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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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Yamazaki-Nakashimada MA, Saez-de-Ocariz M, Maldonado-Colin G, García-Romero MT. Subcutaneous immunoglobulin for the treatment of deep morphoea in a child. Clin Exp Dermatol 2017; 43:303-305. [PMID: 29280519 DOI: 10.1111/ced.13352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2017] [Indexed: 11/30/2022]
Abstract
Morphoea, also known as localized scleroderma, is a disorder characterized by excessive collagen deposition leading to thickening of the dermis and/or subcutaneous tissues. Intravenous IgG therapy has induced improvement in some fibrotic conditions. The primary indication for subcutaneous IgG (SCIG) is in primary immunodeficiency disorders as replacement therapy; however, recently there has been considerable interest in SCIG as an immunomodulatory agent. We report an 11-year-old girl with deep morphoea who was successfully treated with SCIG.
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Affiliation(s)
| | - M Saez-de-Ocariz
- Department of Dermatology, Instituto Nacional Pediatría, Mexico City, Mexico
| | - G Maldonado-Colin
- Department of Dermatology, Instituto Nacional Pediatría, Mexico City, Mexico
| | - M T García-Romero
- Department of Dermatology, Instituto Nacional Pediatría, Mexico City, Mexico
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3
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Dixit S, Kalkur C, Sattur AP, Bornstein MM, Melton F. Scleroderma and dentistry: Two case reports. J Med Case Rep 2016; 10:297. [PMID: 27776552 PMCID: PMC5078903 DOI: 10.1186/s13256-016-1086-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 10/03/2016] [Indexed: 11/10/2022] Open
Abstract
Background Scleroderma is a chronic connective tissue disorder with unknown etiology. It is characterized by excessive deposition of extracellular matrix in the connective tissues causing vascular disturbances which can result in tissue hypoxia. These changes are manifested as atrophy of the skin and/or mucosa, subcutaneous tissue, muscles, and internal organs. Such changes can be classified into two types, namely, morphea (localized) and diffuse (systemic). Morphea can manifest itself as hemifacial atrophy (Parry–Romberg syndrome) although this remains debatable. Hence, we present a case of morphea, associated with Parry–Romberg syndrome, and a second case with the classical signs of progressive systemic sclerosis. Case presentation Case one: A 20-year-old man of Dravidian origin presented to our out-patient department with a complaint of facial asymmetry, difficulty in speech, and loss of taste sensation over the last 2 years. There was no history of facial trauma. After physical and radiological investigations, we found gross asymmetry of the left side of his face, a scar on his chin, tongue atrophy, relative microdontia, thinning of the ramus/body of his mandible, and sclerotic lesions on his trunk. Serological investigations were positive for antinuclear antibody for double-stranded deoxyribonucleic acid and mitochondria. A biopsy was suggestive of morphea. Hence, our final diagnosis was mixed morphea with Parry–Romberg syndrome. Case two: A 53-year-old woman of Dravidian origin presented to our out-patient department with a complaint of gradually decreasing mouth opening over the past 7 years. Her medical history was noncontributory. On clinical examination, we found her perioral, neck, and hand skin to be sclerotic. Also, her fingers exhibited bilateral telangiectasia. An oral examination revealed completely edentulous arches as well as xerostomia and candidiasis. Her serological reports were positive for antinuclear antibodies against centromere B, Scl-70, and Ro-52. A hand and wrist radiograph revealed acro-osteolysis of the middle finger on her right hand. Hence, our final diagnosis was progressive systemic sclerosis. Conclusion Through this article, we have tried to emphasize the importance of a general examination when diagnosing rare systemic diseases such as scleroderma and the role of the general dentist when caring for such patients, even though they can be quite rare in general practice.
