Treatment of severe localized scleroderma by plasmapheresis--report of three cases

Combined plasmapheresis and high-dose intravenous immunoglobulin treatment in systemic sclerosis for 12 months: follow-up of immunopathological and clinical effects

Systemic sclerosis (SSc) is an autoimmune disease which involves the skin, as well as several internal organs. Most therapies available in this disease are symptomatic. Authors present a case of diffuse SSc with progressive disease not responding to currently available treatments. Therefore a 12-month protocol of repeated plasmapheresis and high-dose intravenous immunoglobulin treatment was administered with good clinical efficacy. Apart from monitoring the clinical symptoms throughout the treatment, authors also assessed a number of humoral and cellular immunolaboratory markers in order to obtain information on the immunomodulatory effects of this combined treatment in SSc.

Ultraviolet A phototherapy for sclerotic skin diseases: a systematic review

BACKGROUND

Ultraviolet (UV) A-1 phototherapy is now available for a variety of skin diseases. Increasingly since 1995, there have been investigations of the efficacy of UVA-1 (340-400 nm) therapy for sclerotic skin diseases. Most studies undertaken treated patients who had localized scleroderma, but UVA-1 phototherapy is currently also used for other sclerotic skin conditions.

OBJECTIVE

We sought to assess the efficacy, biological effects, and side effects of UVA-1 in a variety of sclerotic skin diseases (localized scleroderma, eosinophilic fasciitis, chronic graft-versus-host disease, lichen sclerosus et atrophicus, scleredema adultorum, necrobiosis lipoidica, POEMS disease, pansclerotic porphyria cutanea tarda, and drug-induced scleroderma-like disorders).

METHODS

The authors searched for publications dated between January 1996 and November 2007 in the computerized bibliographic database, PubMed. PubMed was searched using medical subject heading terms and open searches to retrieve the latest reports.

RESULTS

The evidence based on research concerning the effect of full-spectrum UVA (320-400 nm) and UVA-1 on these skin diseases is still growing, and appears promising. Up until now, good results are shown for all different doses (low, medium, and high) UVA-1 and UVA. There are insufficient data regarding use of high-dose UVA-1 and there are no comparative studies to make a clear assessment regarding the superiority of low-, medium-, or high-dose UVA-1 therapy. Although UVA-1 has various effects on, for instance, fibroblasts and inflammatory cells, the precise mode of action remains obscure. The main short-term side effects of UVA-1 therapy are erythema, pruritus, xerosis cutis, tanning, and recrudescence of herpes simplex infection. More studies are warranted to investigate the potential long-term risk of photoaging and skin cancer. Currently, UVA-1 is considered to be less carcinogenic than psoralen plus UVA (PUVA).

LIMITATIONS

Because of the limited availability of randomized controlled trials and large cohort studies, it is difficult to draw firm conclusions on the long-term efficacy, optimum dose, and best treatment regimens for UVA-1 when administered to patients with sclerosing skin disorders.

CONCLUSIONS

Full-spectrum UVA and UVA-1 phototherapy seem effective in the treatment of sclerotic skin diseases based on data retrieved from the literature. UVA-1 treatment can shorten the active period of localized scleroderma and pseudoscleroderma and prevent further disease progression, including contractures. Further investigations will be needed to determine any additional biological effects of UVA-1. Although long-term side effects are not yet known, UVA-1 might develop into a promising beneficial and well-tolerated treatment in the therapeutic armamentarium for sclerotic skin diseases. Long-term studies in large groups of patients are clearly needed.

The use of apheresis in immune renal disorders

Rapidly progressive glomerulonephritis (RPGN) is often associated with the presence of autoantibodies. Included in this group are the glomerulonephritides associated with anti-GBM antibody (Goodpasture's syndrome). IgA mesangial deposition (the renal component of Henoch-Schönlein purpura), lupus erythematosus, cryoglobulinemia and the antineutrophil cytoplasmic antibody (ANCA)-associated pauci-immune group. In each of these cases, apheresis may provide a therapeutically useful option. Apheresis has also been found useful in certain types of antibody-mediated transplant rejection and in lowering the levels of preformed cytotoxic antibodies which may preclude transplantation. Finally, there are renal diseases in which the immune component is less clearly involved with pathogenesis but for which apheresis may offer a clear benefit, such as in the renal failure associated with 'cast nephropathy' (multiple myeloma) or the recurrence of FSGS (focal segmental glomerulosclerosis) in transplanted kidneys. It is the purpose of this paper to review the evidence supporting the use of apheresis in immune-related diseases.

