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Lin Z, Pei Y, Tang X, Rong L, Chen L, Jiang X. Classification and rising medication therapy in stiff skin syndrome: A case report and literature review. Dermatol Ther 2022; 35:e15633. [PMID: 35686816 DOI: 10.1111/dth.15633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/30/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022]
Abstract
Stiff skin syndrome (SSS) is a rare disorder characterized by skin induration and limited joint mobility in the absence of visceral, musculoskeletal, vascular, or immunologic abnormalities. Distinctive subsets of SSS could be distinguished by various manifestation and mechanism, which accounts for the high heterogeneity in SSS cases. Although rehabilitation training remains the mainstay of management, rising medications has drawn awareness in recent years, owing to the potential efficacy. Nevertheless, experience was limited, especially in widespread SSS. We report on a 5-year-old girl with widespread SSS, whose lesion stopped progressing after combination therapy by mycophenolic acid (MPA) and losartan (LST) in addition to rehabilitation exercise. Despite limited experience, a combined therapy of MPA and LST seems to be effective in retarding progression of widespread SSS.
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Affiliation(s)
- Zhilang Lin
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yuxin Pei
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xuhua Tang
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Liping Rong
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lizhi Chen
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaoyun Jiang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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Pro-Fibrotic Phenotype in a Patient with Segmental Stiff Skin Syndrome via TGF-β Signaling Overactivation. Int J Mol Sci 2020; 21:ijms21145141. [PMID: 32698527 PMCID: PMC7404389 DOI: 10.3390/ijms21145141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 12/12/2022] Open
Abstract
Transforming growth factor β (TGF-β) superfamily signaling pathways are ubiquitous and essential for several cellular and physiological processes. The overexpression of TGF-β results in excessive fibrosis in multiple human disorders. Among them, stiff skin syndrome (SSS) is an ultrarare and untreatable condition characterized by the progressive thickening and hardening of the dermis, and acquired joint limitations. SSS is distinct in a widespread form, caused by recurrent germline variants of FBN1 encoding a key molecule of the TGF-β signaling, and a segmental form with unknown molecular basis. Here, we report a 12-year-old female with segmental SSS, affecting the right upper limb with acquired thickening of the dermis evident at the magnetic resonance imaging, and progressive limitation of the elbow and shoulder. To better explore the molecular and cellular mechanisms that drive segmental SSS, several functional studies on patient's fibroblasts were employed. We hypothesized an impairment of TGF-β signaling and, consequently, a dysregulation of the associated downstream signaling. Lesional fibroblast studies showed a higher phosphorylation level of extracellular signal-regulated kinase 1/2 (ERK1/2), increased levels of nuclear factor-kB (NFkB), and a nuclear accumulation of phosphorylated Smad2 via Western blot and microscopy analyses. Quantitative PCR expression analysis of genes encoding key extracellular matrix proteins revealed increased levels of COL1A1, COL3A1, AGT, LTBP and ITGB1, while zymography assay reported a reduced metalloproteinase 2 enzymatic activity. In vitro exposure of patient's fibroblasts to losartan led to the partial restoration of normal transforming growth factor β (TGF-β) marker protein levels. Taken together, these data demonstrate that in our patient, segmental SSS is characterized by the overactivation of multiple TGF-β signaling pathways, which likely results in altered extracellular matrix composition and fibroblast homeostasis. Our results for the first time reported that aberrant TGF-β signaling may drive the pathogenesis of segmental SSS and might open the way to novel therapeutic approaches.
