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Jindal AK, Handa S, Loganathan SK, Sudhakar M, Kaushik A, Suri D, Pandiarajan V, Rawat A, Gupta A, De D, Mahajan R, Singh S. Juvenile localized scleroderma: A single-centre experience from India. J Eur Acad Dermatol Venereol 2023; 37:598-604. [PMID: 36413107 DOI: 10.1111/jdv.18765] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Juvenile localized scleroderma (JLS) or morphoea, a rare chronic autoimmune disease predominantly affects skin, subcutaneous tissue and occasionally the adjacent muscle, fascia and bone. We report the largest single-centre cohort of patients with JLS from India. METHODS Patients who were diagnosed to have JLS were enrolled from the Paediatric Dermatology Clinic and the Paediatric Rheumatology Clinic of a tertiary care referral hospital in India. Collected data included details of the clinical profile, laboratory investigations and management. RESULTS We analysed 84 patients with Juvenile localized scleroderma. Median age of disease onset was 5 years, and median age at diagnosis was 8 years. Commonest subtype was linear scleroderma (57 patients, 67.7%) followed by plaque morphoea and generalized morphoea. Fourteen patients (16.6%) were noted to have extracutaneous manifestations (ECMs). These included arthritis in eight (33.3%), brain parenchymal abnormalities in four (4.7%) and pulmonary involvement in two (8.3%) patients. Antinuclear antibody (ANA) was positive in eight/25 patients (32%; diffuse and speckled pattern in four patients each). One amongst these also had elevated anti-dsDNA titres. Positive ANA was found to have no association with ECMs (p 1.000). Patients were treated using methotrexate (61 patients; 72.6%), dexamethasone oral mini-pulse (OMP; 35 patients; 41.6%), calcipotriol (39 patients; 46.4%), topical corticosteroids (32 patients; 38%) and topical tacrolimus (three patients; 3.7%). Using linear regression analysis, administration of dexamethasone OMP and calcipotriol was found to be a predictor of good treatment response (p 0.034 and 0.019, respectively). CONCLUSION Early use of systemic corticosteroids along with methotrexate may be more beneficial than methotrexate therapy alone.
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Affiliation(s)
- Ankur Kumar Jindal
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjeev Handa
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sathish Kumar Loganathan
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Murugan Sudhakar
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akanksha Kaushik
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vignesh Pandiarajan
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anju Gupta
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dipankar De
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rahul Mahajan
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Allergy Immunology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Tapdia MR, Favas TT, Mishra VN, Pathak A, Singh VK. Generalized Morphea Coincident With Aplastic Anemia: A Case Report. Cureus 2022; 14:e20955. [PMID: 35154935 PMCID: PMC8815815 DOI: 10.7759/cureus.20955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 11/05/2022] Open
Abstract
Morphea is a rare skin condition characterized by erythematous or violaceous lesions as well as sclerotic plaques. Patients with morphea frequently have other autoimmune disorders. Contributing factors are thought to be autoimmunity and an increase in extracellular matrix production. A case of a 45-year-old male patient with progressive restriction of both shoulder movements and patchy discoloration over the abdomen, neck, back, forearms, and bilateral axillae is discussed in this article. Examination revealed multiple shiny hyperpigmented to hypopigmented indurated plaques, and some lesions showed erythematous to violaceous borders, fine scales, and woody induration. The neurological examination was normal. Skin biopsy showed a sparse superficial perivascular lymphohistiocytic infiltrate with thickening of collagen bundles that were hyalinized in the reticular dermis, which was consistent with superficial morphea. Hematological tests showed pancytopenia and bone marrow aspiration revealed hypocellular marrow, which was consistent with aplastic anemia. The patient was diagnosed with generalized morphea with aplastic anemia. The patient was referred to a transplant center for further treatment, but, unfortunately, he died of sepsis while waiting for his transplant. Our case may indicate a possible link between aplastic anemia and generalized morphea. Due to a possible similar underlying mechanism of pathogenesis, treatment of aplastic anemia may be effective in morphea also. Aplastic anemia must be detected early to reduce complications and mortality in patients.
