Treatment of atrophies secondary to trilinear scleroderma en coup de sabre by autologous tissue cocktail injection

Hyaluronic Acid Filler Injection for Localized Scleroderma - Case Report and Review of Literature on Filler Injections for Localized Scleroderma

Introduction

Localized scleroderma, also known as Morphea, is a chronic inflammatory condition of connective tissue, the etiology of which is unknown. There is skin thickening with increased quantities of collagen in the indurative lesion. Skin hyperemia is seen in the early inflammatory stage. This is followed by fibrosis, sclerosis, and atrophy with hypopigmentation or hyperpigmentation. Therapeutic options include corticosteroids, oral or subcutaneous methotrexate, calcipotriol, imiquimod, tacrolimus, mycophenolate mofetil, medium-dose UVA1 phototherapy, and CO₂ fractional laser treatment. There is disfigurement in approximately 50% of patients. Surgical excision, autologous bone grafting, and autologous fat grafting have been performed with varying degrees of success in linear morphea. Hyaluronic acid, Calcium hydroxylapatite, Poly L lactic acid, and permanent fillers such as Silicone have been used to correct deformities that occur as a result of morphea. The aim of this case report was to establish hyaluronic acid fillers as an efficacious modality of treating stable localized morphea with facial disfigurement.

Case Report

A 35-year-old lady with stable localized scleroderma had an atrophic scar on the right side of her face extending from the labio-mental crease to the midline of the chin. The contour of the chin was lost leading to facial disfigurement. The atrophic scar was treated with 2 fillers with the same cross-linking polymer but two different G primes with excellent cosmetic outcome. A brief review of literature involving fillers for localized scleroderma is also discussed.

Conclusion

Hyaluronic acid filler can be used safely in cases of stable localized scleroderma with facial atrophies. It is an effective, minimally invasive treatment with minimal downtime. It is extremely important to inject fillers only in stable cases of localized morphea. This modality of treatment should be considered for a larger trial in patients with similar disfigurements.

Therapeutic and Reconstructive Management Options in Scleroderma (Morphea) en Coup de Sabre in Children and Adults. A Systematic Literature Review

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.

Surgical Management of Localized Scleroderma

Background

Localized scleroderma is characterized by a thickening of the skin from excessive collagen deposits. It is not a fatal disease, but quality of life can be adversely affected due to changes in skin appearance, joint contractures, and, rarely, serious deformities of the face and extremities. We present six cases of localized scleroderma in face from our surgical practice.

Methods

We reviewed six localized scleroderma cases that were initially treated with medication and then received follow-up surgery between April 2003 and February 2015. Six patients had facial lesions. These cases presented with linear dermal sclerosis on the forehead, oval subcutaneous and dermal depression in the cheek.

Results

En coup de sabre (n=4), and oval-shaped lesion of the face (n=2) were successfully treated. Surgical methods included resection with or without Z-plasty (n=3), fat graft (n=1), dermofat graft (n=1), and adipofascial free flap (n=1). Deformities of the affected parts were surgically corrected without reoccurrence.

Conclusion

We retrospectively reviewed six cases of localized scleroderma that were successfully treated with surgery. And we propose an algorithm for selecting the best surgical approach for individual localized scleroderma cases. Although our cases were limited in number and long-term follow-up will be necessary, we suggest that surgical management should be considered as an option for treating scleroderma patients.

Efficacy of Autologous Microfat Graft on Facial Handicap in Systemic Sclerosis Patients

Background:

Autologous adipose tissue injection is used in plastic surgery for correction of localized tissue atrophy and has also been successfully offered for treatment of localized scleroderma. We aimed to evaluate whether patients with systemic sclerosis (SSc) and facial handicap could also benefit from this therapy.

Methods:

We included 14 patients (mean age of 53.8 ± 9.6 years) suffering from SSc with facial handicap defined by Mouth Handicap in Systemic Sclerosis Scale (MHISS) score more than or equal to 20, a Rodnan skin score on the face more than or equal to 1, and maximal mouth opening of less than 55 mm. Autologous adipose tissue injection was performed under local anesthesia using the technique of subcutaneous microinjection. The main objective of this study was an improvement of the MHISS score 6 months after the surgical treatment.

Results:

The procedure was well tolerated. We observed a mean decrease in the MHISS score of 10.7 points (±5.1; P < 0.0001) at 6 months (35% improvement). Secondary efficacy parameters assessing perioral skin sclerosis, maximum mouth opening, sicca syndrome, and facial pain significantly improved at 3 and 6 months postsurgery. At a 6-month follow-up, 75% of patients were satisfied or very satisfied of the adipose tissue microinjection therapy.

Conclusions:

Our study suggests that subcutaneous perioral microfat injection in patients with SSc is beneficial in the treatment of facial handicap, skin sclerosis, mouth opening limitation, sicca syndrome, and facial pain. Thus, this minimally invasive approach offers a new hope for face therapy for patients with SSc.