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3
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Varjú C, Kumánovics G, Czirják L, Matucci-Cerinic M, Minier T. Sclerodermalike syndromes: Great imitators. Clin Dermatol 2019; 38:235-249. [PMID: 32513403 DOI: 10.1016/j.clindermatol.2019.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Sclerodermalike syndromes (SLSs) comprise diseases with mucin deposition (eg, scleromyxedema, scleredema), with eosinophilia (eg, eosinophilic fasciitis), metabolic or biochemical abnormalities (eg, nephrogenic systemic fibrosis), or endocrine disorders (eg, POEMS syndrome, or polyneuropathy, organomegaly, endocrinopathy, monoclonal lymphoproliferative disorder, and hypothyroidism). Chronic graft-versus-host disease may also show sclerodermalike skin changes. Inherited progeria syndromes with early aging (eg, Werner syndrome) and a heterogeneous group of hereditary disorders with either skin thickening (eg, stiff skin syndrome) or atrophy and tightening (eg, acrogeria) can also imitate classic systemic sclerosis (SSc). In addition, SLSs can be provoked by several drugs, chemicals, or even physical injury (eg, trauma, vibration stress, radiation). In SLSs, the distribution of skin involvement seems to be atypical compared with SSc. The acral skin involvement is usually missing, and lack of Raynaud phenomenon, scleroderma-specific antinuclear antibodies, the absence of scleroderma capillary pattern, and internal organ manifestations indicate the presence of an SLS. Skin involvement is sometimes nodular, and the underlying tissues can also be affected. For the differential diagnosis, a skin biopsy of the deeper layers including fascia and muscle is required. Histology does not always allow differentiation between SSc and SLSs; therefore, the diagnosis is often based on the distribution, quality of cutaneous involvement, and other accompanying clinical features.
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Affiliation(s)
- Cecília Varjú
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary
| | - Gábor Kumánovics
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Florence, Italy
| | - Tünde Minier
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary.
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Sezer E, Lehman JS, Dasgin E. Congenital Indurated Skin Lesions with Impaired Joint Mobility. Pediatr Dermatol 2017; 34:365-366. [PMID: 28523897 DOI: 10.1111/pde.13130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Engin Sezer
- Department of Dermatology, School of Medicine, Acıbadem University, Istanbul, Turkey
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Emel Dasgin
- Department of Pathology, School of Medicine, Acıbadem University, Istanbul, Turkey
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Myers KL, Mir A, Schaffer JV, Meehan SA, Orlow SJ, Brinster NK. Segmental stiff skin syndrome (SSS): A distinct clinical entity. J Am Acad Dermatol 2016; 75:163-8. [DOI: 10.1016/j.jaad.2016.01.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/12/2016] [Accepted: 01/26/2016] [Indexed: 11/17/2022]
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Plana Pla A, Bielsa Marsol I, Fernández-Figueras M, Ferrándiz Foraster C. Congenital Fascial Dystrophy or Stiff Skin Syndrome: A Case Report. ACTAS DERMO-SIFILIOGRAFICAS 2014. [DOI: 10.1016/j.adengl.2014.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Deng X, Chen F, Song Z, Yan H, You Y, Zhong B, Yang X, Hao F. Four new cases of stiff skin syndrome with unusual presentations. J Eur Acad Dermatol Venereol 2014; 30:163-5. [PMID: 25200307 DOI: 10.1111/jdv.12657] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- X. Deng
- Department of Dermatology; Southwest Hospital; Third Military Medical University; Chongqing China
| | - F. Chen
- Department of Dermatology; Southwest Hospital; Third Military Medical University; Chongqing China
| | - Z. Song
- Department of Dermatology; Southwest Hospital; Third Military Medical University; Chongqing China
| | - H. Yan
- Department of Dermatology; Southwest Hospital; Third Military Medical University; Chongqing China
| | - Y. You
- Department of Dermatology; Southwest Hospital; Third Military Medical University; Chongqing China
| | - B. Zhong
- Department of Dermatology; Southwest Hospital; Third Military Medical University; Chongqing China
| | - X. Yang
- Department of Dermatology; Southwest Hospital; Third Military Medical University; Chongqing China
| | - F. Hao
- Department of Dermatology; Southwest Hospital; Third Military Medical University; Chongqing China
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8
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Plana Pla A, Bielsa Marsol I, Fernández-Figueras M, Ferrándiz Foraster C. Congenital fascial dystrophy or stiff skin syndrome: a case report. ACTAS DERMO-SIFILIOGRAFICAS 2014; 105:805-7. [PMID: 24630430 DOI: 10.1016/j.ad.2014.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 01/07/2014] [Accepted: 01/10/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- A Plana Pla
- Departamento de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España.
