple profibrotic cytokines and chemokines have been identified in lung tissue or broncholveolar lavage samples from scleroderma patients, when compared to healthy controls. These cytokines include transforming growth factor (TGF)-beta, connective tissue growth factor (CTGF), platelet-derived growth factor (PDGF), oncostatin M (OSM), monocyte chemotactic factor-1 and pulmonary and activation-regulated chemokine (PARC). Potential cellular sources of these profibrotic cytokines and chemokines in scleroderma lung disease include alternatively activated macrophages, activated CD8+ T cells, eosinophils, mast cells, epithelial cells and fibroblasts themselves. This review summarizes the literature on involvement of cytokines and chemokines in the development of pulmonary fibrosis in scleroderma.
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Affiliation(s)
- Sergei P Atamas
- Baltimore VA Medical Center, University of Maryland School of Medicine, Research Service (151), Room 3C-126, 10 North Greene Street, Baltimore, MD 21201, USA.
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Abstract
Muscle injuries are a common problem in sports medicine. Skeletal muscle can regenerate itself, but the process is both slow and incomplete. Previously we and others have used growth factors to improve the regeneration of muscle, but the muscle healing was impeded by scar tissue formation. However, when we blocked the fibrosis process with decorin, an antifibrosis agent, we improved the muscle healing. Here we show that gammainterferon (gammaINF)--a cytokine that inhibits the signaling of transforming growth factor beta1 (TGFbeta1), a fibrotic stimulator--reduces fibrosis formation and improves the healing of lacerated skeletal muscle. With gammaINF treatment, the growth rate of muscle-derived fibroblasts was reduced and the level of fibrotic protein expression induced by TGFbeta1 (including TGFbeta1, vimentin, and alpha-smooth muscle actin) was down-regulated in vitro. In a mouse laceration model, the area of fibrosis decreased when gammaINF was injected at either 1 or 2 weeks after injury. More importantly, the injection of gammaINF at either 1 or 2 weeks post-injury was found to improve muscle function in terms of both fast-twitch and tetanic strength. This study demonstrates that gammaINF is a potent antifibrosis agent that can improve muscle healing after laceration injury.
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Affiliation(s)
- William Foster
- Growth and Development Laboratory, Department of Orthopaedic Surgery, 4151 Rangos Research Center, Children's Hospital of Pittsburgh and University of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213-2583, USA
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Obermoser G, Pfausler BE, Linder DM, Sepp NT. Scleroderma en coup de sabre with central nervous system and ophthalmologic involvement: treatment of ocular symptoms with interferon gamma. J Am Acad Dermatol 2003; 49:543-6. [PMID: 12963929 DOI: 10.1067/s0190-9622(03)00901-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Scleroderma en coup de sabre, a variant of localized scleroderma, is a disorder of unknown origin characterized by fibrosis of connective tissue. Rare complications of scleroderma en coup de sabre are orbital and intracerebral involvement. We describe a patient with scleroderma en coup de sabre in whom intracerebral and orbital lesions developed after 2 decades of disease duration. Clinically, she had epilepsy, impaired vision, and retro-ocular pain of the affected eye. A 12-month course of interferon-gamma stopped progression of visual symptoms caused by orbital fibrous tissue. To our knowledge, this is the first patient with scleroderma en coup de sabre complicated by orbital involvement who was successfully treated with interferon-gamma.
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Abstract
The scleroderma disorders remain challenging conditions in pediatric rheumatology to understand pathologically and indeed for which to provide care. It is clear that much progress is being made in the clinical approach to understanding this group of group of disorders. It seems likely that the different lesions of LS may represent unique immunopathogenic mechanisms or perhaps reflect unique genetic or other characteristics of the patients themselves. To take advantage of the revolution in therapies now occurring in rheumatology it is critical that controlled clinical trials are developed with appropriate agreed upon outcome measures for both localized and systemic disease.
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MESH Headings
- Adolescent
- Antibodies, Antinuclear/analysis
- Child
- Diagnosis, Differential
- Esophageal Diseases/complications
- Humans
- Lung Diseases/complications
- Outcome Assessment, Health Care
- Prognosis
- Raynaud Disease/complications
- Scleroderma, Localized/classification
- Scleroderma, Localized/diagnosis
- Scleroderma, Localized/epidemiology
- Scleroderma, Localized/immunology
- Scleroderma, Localized/therapy
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/diagnosis
- Scleroderma, Systemic/immunology
- Scleroderma, Systemic/therapy
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Affiliation(s)
- Kevin J Murray
- Department of Rheumatology, Princess Margaret Hospital for Children, GPO Box D184, Perth, WA 6008, Australia.