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Affiliation(s)
- Shantanu Dixit
- Department of Oral Medicine and Radiology, Dhulikhel hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal.
| | - Chaithra Kalkur
- Department of Oral Medicine and Radiology, Century International Institute of Dental Science and Research Centre, Kasargod, Kerala, India
| | - Atul P Sattur
- Department of Oral Medicine and Radiology, SDM College of Dental Sciences, Sattur, Karnataka, India
| | - Michael M Bornstein
- Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Bern, Switzerland
| | - Fred Melton
- General Practitioner, Wenatchee, Washington, USA
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Abstract
Localized scleroderma (LoS) comprises a heterogeneous spectrum of fibrotic diseases that primarily affect the skin with inflammation and skin thickening. The extent of skin involvement and manifestation at extra-cutaneous structures characterizes the specific subset. Fat tissue, fascia, and sometimes muscle, and bones might be involved, and in rare cases the central nervous or ocular system. A worldwide accepted classification system for LoS is still lacking. The latest guidelines have proposed a distinction of limited, generalized, linear, deep, and mixed types. The exact pathophysiology of LoS is not fully understood yet, but it is thought that an externally triggered release of pro-inflammatory cytokines leads to a dysregulation of the connective tissue metabolism. LoS is diagnosed according to typical clinical features. Further diagnostic procedures are helpful to characterize the subtype and to define the extent of inflammation and fibrosis. Due to the heterogeneity of LoS, therapeutic strategies should always be selected depending on the respective subtype. The stage of tissue inflammation and sclerosis has to be considered. Treatment options such as topical corticosteroids, calcipotriol, and calcineurin inhibitors as well as phototherapy are well established. In subsets with severe wide-spread skin manifestation and/or extra-cutaneous involvement, methotrexate monotherapy or a combination of methotrexate and systemic corticosteroids need to be considered. Physical treatment should always be added to the topical and systemic treatment to prevent significant disabilities due to LoS. This article provides an updated review on the epidemiology, pathophysiology, clinical classification and treatment options for patients suffering from LoS.
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Careta MF, Romiti R. Localized scleroderma: clinical spectrum and therapeutic update. An Bras Dermatol 2015; 90:62-73. [PMID: 25672301 PMCID: PMC4323700 DOI: 10.1590/abd1806-4841.20152890] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 10/11/2013] [Indexed: 12/31/2022] Open
Abstract
Scleroderma is a rare connective tissue disease that is manifested by cutaneous
sclerosis and variable systemic involvement. Two categories of scleroderma are known:
systemic sclerosis, characterized by cutaneous sclerosis and visceral involvement,
and localized scleroderma or morphea which classically presents benign and
self-limited evolution and is confined to the skin and/or underlying tissues.
Localized scleroderma is a rare disease of unknown etiology. Recent studies show that
the localized form may affect internal organs and have variable morbidity. Treatment
should be started very early, before complications occur due to the high morbidity of
localized scleroderma. In this review, we report the most important aspects and
particularities in the treatment of patients diagnosed with localized
scleroderma.