| | - I Bielsa Marsol
- Departamento de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - M Fernández-Figueras
- Departamento de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - C Ferrándiz Foraster
- Departamento de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
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Halverstam CP, Mercer SE, Harwayne-Gidansky I, Geller L, Phelps RG. Stiff skin syndrome in a newborn infant. Int J Dermatol 2012; 52:993-5. [DOI: 10.1111/j.1365-4632.2012.05478.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Amorim AGDF, Aidé MK, Durães SMB, Rochael MC. Stiff skin syndrome--case report. An Bras Dermatol 2012; 86:S178-81. [PMID: 22068804 DOI: 10.1590/s0365-05962011000700046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Accepted: 11/01/2010] [Indexed: 11/22/2022] Open
Abstract
Stiff skin syndrome is a rare scleroderma-like disorder of unknown etiology characterized by stone-hard indurations of skin, mild hypertrichosis and limited joint mobility. No effective treatment has yet been found. Exercises and rehabilitative therapy are important in maintaining the patient's quality of life. The authors present a case of a two-year-old boy with progressive skin hardening since he was eight-month old and secondary restricted joint mobility, diagnosed as Stiff skin syndrome.
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Mishra N, Shrestha D, Poudyal RB, Shiva Raj KC. Atypical presentation of scleroderma in infancy. Rheumatol Int 2011; 32:1069-74. [PMID: 21327434 DOI: 10.1007/s00296-011-1803-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Accepted: 01/16/2011] [Indexed: 11/30/2022]
Abstract
We present a case of a female child who had developed progressive skin tightening of whole body, sclerodactyly, and severe contracture of all joints with restricted opening of mouth with disease onset at 6 weeks of life. The child also had anemia, failure to thrive, recurrent diarrhea, and ascites. Skin biopsy revealed characteristic histopathological features suggestive of scleroderma. Echocardiography revealed thrombus in the right atrium extending to inferior vena cava. Serological markers (antinuclear antibody, antiscl 70, anti-double-stranded DNA, anticentromere antibody) were negative. To our knowledge, this case of scleroderma with disease onset at 6 weeks of life could possibly be among youngest cases reported in the literature. Also, thrombosis in inferior vena cava in a child with scleroderma is being reported for the first time.
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Loeys BL, Gerber EE, Riegert-Johnson D, Iqbal S, Whiteman P, McConnell V, Chillakuri CR, Macaya D, Coucke PJ, De Paepe A, Judge DP, Wigley F, Davis EC, Mardon HJ, Handford P, Keene DR, Sakai LY, Dietz HC. Mutations in fibrillin-1 cause congenital scleroderma: stiff skin syndrome. Sci Transl Med 2010; 2:23ra20. [PMID: 20375004 PMCID: PMC2953713 DOI: 10.1126/scitranslmed.3000488] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The predisposition for scleroderma, defined as fibrosis and hardening of the skin, is poorly understood. We report that stiff skin syndrome (SSS), an autosomal dominant congenital form of scleroderma, is caused by mutations in the sole Arg-Gly-Asp sequence-encoding domain of fibrillin-1 that mediates integrin binding. Ordered polymers of fibrillin-1 (termed microfibrils) initiate elastic fiber assembly and bind to and regulate the activation of the profibrotic cytokine transforming growth factor-beta (TGFbeta). Altered cell-matrix interactions in SSS accompany excessive microfibrillar deposition, impaired elastogenesis, and increased TGFbeta concentration and signaling in the dermis. The observation of similar findings in systemic sclerosis, a more common acquired form of scleroderma, suggests broad pathogenic relevance.