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Abstract
Several distinct entities associated with dermal fibrosis can mimic scleroderma/systemic sclerosis. The list of scleroderma-like conditions or scleroderma variants includes eosinophilic fasciitis, localized forms of scleroderma, scleredema and scleromyxedema, keloids, and environmental exposure-associated conditions including eosinophilia-myalgia syndrome and pseudosclerodermas induced by various drugs. Although these conditions are relatively uncommon, their accurate recognition is essential to avoid misdiagnosis and inappropriate therapy. The pathogenesis of these scleroderma variants appears to share similarities with each other and with that of scleroderma. Better understanding of scleroderma-like disorders is emerging through epidemiologic investigations, and in vivo and in vitro experimental research. Activation of eosinophils and disordered regulation of fibroblast collagen synthesis, apoptosis, and proliferation are recurrent findings in these disorders. The etiologic role of infection with Borrelia species or other microorganisms remains controversial. Cytokines such as transforming growth factor-beta, interleukin-4, interleukin-13, and connective tissue growth factor contribute to fibrosis in these disorders by inducing an accentuated and persistent fibrogenic response to tissue injury. The role of genetic factors in susceptibility and clinical expression of scleroderma-like conditions remains to be systematically addressed. Because of the relative rarity of these conditions, few well-controlled clinical treatment trials have been performed. In addition, there is no consensus on optimal management. Much anecdotal information and small clinical series indicate that phototherapy may have a role in the treatment of scleroderma-like conditions.
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Affiliation(s)
- Yasuji Mori
- Section of Rheumatology, University of Illinois at Chicago College of Medicine, 1158 MBRB, 900 S. Ashland Avenue, Chicago, IL 60607-7171, USA.
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Kyriakidi M, Ioannidis JPA. Design and quality considerations for randomized controlled trials in systemic sclerosis. ARTHRITIS AND RHEUMATISM 2002; 47:73-81. [PMID: 11932881 DOI: 10.1002/art1.10218] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To appraise systematically randomized controlled trials (RCTs) on systemic sclerosis (SSc) in order to determine whether the parameter of study design and its quality may influence the reporting of efficacy for tested interventions. METHODS Seventy RCTs were analyzed (1965-2000) in terms of design, patient characteristics, outcomes, and reported results. RESULTS Median sample size was 28 patients. Fifty-nine trials were double blind, but only 16 mentioned the randomization mode and only 7 described allocation concealment. There was sufficient information on withdrawals in 37 trials. Larger trials with longer followup scored higher on quality characteristics, but had higher withdrawal rates. Only 8 trials had a followup of more than 1 year. Significant efficacy was less likely to be reported in double-blind studies (P = 0.029) and in studies with larger rates of withdrawal (P = 0.032). Specification of the following parameters improved over time: power calculations (P = 0.0003), outcomes (P = 0.001), and sample size per arm (P = 0.011). CONCLUSIONS Several aspects of the quality of design and conduct of SSc RCTs can be improved. Adequately powered trials with longer followup and clear outcomes are needed.
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Abstract
Juvenile scleroderma is a rare disease of childhood. The 2 main forms are localised and systemic scleroderma, although the pathogenesis of both forms is still unclear. The main clinical characteristic is the presence of skin sclerosis. Localised scleroderma can be divided into 3 different subtypes: morphoea, linear scleroderma and 'coup de sabre' lesions. The incidence is 0.2 to 0.4 per 100,000. 25 to 40% of patients are rheumatoid factor positive and 23 to 67% antinuclear antibody positive. An increased number of eosinophils occur in 31% of patients. Systemic sclerosis is an even rarer disease; approximately 10% of patients evolve the disease before the age of 18 years. The clinical presentation and disease course differ from the adult disease. This is reflected in the much better outcome. With regard to therapeutic options, there is still no gold standard for either form of the disease.
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Affiliation(s)
- I Foeldvari
- Paediatric Rheumatology Clinic, AK-Eilbek, Hamburg, Germany
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49
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50
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Hawk A, English JC. Localized and systemic scleroderma. SEMINARS IN CUTANEOUS MEDICINE AND SURGERY 2001; 20:27-37. [PMID: 11308134 DOI: 10.1053/sder.2001.23093] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Scleroderma is a broad term encompassing both localized and systemic sclerosis. Localized scleroderma is a cutaneous limited fibrosis that manifests as plaque morphea, generalized morphea, linear scleroderma, and deep morphea. Systemic scleroderma (sclerosis) can manifest as either limited or diffuse disease. Limited systemic sclerosis is typically preceded by Raynaud's phenomenon, involves cutaneous sclerosis distal to the elbows, with gastrointestinal and pulmonary fibrosis, and anticentromere antibody positivity. Diffuse systemic scleroderma is characterized by simultaneous Raynaud's phenomenon, cutaneous skin involvement proximal to the elbow with gastrointestinal, pulmonary, renal and cardiac fibrosis, and positive serology for antitopoisomerase and anti-RNAP III antibodies. This article discusses the classification, epidemiology, pathogenesis, clinical manifestations, treatment, and prognosis of the scleroderma.
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MESH Headings
- Adult
- Bone Marrow Transplantation
- Calcium Channel Blockers/therapeutic use
- Child
- Humans
- Immunosuppression Therapy/methods
- Male
- PUVA Therapy
- Photopheresis
- Prognosis
- Prostaglandins/therapeutic use
- Relaxin/therapeutic use
- Scleroderma, Localized/diagnosis
- Scleroderma, Localized/epidemiology
- Scleroderma, Localized/immunology
- Scleroderma, Localized/physiopathology
- Scleroderma, Localized/therapy
- Scleroderma, Systemic/diagnosis
- Scleroderma, Systemic/epidemiology
- Scleroderma, Systemic/immunology
- Scleroderma, Systemic/physiopathology
- Scleroderma, Systemic/therapy
- Skin/pathology
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Affiliation(s)
- A Hawk
- Department of Dermatology, University of Virginia School of Medicine, Charlottesville 22908-0718, USA
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