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Ravelli FN, Andriolo BNG, Vasconcellos MRA, Lyddiatt A, Fernandes Moça Trevisani V. Interventions for morphea. Hippokratia 2014. [DOI: 10.1002/14651858.cd005027.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Flávia Naranjo Ravelli
- Centro de Estudos de Medicina Baseada em Evidências e Avaliação Tecnológica em Saúde; Brazilian Cochrane Centre; Rua Borges Lagoa, 564 cj 63 Vl. Clementino São Paulo São Paulo Brazil 04038-000 São Paulo
| | - Brenda NG Andriolo
- Centro de Estudos de Medicina Baseada em Evidências e Avaliação Tecnológica em Saúde; Brazilian Cochrane Centre; Rua Borges Lagoa, 564 cj 63 Vl. Clementino São Paulo São Paulo Brazil 04038-000 São Paulo
| | - Monica RA Vasconcellos
- Universidade Federal de São Paulo; Department of Dermatology; Pedro de Toledo St. 508 São Paulo Brazil 04039-001
| | - Anne Lyddiatt
- The University of Nottingham; c/o Cochrane Skin Group; A103, King's Meadow Campus Lenton Lane Nottingham UK NG7 2NR
| | - Virginia Fernandes Moça Trevisani
- Universidade Federal de São Paulo; Rheumatology/Internal Medicine and Therapeutics; Rua Marie Satzke 119 São Paulo São Paulo Brazil 04664-150
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7
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Thareja SK, Sadhwani D, Alan Fenske N. En coup de sabre morphea treated with hyaluronic acid filler. Report of a case and review of the literature. Int J Dermatol 2013; 54:823-6. [DOI: 10.1111/ijd.12108] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 11/21/2012] [Accepted: 12/03/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Sumeet K. Thareja
- Department of Dermatology; University of South Florida; Tampa FL USA
| | - Divya Sadhwani
- Department of Dermatology; University of South Florida; Tampa FL USA
| | - Neil Alan Fenske
- University of Central Florida College of Medicine; Orlando FL USA
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8
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Li SC, Torok KS, Pope E, Dedeoglu F, Hong S, Jacobe HT, Rabinovich CE, Laxer RM, Higgins GC, Ferguson PJ, Lasky A, Baszis K, Becker M, Campillo S, Cartwright V, Cidon M, Inman CJ, Jerath R, O'Neil KM, Vora S, Zeft A, Wallace CA, Ilowite NT, Fuhlbrigge RC. Development of consensus treatment plans for juvenile localized scleroderma: a roadmap toward comparative effectiveness studies in juvenile localized scleroderma. Arthritis Care Res (Hoboken) 2012; 64:1175-85. [PMID: 22505322 DOI: 10.1002/acr.21687] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Juvenile localized scleroderma (LS) is a chronic inflammatory skin disorder associated with substantial morbidity and disability. Although a wide range of therapeutic strategies has been reported in the literature, a lack of agreement on treatment specifics and accepted methods for clinical assessment has made it difficult to compare approaches and identify optimal therapy. Our objective was to develop standardized treatment plans, clinical assessments, and response criteria for active, moderate to high severity juvenile LS. METHODS A core group of pediatric rheumatologists, dermatologists, and a lay advisor was engaged by the Childhood Arthritis and Rheumatology Research Alliance (CARRA) to develop standardized treatment plans and assessment parameters for juvenile LS using consensus methods/nominal group techniques. Recommendations were validated in 2 face-to-face conferences with a larger group of practitioners with expertise in juvenile LS and with the full membership of CARRA, which encompasses the majority of pediatric rheumatologists in the US and Canada. RESULTS Consensus was achieved on standardized treatment plans that reflect the prevailing treatment practices of CARRA members. Standardized clinical assessment methods and provisional treatment response criteria were also developed. Greater than 90% of pediatric rheumatologists responding to a survey (66% of CARRA membership) affirmed the final recommendations and agreed to utilize these consensus plans to treat patients with juvenile LS. CONCLUSION Using consensus methodology, we have developed standardized treatment plans and assessment methods for juvenile LS. The high level of support among pediatric rheumatologists will support future comparative effectiveness studies and enable the development of evidence-based guidelines for the treatment of juvenile LS.
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Affiliation(s)
- Suzanne C Li
- Hackensack University Medical Center, New Jersey, USA
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9
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Kaliyadan F, Biswas K, Dharmaratnam AD. Progressive facial hemiatrophy - a case series. Indian J Dermatol 2011; 56:557-60. [PMID: 22121278 PMCID: PMC3221223 DOI: 10.4103/0019-5154.87155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Six female patients diagnosed with Progressive Facial Hemiatrophy are presented here. The clinical and serological features are highlighted, and treatment options for the condition are discussed. We would like to highlight the need to differentiate the condition from localized scleroderma and the with limitation of its medical management.