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Mastrantonio S, Hinds BR, Schneider JA, Sennett R, Cotter DG. An Unusual Case of Morphea in the Setting of Aplastic Anemia. Cureus 2020; 12:e7562. [PMID: 32382464 PMCID: PMC7202578 DOI: 10.7759/cureus.7562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Cutaneous sclerosis occurs in association with a variety of systemic diseases, including hematologic malignancy, plasma cell dyscrasias, solid organ tumors, and other systemic autoimmune conditions. Herein, we present a unique case of morphea/lichen sclerosus overlap arising in association with aplastic anemia. To expand upon this rare case, we also review the literature surrounding paraneoplastic sclerosing skin disorders. A 53-year-old man presented with a 13-month history of progressive and generalized skin changes. Exam revealed irregular, hypopigmented indurated plaques with focal areas of scale on the bilateral axillae and hips, as well as hyperpigmented brown papules and plaques on the back. Laboratory evaluation revealed pancytopenia and positive anti-nuclear antibody (1:160). Bone marrow biopsy demonstrated hypocellular marrow consistent with aplastic anemia. Furthermore, skin biopsies revealed lichen sclerosus overlying superficial morphea, consistent with a paraneoplastic sclerodermoid-like eruption. While preparations for hematologic-directed therapies were made, skin-directed therapy with a combination topical steroids and topical calcineurin inhibitors was initiated. Eosinophilic fasciitis and scleroderma have been linked to aplastic anemia, and herein, we expand upon this phenomenon by presenting our case of generalized plaque morphea/lichen sclerosus overlap arising in the setting of aplastic anemia. Dermatologists must be aware of this rare association in order to identify precocious hematologic disease.
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Affiliation(s)
- Sierra Mastrantonio
- Department of Dermatology, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
| | - Brian R Hinds
- Department of Dermatology, University of California San Diego, San Diego, USA
| | - Jeremy A Schneider
- Department of Dermatology, University of California San Diego, San Diego, USA
| | - Rachel Sennett
- Department of Dermatology, University of California San Diego, San Diego, USA
| | - David G Cotter
- Department of Dermatology, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
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Li SC, Zheng RJ. Overview of Juvenile localized scleroderma and its management. World J Pediatr 2020; 16:5-18. [PMID: 31786801 DOI: 10.1007/s12519-019-00320-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/26/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Juvenile localized scleroderma (JLS) is a rare pediatric disease characterized by inflammation and skin thickening. JLS is associated with deep tissue and extracutaneous involvement that often results in functional impairment and growth disturbances. This article provides an overview of the disease with a focus on active features and treatment. DATA SOURCES We searched databases including PubMed, Elsevier and MedLine and Wanfang, reviewing publications from 2013 to 2019. Selected earlier publications were also reviewed. RESULTS Linear scleroderma is the most common JLS subtype. Several lines of evidence suggest that JLS is an autoimmune disease. Extracutaneous involvement is common and can present before the onset of skin disease. Multiple skin features are associated with disease activity, and activity can also manifest as arthritis, myositis, uveitis, seizures, and growth impairment. Systemic immunosuppressive treatment, commonly methotrexate with or without glucocorticoids, greatly improves outcome and is recommended for treating JLS patients with active disease and moderate or higher severity. Long term monitoring is needed because of the disease's chronicity and the high frequency of relapses off of treatment. CONCLUSIONS JLS is associated with a risk for disabling and disfiguring morbidity for the growing child. Identifying active disease is important for guiding treatment, but often difficult because of the paucity of markers and lack of a universal skin activity feature. More studies of JLS pathophysiology are needed to allow the identification of biomarkers and therapeutic targets. Comparative effectiveness treatment studies are also needed to work towards optimizing care and outcome.
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Affiliation(s)
- Suzanne C Li
- Department of Pediatrics, Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, 30 Prospect Avenue, Imus 337, Hackensack, 07601, NJ, USA.
