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Knobler R, Geroldinger-Simić M, Kreuter A, Hunzelmann N, Moinzadeh P, Rongioletti F, Denton CP, Mouthon L, Cutolo M, Smith V, Gabrielli A, Bagot M, Olesen AB, Foeldvari I, Jalili A, Kähäri V, Kárpáti S, Kofoed K, Olszewska M, Panelius J, Quaglino P, Seneschal J, Sticherling M, Sunderkötter C, Tanew A, Wolf P, Worm M, Skrok A, Rudnicka L, Krieg T. Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes. J Eur Acad Dermatol Venereol 2024; 38:1251-1280. [PMID: 38456584 DOI: 10.1111/jdv.19912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/26/2024] [Indexed: 03/09/2024]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - M Geroldinger-Simić
- Department of Dermatology, Ordensklinikum Linz Elisabethinen, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - P Moinzadeh
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - F Rongioletti
- Vita Salute University IRCSS San Raffaele Hospital, Milan, Italy
| | - C P Denton
- Center for Rheumatology, Royal Free and University College Medical School, London, UK
| | - L Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, APHP-CUP, Hôpital Cochin, Paris, France
- Institut Cochin, Université de Paris Cité, Paris, France
| | - M Cutolo
- Laboratories for Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University Medical School of Genoa, IRCCS San Martino Genoa, Genoa, Italy
| | - V Smith
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - A Gabrielli
- Fondazione di Medicina Molecolare e Terapia Cellulare, Università Politecnica delle Marche, Ancona, Italy
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - A B Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - I Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - A Jalili
- Dermatology & Skin Care Clinic, Buochs, Switzerland
| | - V Kähäri
- Department of Dermatology and Venereology, University of Turku and Turku University Hospital, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- The Skin Clinic, Copenhagen, Denmark
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - J Panelius
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, CNRS, Immuno CencEpT, UMR 5164, Bordeaux, France
| | - M Sticherling
- Department of Dermatology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Tanew
- Private Practice, Vienna, Austria
| | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - M Worm
- Division of Allergy and Immunology, Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - T Krieg
- Department of Dermatology and Venereology, and Translational Matrix Biology, University of Cologne, Cologne, Germany
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Teske N, Fett N. Recent Advances in Treatment of Systemic Sclerosis and Morphea. Am J Clin Dermatol 2024; 25:213-226. [PMID: 38087156 DOI: 10.1007/s40257-023-00831-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 02/16/2024]
Abstract
Systemic sclerosis (SSc) and morphea are autoimmune sclerosing diseases that cause significant morbidity, and in the case of SSc, mortality. The pathogenesis of both SSc and morphea share vascular dysfunction, auto-reactive T cells and Th2-associated cytokines, such as interleukin 4, and overproduction of transforming growth factor beta (TGFβ). TGFβ stimulates fibroblast collagen and extra-cellular matrix production. Although morphea and SSc have similar pathogenic pathways and histological findings, they are distinct diseases. Recent advances in treatment of morphea, skin sclerosis in SSc, and interstitial lung disease in SSc are focused on targeting known pathogenic pathways.
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Affiliation(s)
- Noelle Teske
- Department of Dermatology, Oregon Health and Science University, 3303 SW Bond Avenue, Portland, OR, 97239, USA
| | - Nicole Fett
- Department of Dermatology, Oregon Health and Science University, 3303 SW Bond Avenue, Portland, OR, 97239, USA.
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3
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Shi Y, Xiao Y, Yu J, Liu J, Liu L, Ding Y, Qiu X, Zhan Y, Tang R, Zeng Z, Xiao R. UVA1 irradiation attenuates collagen production via Ficz/AhR/MAPK signaling activation in scleroderma. Int Immunopharmacol 2023; 116:109764. [PMID: 36706594 DOI: 10.1016/j.intimp.2023.109764] [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: 10/21/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023]
Abstract
Scleroderma is an autoimmune disease mainly characterized by progressive fibrosis of the skin. There are two types of scleroderma, namely localized scleroderma (LS) and systemic sclerosis (SSc); skin lesions in both types of scleroderma are histologically identical. Progressive skin sclerosis induces psychological and ecological burden for scleroderma patients. However, there is no effective treatment for scleroderma due to its unclear etiology. Aryl hydrocarbon receptor (AhR) is recognized as an environmental chemical effector that can respond to ultraviolet radiation, which has been demonstrated to participate in the pathogenesis of SSc in our previous study. In this study, we verify whether the anti-fibrosis effect of ultraviolet A1 (UVA1) phototherapy could be partially induced through Ficz/AhR/MAPK signaling activation for fibrotic lesions in both SSc and LS patients. This is the first study to show the association between the AhR pathway and the anti-fibrotic mechanism of UVA1 phototherapy, which provides additional evidence of the role of AhR in the fibrotic mechanism of systemic scleroderma from different perspectives. Ficz and other AhR agonists may replace UVA1 phototherapy as anti-fibrotic agents in scleroderma.