New fat-derived products for treating skin-induced lesions of scleroderma in nude mice

INTRODUCTION

Scleroderma is characterized by cutaneous manifestations that mainly affect the hands, arms and face. As of today, there is no treatment for fibrotic skin lesions of scleroderma. Previously we generated and validated a model of scleroderma-like skin sclerosis in nude mice, appropriate to inject human derived products. We showed that the subcutaneous injection of micro-fat (MF), purified and injected using small caliber cannulas, have anti-fibrotic and pro-angiogenic effects and appears more suitable for the treatment of skin lesions of scleroderma compared to the gold standard (Coleman's technique or macro-fat). Here we compared the long-term efficacy of micro-fat "enriched" with other therapeutic products including the stromal vascular fraction (SVF) of fat and platelet-rich plasma (PRP) from blood in our murine model of scleroderma.

METHODS

We used 72 nude mice in this study. We formed six experimental groups: Macro-fat, MF, SVF, PRP, MF + SVF, MF + PRP. This project has three phases: i) Induction of skin sclerosis by daily subcutaneous injections of bleomycin (BLM) for 4 weeks in nude mice; ii) Purification and injection of the different cell therapy products; iii) Histological analyses done 8 weeks post-injections.

RESULTS

MF + SVF and MF + PRP significantly reversed dermal and epidermal sclerosis (P <0.01). Macro-fat, SVF, PRP only corrected the dermal sclerosis (P <0.05). Epidermal sclerosis was reduced in treatments containing MF (P <0.01). MF was more stable. Products containing the SVF were associated with a significant increase of the local vascularization (P <0.01).

CONCLUSIONS

All tested substances were effective in treating skin-induced lesions of scleroderma with different levels of fibrosis and vascular improvement; MF derived products are more stable and SVF demonstrated better pro-angiogenic effects. The observed efficacy of this combination of products in the animal model provides a rationale for potential clinical applications to treat human disease.

[Interests and potentials of adipose tissue in scleroderma]

Systemic sclerosis is a disorder involving the connective tissue, arterioles and microvessels. It is characterized by skin and visceral fibrosis and ischemic phenomena. Currently, therapy is limited and no antifibrotic treatment has proven its efficacy. Beyond some severe organ lesions (pulmonary arterial hypertension, pulmonary fibrosis, scleroderma renal crisis), which only concern a minority of patients, the skin sclerosis of hands and face and the vasculopathy lead to physical and psychological disability in most patients. Thus, functional improvement of hand motion and face represents a priority for patient therapy. Due to its easy obtention by fat lipopaspirate and adipocytes survival, re injection of adipose tissue is a common therapy used in plastic surgery for its voluming effect. Identification and characterization of the adipose tissue-derived stroma vascular fraction, mainly including mesenchymal stem cells, have revolutionized the science showing that adipose tissue is a valuable source of multipotent stem cells, able to migrate to site of injury and to differentiate according to the receiver tissue's needs. Due to easy harvest by liposuction, its abundance in mesenchymal cells far higher that the bone marrow, and stroma vascular fraction's ability to differentiate and secrete growth angiogenic and antiapoptotic factors, the use of adipose tissue is becoming more attractive in regenerative medicine. We here present the interest of adipose tissue use in the treatment of the hands and face in scleroderma.

En Coup de Sabre Scleroderma and Parry-Romberg Syndrome in Adolescents: Surgical Options and Patient-related Outcomes

Objective.

There is little information regarding surgical options and outcomes in patients with facial localized scleroderma. We evaluated the surgical outcomes of procedures performed for linear scleroderma of the face in the pediatric age group; and assessed psychosocial effects of surgical interventions on the affected children.

Methods.

A retrospective chart review was performed of children with en coup de sabre scleroderma (ECDS) and Parry-Romberg syndrome (PRS) who underwent surgical intervention; this included demographic data, clinical features, and type of surgical interventions. A questionnaire of 13 questions covering 4 domains (physical, emotional, social, and symptoms) was sent to patients who consented to take part in the survey. Surgical treatments and outcomes were analyzed retrospectively.

Results.

Seventeen patients underwent surgical intervention (autologous fat injections, Medpor implants, bone paste cranioplasty, and free groin flap) to correct facial asymmetry. Ten patients answered the questionnaire (58.8% response rate). Unhappiness with their appearance, loss of confidence, and bullying were cited as reasons for surgery. The appearance subscale of the survey demonstrated the lowest standardized scores and greatest negative effect on the patients’ quality of life compared to the 3 other subscales. All subjects would consider another surgery and would recommend surgery to other patients with ECDS and PRS.

Conclusion.

Surgical treatment is a potential useful intervention in children with facial disfigurement. Prospective data are needed.

Skin signs of systemic disease in childhood

Several systemic disorders of childhood are characterized by cutaneous stigmata, and these skin signs can serve as important diagnostic clues. Many of the systemic illnesses that are seen in both the pediatric and adult populations often manifest in different ways with respect to their cutaneous features. Also, there are conditions that uniquely present in childhood, such as KD, HSP, acute hemmorhagic edema of infancy, and NOMID. Early recognition of these disorders is important for initiation of appropriate therapy and prevention of adverse outcomes.