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Affiliation(s)
- B L Loeys
- Institute of Genetic Medicine and Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Broadway Research Building, Room 539, 733 North Broadway, Baltimore, MD 21205, USA
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Hernandez-Martin A, Colmenero I, Torrelo A. Eleven-year-old girl with skin hardening and restricted mobility in the lower limbs. Int J Dermatol 2010; 49:687-9. [PMID: 20618477 DOI: 10.1111/j.1365-4632.2009.04340.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Azevedo VF, Serafini SZ, Werner B, Müller CS, Franchini CFM, Morais RLSL. Stiff skin syndrome versus scleroderma: a report of two cases. Clin Rheumatol 2009; 28:1107-11. [PMID: 19415378 DOI: 10.1007/s10067-009-1178-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Revised: 03/23/2009] [Accepted: 03/27/2009] [Indexed: 11/26/2022]
Abstract
Stiff skin syndrome is a rare cutaneous disease, scleroderma-like disorder that presents in infancy or early childhood with rock-hard skin, limited joint mobility, and mild hypertrichosis. Normally, it occurs in the absence of visceral or muscle involvement. Patients do not present immunologic abnormalities or vascular hyperactivity. We describe two adults who initially were diagnosed suffering from scleroderma but fit criteria for stiff skin syndrome. A review of the clinical range of this disorder and discussion of the differential diagnosis with scleroderma is presented.
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Affiliation(s)
- V F Azevedo
- Spondylarthropathies Clinic, Hospital de Clínicas, Federal University of Paraná, Rebouças, Curitiba, PR CEP 80250-020, Brasil.
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Affiliation(s)
- Olivier N Pages
- Pediatric Surgery Department, American Memorial Hospital, Reims, France.
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Abstract
Stiff skin syndrome is a rare disorder characterized by pronounced skin induration, mild hypertrichosis and limited joint mobility, predominantly on the buttocks and thighs. Many heterogeneous cases have been reported under the name of stiff skin syndrome. We present a case of stiff skin syndrome from China, the diagnosis based on the patient's typical clinical and histopathological features.
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Affiliation(s)
- S Geng
- Department of Dermatology, Second Hospital of Xian Jiaotong University, 157 Xiwu Road, Xi'an, Shaanxi Province, China.
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Zulian F, Vallongo C, de Oliveira SKF, Punaro MG, Ros J, Mazur-Zielinska H, Galea P, Da Dalt L, Eichenfield LF. Congenital localized scleroderma. J Pediatr 2006; 149:248-51. [PMID: 16887444 DOI: 10.1016/j.jpeds.2006.04.052] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Revised: 02/14/2006] [Accepted: 04/13/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Juvenile localized scleroderma (JLS) usually has its onset during later childhood. This report describes the clinical and serologic features of six children with congenital localized scleroderma (CLS). STUDY DESIGN A large, multinational study was conducted among pediatric rheumatology and dermatology centers by collecting information on demographics, family history, triggering environmental factors, clinical features, laboratory reports, and treatment of patients with JLS. Patients with onset at birth were carefully examined. RESULTS Among 750 patients with JLS, 6 patients (0.8%) had scleroderma-related lesions at birth. Female-to-male ratio was 2:1. All patients had linear scleroderma, in four involving the face with en coup de sabre appearance. Two patients were misdiagnosed as having skin infection, one nevus, one salmon patch, and two undefined skin lesions. The mean diagnostic delay was 3.9 years. In comparison with the group of 733 patients with late-onset JLS, CLS presented a significantly more prolonged disease duration at diagnosis and a higher frequency of en coup de sabre subtypes. CONCLUSIONS Congenital localized scleroderma is a rare and probably underestimated condition in neonates. The linear subtype was the exclusive manifestation of the disease. CLS should be included in the differential diagnosis of infants with cutaneous erythematous fibrotic lesions to avoid functional and aesthetic sequelae and to allow prompt therapy.
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