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Affiliation(s)
- Yaqian Shi
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Hunan Key Laboratory of Medical Epigenetics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Yangfan Xiao
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jiangfan Yu
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Hunan Key Laboratory of Medical Epigenetics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jiani Liu
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Hunan Key Laboratory of Medical Epigenetics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Licong Liu
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Hunan Key Laboratory of Medical Epigenetics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Yan Ding
- Department of Dermatology, Hainan Provincial Hospital of Skin Disease, Haikou, Hainan 570100, China
| | - Xiangning Qiu
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Hunan Key Laboratory of Medical Epigenetics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Yi Zhan
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Hunan Key Laboratory of Medical Epigenetics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Rui Tang
- Department of Rheumatology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410000, China
| | - Zhuotong Zeng
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Hunan Key Laboratory of Medical Epigenetics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.
| | - Rong Xiao
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Hunan Key Laboratory of Medical Epigenetics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.
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Papara C, De Luca DA, Bieber K, Vorobyev A, Ludwig RJ. Morphea: The 2023 update. Front Med (Lausanne) 2023; 10:1108623. [PMID: 36860340 PMCID: PMC9969991 DOI: 10.3389/fmed.2023.1108623] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/18/2023] [Indexed: 02/15/2023] Open
Abstract
Morphea, also known as localized scleroderma, is a chronic inflammatory connective tissue disorder with variable clinical presentations, that affects both adults and children. It is characterized by inflammation and fibrosis of the skin and underlying soft tissue, in certain cases even of the surrounding structures such as fascia, muscle, bone and central nervous system. While the etiology is still unknown, many factors may contribute to disease development, including genetic predisposition, vascular dysregulation, TH1/TH2 imbalance with chemokines and cytokines associated with interferon-γ and profibrotic pathways as well as certain environmental factors. Since the disease may progress to permanent cosmetic and functional sequelae, it is crucial to properly assess the disease activity and to initiate promptly the adequate treatment, thus preventing subsequent damage. The mainstay of treatment is based on corticosteroids and methotrexate. These, however, are limited by their toxicity, especially if applied long-term. Furthermore, corticosteroids and methotrexate often do not sufficiently control the disease and/or the frequent relapses of morphea. This review presents the current understanding of morphea by discussing its epidemiology, diagnosis, management and prognosis. In addition, it will describe recent pathogenetic findings, thus proposing potential novel targets for therapeutic development in morphea.
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Affiliation(s)
- Cristian Papara
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany,*Correspondence: Cristian Papara, ✉
| | - David A. De Luca
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Artem Vorobyev
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Ralf J. Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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5
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Tognetti L, Marrocco C, Carraro A, Guerrini G, Mariotti GI, Cinotti E, Rubegni P. Clinical and laboratory characterization of patients with localized scleroderma and response to UVA-1 phototherapy: In vivo and in vitro skin models. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2022; 38:531-540. [PMID: 35324032 PMCID: PMC9790552 DOI: 10.1111/phpp.12786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/07/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND/PURPOSE Localized scleroderma (LS) is a rare disease leading to progressive hardening and induration of the skin and subcutaneous tissues. LS is responsive to UVA-1 phototherapy, though its exact mechanism of action dermal fibrosis is yet to be fully elucidated. We aimed to investigate the molecular changes induced by UVA-1 rays in human primary fibroblasts cultures. METHODS A total of 16 LS patients were treated with medium-dose UVA-1 phototherapy. At baseline, during and after therapy, Localized Scleroderma Assessment Tool, Dermatology Life Quality Index and lesions' staging and mapping were performed along with high-frequency ultrasound (HFUS) examination for dermal thickness assessment. Gene expression analysis for 23 mRNA transcripts, in vitro UVA-1 irradiation and viability tests were realized on lesional fibroblasts' primary cultures, before and 3 months after therapy. RESULTS The dermal thickness, the LoSCAT and the DLQI progressively decreased starting from the last phototherapy session up to the 6 and 9 month follow-ups (-57% and -60%, respectively). Molecular gene analysis (rt-PCR) revealed that UVA-1 phototherapy exerts multiple effects: the activation of specific anti-fibrotic pathways (e.g., overexpression of CTHRC1 and metalloproteases 1, 2, 7, 8, 9, 12, suppression of TIMP-1), the downregulation of peculiar pro-fibrotic pathways (e.g., downregulation of TGF-ß, TGF-ßrII, Grb2, SMAD 2/3, TNRSF12A, CTGF) through a significant overexpression of IL-1ß; the stabilization of collagen synthesis acting on genes COL1A1, COL3A1, COL8A1, COL10A1, COL12A1. CONCLUSION UVA-1 phototherapy adds significant benefits in local tissue remodeling, rebalancing the alteration between pro-fibrotic and anti-fibrotic pathways; these changes can be well monitored by HFUS.