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Affiliation(s)
- Feroze Kaliyadan
- Department of Dermatology, Amrita Institute of Medical Sciences and Research Center, Kochi, India
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10
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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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11
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Hansen CB, Callen JP. Connective tissue panniculitis: lupus panniculitis, dermatomyositis, morphea/scleroderma. Dermatol Ther 2010; 23:341-9. [DOI: 10.1111/j.1529-8019.2010.01334.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
A 5-year-old girl presented with a 2-month history of an indurated hypopigmented, atrophic plaque of biopsy-documented morphea over the right hip area. Previous treatment with 0,1% betamethasone valerate cream twice a day for 3 months failed to improve the lesion. She was treated with calcipotriol ointment twice daily, with nightly occlusion to the plaque for 9 months, and this resulted in resolution. No side effects were noted.
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Affiliation(s)
- Y K Tay
- National Skin Centre, and Changi General Hospital, 2 Simei Street 3, Singapore 529889.
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13
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Onesti MG, Troccola A, Scuderi N. Volumetric correction using poly-L-lactic acid in facial asymmetry: Parry Romberg syndrome and scleroderma. Dermatol Surg 2009; 35:1368-75. [PMID: 19500125 DOI: 10.1111/j.1524-4725.2009.01243.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Linear scleroderma and Parry-Romberg Syndrome (PRS) are chronic diseases that can affect the face, with patients therefore requiring facial volumetric correction. OBJECTIVE We have used poly-L-lactic acid (PLLA) to treat facial asymmetry in patients with linear scleroderma and PRS, because it can restore volumetric defects and has been proven to be safe. MATERIALS AND METHODS Since February 2004, we have treated six patients: four with linear scleroderma and two with PRS. The patients were treated every 4 weeks for three to five sessions. Photographic documentation was taken at the beginning and at the completion of every treatment and 12 and 18 months later. RESULTS In patients with PRS and linear scleroderma of the face, we noticed good restoration of facial volume and symmetry and improvement in skin quality. The results were found to be permanent at 18 months in patients with PRS and 12 months in patients with linear scleroderma. CONCLUSIONS PLLA has been shown to be a useful material for the correction of small volumetric defects caused by linear scleroderma and PRS. The authors have indicated no significant interest with commercial supporters.
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Affiliation(s)
- Maria Giuseppina Onesti
- Department of Dermatologic Diseases and Plastic and Reconstructive Surgery, Policlinico Umberto I degrees, University of Rome La Sapienza, Rome, Italy
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14
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Zancanaro PCQ, Isaac AR, Garcia LT, Costa IMC. Esclerodermia localizada na criança: aspectos clínicos, diagnósticos e terapêuticos. An Bras Dermatol 2009; 84:161-72. [DOI: 10.1590/s0365-05962009000200009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A esclerodermia localizada, ou morféia, acomete crianças em idade escolar e, em geral, é autolimitada, apesar de localmente desfiguradora. A literatura descreve inúmeros fatores etiopatogênicos, bem como modalidades de investigação e tratamento. Este artigo reúne os estudos mais recentes e discute sua aplicação clínica.
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15
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Abstract
Enophthalmos is a relatively frequent and misdiagnosed clinical sign in orbital diseases. The knowledge of the different etiologies of enophthalmos and its adequate management are important, because in some cases, it could be the first sign revealing a life-threatening disease. This article provides a comprehensive review of the pathophysiology, evaluation, and management of enophthalmos. The main etiologies, such as trauma, chronic maxillary atelectasis (silent sinus syndrome), breast cancer metastasis, and orbital varix, will be discussed. Its objective is to enable the reader to recognize, assess, and treat the spectrum of disorders causing enophthalmos.
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Affiliation(s)
- Mehrad Hamedani
- Jules Gonin Eye Hospital--University of Lausanne, Lausanne, Switzerland
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Dirschka T, Jackowski J, Bierhoff E, Fölster-Holst R. Operative Korrektur einer Sklerodermie en coup de sabre durch En-bloc-Resektion. Hautarzt 2007; 58:611-4. [PMID: 17464490 DOI: 10.1007/s00105-006-1277-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A 15-year-old patient developed scleroderma en coup de sabre on right temple at 5 years of age. Multiple treatments (3 cycles of intravenous penicillin, topical glucocorticosteroids, topical calcipotriol, and cream PUVA phototherapy combined with topical calcipotriol) produced no improvement. The patient suffered greatly from the psychosocial stigmatization, so that the entire lesion was resected at 14 years of age. One year after the operation a thin non-sclerotic scar was present; tiny lateral areas of sclerosis not included in the operative field were unchanged. The operation greatly improved the patient's daily life. The surgical therapy of scleroderma en coup de sabre offers an interesting therapeutic alternative.
