Nodular morphea in a linear pattern

Nodular scleroderma: Characterization of a distinct clinical phenotype

Nodular scleroderma is a rare variant of systemic sclerosis (SSc) characterized by fleshy, indurated nodules commonly distributed over the upper and lower extremities and in the trunk. Most scientific publications of the nodular and keloid variants of scleroderma use the terms interchangeably. However, nodular scleroderma has been recently differentiated from keloid forms. Although few cases of isolated local involvement have been reported, nodular scleroderma more commonly presents in conjunction with other manifestations of SSc. We performed a review of all cases of nodular scleroderma reported in the literature to characterize their clinical features. This review indicated that Nodular Scleroderma is usually associated with a Diffuse SSc phenotype and develops during the early progressive skin involvement. Patients with the Nodular Scleroderma phenotype display antinuclear antibodies with speckled or nucleolar patterns, a low frequency of positive SSc-specific antibodies, and typical SSc multiorgan involvement. However, a very low frequency of pulmonary hypertension was found in these patients. Although immunosuppressive or antifibrotic treatment may improve skin thickening and organ involvement, the characteristic nodules are refractory to treatment with these agents. This is the first review, to our knowledge, characterizing the nodular phenotype in patients with SSc.

Nodular/Keloidal Scleroderma with No Systemic Involvement-A Case Report and a Review of the Literature

Nodular or keloidal scleroderma is a rare condition with unclear cause and sporadic mentions in the medical literature. It was first recognized in the 19th century, yet its classification is still debated due to the limited number of reported cases. This rare variant of scleroderma is associated with either progressive systemic sclerosis or localized morphea. Clinically, it presents with asymptomatic nodules or plaques, resembling spontaneous keloid formation, often found on the trunk and proximal extremities. Recent literature reviews show a predominance of women with a mean age of 44 years. Diagnosis relies on clinical and histopathological findings, which usually show overlapping features of both scleroderma and true keloids, secondarily to an excessive fibrosing reaction attributed to collagen formation. We present an unusual case of a 70-year-old female patient who displayed the coexistence of two distinct subtypes of morphea (nodular/keloidal and linear), and exclusive skin involvement, which contrasts with the typical presentation of nodular/keloidal scleroderma, often associated with organ-specific disease. However, recent publications have diverged from previous ones regarding systemic sclerosis, with no systemic involvement reported between 2018 and 2024, which we evaluated in our descriptive literature review. With less than 50 cases reported in total, our case underlines the importance of recognizing this rare disease, ensuring appropriate evaluation, treatment, and follow-up.

Scleroderma with Nodular Scleroderma

BACKGROUND

Nodular scleroderma is a rare variant of scleroderma which can occur in connection with systemic sclerosis or morphea. A biopsy from the lesion can demonstrate the scleroderma pattern, i.e., keloid pattern or mixed type. Treatment is challenging, and several treatments modalities have been reported with unsatisfactory results.

MAIN OBSERVATIONS

We present a case of systemic sclerosis in a 50-year-old female who developed nodular scleroderma in the absence of deterioration of the scleroderma condition. Although no additional treatment was given, the lesions remained stable without progression.

CONCLUSIONS

Although this condition is rare, it has been reported sporadically, and clinicians should be able to recognize this variant in cases of scleroderma presenting with firm nodules or plaques.

Nodular Scleroderma: Increased Expression of Connective Tissue Growth Factor

BACKGROUND

Nodular scleroderma is a fibrosing reaction, presenting well-defined, firm, raised nodules, which resembles keloid. Recent studies suggest that connective tissue growth factor (CTGF) is involved in the fibrotic process, and its expression is increased in many fibrosing diseases.

OBJECTIVE

In this study, we report 3 cases of nodular scleroderma, and the expression of CTGF is also investigated.

METHODS

Three patients who developed nodular scleroderma are described. Expression of CTGF protein and transcripts in nodular scleroderma was examined by immunohistochemistry and in situ hybridization.

RESULTS

Patients were 1 female and 2 males, and all cases were associated with diffuse systemic sclerosis. Nodular lesions were found on the chest (2 cases), back (1 case), upper arm (1 case) and nape (1 case). Histology of the nodular lesions showed thickened collagen bundles in the dermis. Results of immunohistochemistry showed that expression of CTGF was detected on the sclerotic fibroblasts in the lesions of nodular scleroderma, while it was not detected in fibroblasts in normal skin. In situ expression of CTGF transcripts was abundantly detected on the fibroblastic cells in nodular scleroderma.

CONCLUSION

Our data showed increased expression of CTGF in the sclerotic fibroblasts of nodular scleroderma, suggesting that CTGF plays an important role in its pathogenesis.

Keloidal scleroderma

Progressive systemic sclerosis (PSS) can involve the skin diffusely or in a limited way. Rarely cutaneous involvement can assume a hypertrophic form, described in the literature as keloidal scleroderma. The authors describe a PSS patient who presented cutaneous manifestations compatible with the diagnosis of this clinical situation. The clinical features, pathogenic mechanism and therapeutic approach are discussed and a broad review of the literature is given.

Keloid-like scleroderma

A 62-year-old female who developed concomitantly acrosclerosis and keloid-like lesions is described. Biopsy specimens from these linear lesions showed a fibrous proliferation in the dermis composed mostly of normal-appearing, horizontally oriented collagen bundles and myofibroblasts, thus resembling a scar. Keloidal scleroderma is a rare variant of scleroderma. The diagnosis is considered for patients with scleroderma who develop lesions clinically and histologically indistinguishable from keloids. This case demonstrates for the first time that the histopathologic findings can mimic those of a scar, rather than a keloid, and hence is appropriately designated as keloid-like scleroderma. Clinical pathological correlation is mandatory for the correct diagnosis.

Adult acral cutaneous myofibromas in a patient with generalized morphea

Myofibroma is the term for a group of solitary or generalized soft tissue tumors that may be located in the skin or within skeletal muscle, bone, and viscera. These tumors occur most commonly in children. However, examples of myofibroma have been reported in adults, in whom they usually present as solitary lesions of the head and neck, trunk, and extremities. "Cutaneous nodules" have been reported in both localized and systemic scleroderma, but to our knowledge, there are no specific reports of myofibromas developing in this patient population. We report a case of acral myofibromas in a patient with generalized cutaneous morphea. This occurrence is of interest in view of the possible role of myofibroblasts in the pathogenesis of scleroderma.