- Department of Pediatrics, Hackensack Meridian School of Medicine at Seton Hall University, Clifton, 07110, NJ, USA.
| | - Rong-Jun Zheng
- Department of Rheumatology, Immunology, and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
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Martini G, Fadanelli G, Agazzi A, Vittadello F, Meneghel A, Zulian F. Disease course and long-term outcome of juvenile localized scleroderma: Experience from a single pediatric rheumatology Centre and literature review. Autoimmun Rev 2018; 17:727-734. [DOI: 10.1016/j.autrev.2018.02.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/11/2018] [Indexed: 12/20/2022]
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Jindal AK, Gupta A, Dogra S, Rawat A, Suri D, Ahluwalia J, Singh S. Thrombocytopenia Associated with Localized Scleroderma: Report of Four Pediatric Cases and Review of the Literature. Pediatr Dermatol 2017; 34:e174-e178. [PMID: 28543515 DOI: 10.1111/pde.13159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report on four children with localized scleroderma (morphea) and thrombocytopenia. All four had the en coup de sabre subtype of morphea and had varying degrees of thrombocytopenia (8 × 109 /L to 120 × 109 /L). None of them had major bleeding manifestations, and thrombocytopenia resolved with treatment of morphea. (One patient was also given an injection of anti-D immunoglobulin.) We propose that thrombocytopenia associated with localized scleroderma is usually benign and requires no specific therapy.
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Affiliation(s)
- Ankur Kumar Jindal
- Department of Paediatrics, Advanced Pediatrics Centre, Chandigarh, India
| | - Anju Gupta
- Department of Paediatrics, Advanced Pediatrics Centre, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Department of Paediatrics, Advanced Pediatrics Centre, Chandigarh, India
| | - Deepti Suri
- Department of Paediatrics, Advanced Pediatrics Centre, Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Department of Paediatrics, Advanced Pediatrics Centre, Chandigarh, India
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Kim A, Marinkovich N, Vasquez R, Jacobe HT. Clinical features of patients with morphea and the pansclerotic subtype: a cross-sectional study from the morphea in adults and children cohort. J Rheumatol 2013; 41:106-12. [PMID: 24293577 DOI: 10.3899/jrheum.130029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Pansclerotic morphea is a poorly described form of morphea with little information on prevalence, demographics, and clinical features. Classification criteria for this subtype varies and the distinction from other forms of morphea, such as extensive generalized morphea and pansclerotic morphea, is not always clear. The purpose of our study was to clarify classification criteria for pansclerotic morphea by identifying its prevalence in the morphea in adults and children (MAC) cohort and describing its demographic and clinical features as compared with generalized morphea. METHODS Patients who met predefined criteria for generalized and pansclerotic morphea were identified using a modified Laxer and Zulian classification system. Baseline demographic and clinical features of the patients were compiled and then analyzed for traits characteristic of pansclerotic morphea versus those of generalized morphea. One hundred and thirteen patients met the criteria for inclusion: pansclerotic (n = 13) and generalized morphea type (n = 100). RESULTS Patients with pansclerotic morphea were more frequently male (46.2% vs 6%; p < 0.0001); had a shorter time to diagnosis (mean difference of 10.4 mos; 95% CI: 0.8-19.9 mos; p = 0.0332); higher rates of functional impairment (61.5% vs 16%; p = 0.0046); higher rates of deep involvement (61.5% vs 17%; p = 0.004); and higher average Rodnan Skin Score (mean difference of 10.8 points; 95% CI: 5-16.6; p = 0.0017), Localized Scleroderma Skin Damage Index (mean difference 28.3; 95% CI: 9-47.6; p = 0.009), and Physician Global Assessment of Disease Damage scores (mean difference 25.1; 95% CI: 0.3-50; p = 0.048). CONCLUSION Our results suggest demographic and clinical features are sufficient to define the pansclerotic subtype as they represent a distinct clinical phenotype with a more rapidly progressive and severe course commonly accompanied by disability. Presence of features of the pansclerotic phenotype should alert practitioners to the possibility of significant morbidity and the need for early aggressive treatment.
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Affiliation(s)
- Andrew Kim
- From the Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Dermatology, Washington Hospital Center, Washington, DC, USA
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