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Affiliation(s)
- T Dirschka
- Dermatologische Praxis Wuppertal, Schuchardstrasse 15, 42275 Wuppertal, Germany.
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Abstract
Deep morphea encompasses a variety of clinical entities in which inflammation and sclerosis are found in the deep dermis, panniculus, fascia, or superficial muscle. Morphea profunda, eosinophilic fasciitis, and disabling pansclerotic morphea of children are included in this group, but overlapping of the extent and depth of cutaneous involvement in these various conditions precludes their distinction on the sole basis of clinical or even histologic examination. Furthermore, the limits between morphea profunda and generalized morphea, which usually are classified outside this group, are not clear. Histologically, all these disorders show similar inflammatory and sclerotic findings, the primary difference being the depth of these changes. Associated clinical findings, including arthralgias, arthritis, contractures, or carpal tunnel syndrome, are frequent. Although visceral complications are uncommon, pulmonary, esophageal, and even cardiac abnormalities have been reported. Eosinophilia, hypergammaglobulinemia, and increased erythrocyte sedimentation rate may be present with disease activity. Laboratory studies may demonstrate autoantibody production. Treatment is nonstandardized but UVA irradiation and antiinflammatory or immunosuppressive drugs (mainly antimalarial agents and corticosteroids) may be beneficial.
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Affiliation(s)
- Isabel Bielsa
- Department of Dermatology, Hospital Germans Trias i Pujol, Autonomous University of Barcelona, Badalona, Barcelona, Spain.
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Abstract
We describe a 4-year-old girl with hemifacial atrophy. She had a linear white-colored sclerotic plaque on the right submandibular area of skin. Histologic findings of the lesion were consistent with a diagnosis of scleroderma. The relationship between progressive facial hemiatrophy and linear scleroderma are discussed. We think that linear scleroderma of childhood and hemifacial atrophy have considerable clinical overlap and these two syndromes appear to be manifestations of the same or related pathogenic processes. Recently, the beneficial effects of 1.25-dihydroxyvitamin D3 (calcitriol) were reported in adults and in children with linear scleroderma. We assessed the efficacy of oral calcitriol treatment in our patient. Our result indicates that calcitriol may be an effective agent for treating localized scleroderma in children.
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Affiliation(s)
- Emine Dervis
- Department of Dermatology, Hospital of Haseki, Istanbul University, Turkey
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19
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Anderson PJ, Molony D, Haan E, David DJ. Familial Parry-Romberg disease. Int J Pediatr Otorhinolaryngol 2005; 69:705-8. [PMID: 15850693 DOI: 10.1016/j.ijporl.2004.12.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2004] [Revised: 10/11/2004] [Accepted: 12/10/2004] [Indexed: 12/01/2022]
Abstract
Parry-Romberg disease (or hemifacial atrophy) is a rare condition affecting the face. It commences in childhood but its aetiology remains unknown, and is sporadic. Two cases are presented who were biological first cousins. We believe that this is the first recorded example of this condition occurring in family members.
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Affiliation(s)
- Peter J Anderson
- Australian Craniofacial Unit, Women's and Children's Hospital, SA, Australia.