Scleroderma in children and adolescents

The scleroderma disorders remain challenging conditions in pediatric rheumatology to understand pathologically and indeed for which to provide care. It is clear that much progress is being made in the clinical approach to understanding this group of group of disorders. It seems likely that the different lesions of LS may represent unique immunopathogenic mechanisms or perhaps reflect unique genetic or other characteristics of the patients themselves. To take advantage of the revolution in therapies now occurring in rheumatology it is critical that controlled clinical trials are developed with appropriate agreed upon outcome measures for both localized and systemic disease.

Apheresis for Renal Disease

Many primary renal diseases are associated with either antibody deposition within the glomerulus or an antibody associated autoimmunity, as may be seen with certain vasculitidies. Examples of these diseases include Goodpasture's syndrome, cryoglobulinemia, antineutrophil cytoplasmic antibody positive syndromes, and other forms of rapidly progressive glomerulonephritis. Immunoglobulins also may be nephrotoxic to the tubules such as is the case with myeloma related light chains. Given the rapid removal of immunoglobulins by therapeutic plasma exchange, this modality has been considered an appealing management option in the treatment of these renal diseases. Although not classically considered as autoimmune diseases, thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are related syndromes which often involve the kidneys. Although previously unexplained, it has been long appreciated that therapeutic plasma exchange (PE) can be a useful treatment for these microangiopathic hemolytic anemias, but the most recent insights into their pathogenesis suggest that PE may be beneficial by replacing a missing enzyme or removing pathogenic autoantibodies.

Apheresis

The removal of pathologic humors by various methods is an ancient medical remedy used in the management of diseases whose pathophysiology is poorly understood and whose effective treatment modalities are lacking. The contemporary means for such an approach involves apheresis, which is now possible due to advances in blood banking technologies. Apheresis has been used in most of the major rheumatic diseases, in particular systemic lupus erythematosus and rheumatoid arthritis. Although numerous case reports describe clinical benefits of apheresis in rheumatologic disorders, data from clinical trials are discouraging and suggest a limited role for apheresis in rheumatic disease management.

Effect of penicillin G on corium thickness in linear morphea of childhood: An analysis using ultrasound technique

Linear morphea is the most common form of localized scleroderma in children. The pathogenesis of this disorder is unknown. We report a child with a 6-year history of linear morphea in whom intravenous administration of 5 MU aqueous penicillin G three times a day for 10 consecutive days caused reduction in the thickness of the corium as demonstrated by ultrasound measurements.

Therapeutic apheresis for renal disorders

Many primary renal diseases are associated with either antibody deposition within the glomerulus or an antibody associated autoimmunity, as may be seen with certain vasculitidies. Other immunoglobulins may be nephrotoxic or glomerulopathic; such may be the case with myeloma related light chains or cryoglobulins. Given the rapid removal of immunoglobulins by therapeutic plasma exchange, this modality has been considered an appealing management option in the treatment of these autoimmune related renal diseases. Although not classically considered as autoimmune diseases, thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are related syndromes which often involve the kidneys. In many cases therapeutic plasma exchange has been found to be a useful treatment modality for these microangiopathic hemolytic anemias. This paper will provide a concise review of the renal indications for therapeutic plasma exchange.

Management of collagen vascular diseases in childhood

Collagen vascular diseases seen in children include systemic, discoid and neonatal lupus, dermatomyositis, scleroderma, juvenile rheumatoid arthritis, and, in rare cases, Sjogren's syndrome. Although these diseases are uncommon in children, when seen, they are associated with significant morbidity. This review describes the clinical features of each condition and provides an overview of treatment options now available. These include numerous systemic treatments which can be used as steroid-sparing agents.

Pediatric scleroderma

Scleroderma is a diverse group of conditions which have in common fibrosis of skin and other tissues. Although less common in children than in adults, these conditions are an important cause of morbidity and occasional mortality when they occur in the pediatric population. Children are more likely than adults to develop localized forms of scleroderma, and because of the impact on growth, these can result in major facial or limb asymmetry, flexion contractures, and disability. Management approaches must take into consideration the effect of medications on the child (for example, growth failure and osteoporosis from corticosteroids) as well as the psychosocial impact of chronic illness and physical deformity on the child and family. This article describes the types of scleroderma identified in children, reviews epidemiologic and etiologic factors, and discusses management options. Because this is a rare group of diseases managed by both dermatologists and rheumatologists, large series of patients are rare, and controlled studies of management are not available.

Management of localized scleroderma

Localized scleroderma denotes a spectrum of conditions characterized by circumscribed fibrotic areas involving different levels of the dermis, subcutis, and sometimes underlying soft tissue and bone. Although the clinical course of the disease is often benign, widespread lesions and disabling joint contractures may lead to significant complications. The pathogenesis of the different types of localized scleroderma is still unknown. Numerous therapeutic agents have been reported to be effective in this disease spectrum, but controlled studies are rare. The purpose of this review is to summarize previous experience and to discuss recent advances in the management of localized scleroderma.