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20
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Gambichler T, Kreuter A, Rotterdam S, Altmeyer P, Hoffmann K. Linear scleroderma 'en coup de sabre' treated with topical calcipotriol and cream psoralen plus ultraviolet A. J Eur Acad Dermatol Venereol 2003; 17:601-2. [PMID: 12941109 DOI: 10.1046/j.1468-3083.2003.00626.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Cosnes A, Anglade MC, Revuz J, Radier C. Thirteen-megahertz ultrasound probe: its role in diagnosing localized scleroderma. Br J Dermatol 2003; 148:724-9. [PMID: 12752130 DOI: 10.1046/j.1365-2133.2003.05289.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ultrasound imaging has been shown to be useful for the evaluation of systemic and localized scleroderma (LS). However, its specificity and sensitivity have not been studied. OBJECTIVES To define morphological ultrasound diagnostic criteria in LS and to test their sensitivity and specificity with a 13-MHz ultrasound probe. METHODS Forty plaques in 26 consecutive patients with LS were examined and compared blindly with 17 control plaques in 16 patients with skin diseases where LS was in the differential diagnosis. Data were also compared with a normal control group. Five patients were re-evaluated 12-18 months after the first examination. RESULTS Ultrasound examination disclosed a characteristic dense image resembling a flattened 'yo-yo'. Undulations of the dermis, disorganization, loss of thickness and thickened hyperechoic bands in the hypodermis, and the 'yo-yo' image had a high sensitivity and a high specificity for LS. A 92% sensitivity and a 100% specificity for LS were found when at least four of these five signs were present. CONCLUSIONS Thirteen-megahertz ultrasound is a valuable tool for diagnosing LS. Morphological ultrasound diagnostic criteria had a high specificity and a high sensitivity.
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Affiliation(s)
- A Cosnes
- Service de Dermatologie and Service de Radiologie, Hôpital Henri Mondor, Créteil, France.
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22
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Karrer S, Bosserhoff AK, Weiderer P, Landthaler M, Szeimies RM. Influence of 5-aminolevulinic acid and red light on collagen metabolism of human dermal fibroblasts. J Invest Dermatol 2003; 120:325-31. [PMID: 12542540 DOI: 10.1046/j.1523-1747.2003.12037.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients with localized scleroderma receiving topical photodynamic therapy with 5-aminolevulinic acid show a reduction in skin tightness, suggesting that this therapy reduces skin sclerosis. To investigate potential mechanisms, the effects of 5-aminolevulinic acid and light on collagen metabolism were studied in vitro. Normal and scleroderma fibroblasts were treated with sublethal doses of 5-aminolevulinic acid and red light and transferred to three-dimensional collagen lattices. Cell supernatants were taken 6-72 h after photodynamic therapy to determine protein levels of the matrix metalloproteinases 1, 2, and 3, and of their inhibitors, tissue inhibitor of metalloproteinase 1 and 2 by enzyme-linked immunosorbent assay. Cellular mRNA expression of these proteins and of collagen type I and III was measured by quantitative real-time polymerase chain reaction. A significant, time-dependent induction of matrix metalloproteinase 1 (up to 2.4-fold after 48 h) and matrix metalloproteinase 3 (up to 4.3-fold after 48 h) protein levels was seen after 5-aminolevulinic acid-photodynamic therapy. Irradiation with ultraviolet A light, used as a positive control, showed a similar induction of matrix metalloproteinase 1 (2.3-fold after 48 h). The mRNA levels of matrix metalloproteinase 1 and matrix metalloproteinase 3 were significantly increased 12 h after irradiation, whereas collagen type I mRNA was strongly decreased already 6 h following irradiation. Collagen type III, tissue inhibitor of metalloproteinase 1, and matrix metalloproteinase 2 did not change after photodynamic therapy. Addition of nontoxic concentrations of sodium azide, a singlet-oxygen quencher, significantly inhibited induction of matrix metalloproteinase 1 by 5-aminolevulinic acid and light. These data show that 5-aminolevulinic acid and light induce matrix metalloproteinase 1 and matrix metalloproteinase 3 expression in normal and scleroderma fibroblasts in a singlet oxygen-dependent way while reducing collagen type I mRNA expression. Induction of collagen-degrading enzymes together with reduction of collagen production might be responsible for the anti-sclerotic effects of 5-aminolevulinic acid-photodynamic therapy observed in vivo.
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Affiliation(s)
- Sigrid Karrer
- Department of Dermatology, University of Regensburg, Regensburg, Germany.
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Gambichler T, Kreuter A, Hoffmann K, Bechara FG, Altmeyer P, Jansen T. Bilateral linear scleroderma "en coup de sabre" associated with facial atrophy and neurological complications. BMC DERMATOLOGY 2001; 1:9. [PMID: 11741509 PMCID: PMC61032 DOI: 10.1186/1471-5945-1-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2001] [Accepted: 12/04/2001] [Indexed: 11/10/2022]
Abstract
BACKGROUND Linear scleroderma "en coup de sabre" (LSCS) usually affects one side of the face and head in the frontoparietal area with band-like indurated skin lesions. The disease may be associated with facial hemiatrophy. Various ophthalmological and neurological abnormalities have been observed in patients with LSCS. We describe an unusual case of LSC. CASE PRESENTATION A 23 year old woman presented bilateral LSCS and facial atrophy. The patient had epileptic seizures as well as oculomotor and facial nerve palsy on the left side which also had pronounced skin involvement. Clinical features of different stages of the disease are presented. CONCLUSIONS The findings of the presented patient with bilateral LSCS and facial atrophy provide further evidence for a neurological etiology of the disease and may also indicate that classic progressive facial hemiatrophy (Parry-Romberg syndrome) and LSCS actually represent different spectra of the same disease.
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Affiliation(s)
- Thilo Gambichler
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791, Bochum, Germany
| | - Alexander Kreuter
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791, Bochum, Germany
| | - Klaus Hoffmann
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791, Bochum, Germany
| | - Falk G Bechara
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791, Bochum, Germany
| | - Peter Altmeyer
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791, Bochum, Germany
| | - Thomas Jansen
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791, Bochum, Germany
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24
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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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25
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Arpey CJ, Patel DS, Stone MS, Qiang-Shao J, Moore KC. Treatment of atrophoderma of Pasini and Pierini-associated hyperpigmentation with the Q-switched alexandrite laser: a clinical, histologic, and ultrastructural appraisal. Lasers Surg Med 2001; 27:206-12. [PMID: 11013382 DOI: 10.1002/1096-9101(2000)27:3<206::aid-lsm2>3.0.co;2-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVE Atrophoderma of Pasini and Pierini (APP) is an uncommon cutaneous disorder, with no known effective treatment, manifested by hyperpigmented patches that appear to be depressed compared with surrounding skin. This study investigated the effectiveness of the Q-switched alexandrite laser on a patient with extensive APP, and evaluated histopathologic and ultrastructural changes. STUDY DESIGN/MATERIALS AND METHODS A man with stable APP underwent Q-switched alexandrite laser treatment to a patch on the trunk. Biopsies were obtained from treated and untreated sites of involvement. Light and transmission electron microscopic evaluation was performed to investigate melanosome number, size, and volume, as well as melanin granule number and size. RESULTS After three treatment sessions, the treated area showed marked clinical improvement. Electron microscopy showed a 19% reduction in melanin granule number and size and a 65% reduction in melanosome number, size, and volume in larger melanosomes in treated compared with untreated sites. CONCLUSION Treatment of APP with the Q-switched alexandrite laser results in clinical improvement. Electron microscopic evaluation suggests that the mechanism may be a reduction in the number, size, and volume of larger melanosomes as well as a decrement in melanin granule number and size.
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Affiliation(s)
- C J Arpey
- Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA
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26
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Affiliation(s)
- M A De Rie
- Department of Dermatology, Academical Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Fadilah SA, Cheong SK, Shahdan S. Extreme hypereosinophilia in a young male patient presenting with palindromic morphoea. Rheumatology (Oxford) 1999; 38:1158-9. [PMID: 10556274 DOI: 10.1093/rheumatology/38.11.1158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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