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Affiliation(s)
- Linda Tognetti
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Camilla Marrocco
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Andrea Carraro
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Giuditta Guerrini
- Laboratory of Molecular Microbiology and Biotechnology, Department of Medical BiotechnologiesUniversity of SienaSienaItaly
| | - GIancarlo Mariotti
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Elisa Cinotti
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
| | - Pietro Rubegni
- Dermatology Unit and Skin Bank Unit, Department of Clinical Surgical and Neuro‐sciencesUniversity of SienaSienaItaly
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6
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LaChance AH, Goldman N, Kassamali B, Vleugels RA. Immunologic underpinnings and treatment of morphea. Expert Rev Clin Immunol 2022; 18:461-483. [DOI: 10.1080/1744666x.2022.2063841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Avery H. LaChance
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nathaniel Goldman
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
- New York Medical College School of Medicine, Valhalla, NY
| | - Bina Kassamali
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Ruth Ann Vleugels
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
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7
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Effect of UVA1 on hypertrophic scarring in the rabbit ear model. Biosci Rep 2021; 40:221742. [PMID: 31894858 PMCID: PMC6974420 DOI: 10.1042/bsr20190007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 11/28/2019] [Accepted: 12/19/2019] [Indexed: 01/30/2023] Open
Abstract
Hypertrophic scars (HTSs) are common and cause functional and psychological morbidity. UVA1 (340-400 nm) phototherapy has been previously shown to be effective in the treatment of localized scleroderma, systemic sclerosis, and POEMS syndrome with minimal side effects, all of which are presented as collagen fibrils hyperplasia that is common with scarring in skin histology. In the present study, we aimed to investigate the impact of UVA1 on the protein expression of TGF-β signal pathway and myofibroblasts in a rabbit model of cutaneous scarring. Full-thickness skin wounds (2 cm × 5 cm in diameter) were made in New Zealand white rabbits to establish the hypertrophic scarring model. New Zealand white rabbits were divided into two treatment groups (n=30 wounds per group with an equal number of controls): medium-dose of UVA1 phototherapy group: 60 J/cm2; high-dose of UVA1 phototherapy group: 110 J/cm2. Left ears were used for treatment and the right ones were used for control. Treatment was administered five times weekly for 6 weeks. Treated and untreated control wounds were harvested at various time points and examined by histologic examination, immunohistochemical assessment, and ultrastructural evaluation. The results showed that UVA1 phototherapy caused a significant reduction in dermal thickness by histological features, whereas the scar index was descended significantly in both medium- and high-dose UVA1 groups compared with the control group. Examination of immunohistochemistry also revealed a marked suppression of tissue growth factor-β (TGF-β) (both medium- and high-dose), α smooth muscle actin (α-SMA) (only high-dose), and tissue inhibitor of metalloproteinase 1 (TIMP-1) (only high-dose), and apparent increase in matrix metalloproteinases (MMP-1) (both medium- and high-dose) compared with the control. The ultrastructural evaluation showed the collagen fibers' diameter had shrunk, and that fibroblastic cytoplasm was not affluent and in a quiescent stage. These findings of the present study suggested that administration of UVA1 irradiation is effective to improve the experimental HTS model and raises a possibility of the therapeutic approach of UVA1 in the scar. Although not directly examined in the present study, MMP inhibition is hypothesized to be responsible for this effect. However, early UVA1 treatment could not prevent the formation of scar model.
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8
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Vieyra-Garcia PA, Wolf P. A deep dive into UV-based phototherapy: Mechanisms of action and emerging molecular targets in inflammation and cancer. Pharmacol Ther 2020; 222:107784. [PMID: 33316286 DOI: 10.1016/j.pharmthera.2020.107784] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
UV-based phototherapy (including psoralen plus UVA (PUVA), UVB and UVA1) has a long, successful history in the management of numerous cutaneous disorders. Photoresponsive diseases are etiologically diverse, but most involve disturbances in local (and occasionally systemic) inflammatory cells and/or abnormalities in keratinocytes that trigger inflammation. UV-based phototherapy works by regulating the inflammatory component and inducing apoptosis of pathogenic cells. This results in a fascinating and complex network of simultaneous events-immediate transcriptional changes in keratinocytes, immune cells, and pigment cells; the emergence of apoptotic bodies; and the trafficking of antigen-presenting cells in skin-that quickly transform the microenvironment of UV-exposed skin. Molecular elements in this system of UV recognition and response include chromophores, metabolic byproducts, innate immune receptors, neurotransmitters and mediators such as chemokines and cytokines, antimicrobial peptides, and platelet activating factor (PAF) and PAF-like molecules that simultaneously shape the immunomodulatory effects of UV and their interplay with the microbiota of the skin and beyond. Phototherapy's key effects-proapoptotic, immunomodulatory, antipruritic, antifibrotic, propigmentary, and pro-prebiotic-promote clinical improvement in various skin diseases such as psoriasis, atopic dermatitis (AD), graft-versus-host disease (GvHD), vitiligo, scleroderma, and cutaneous T-cell lymphoma (CTCL) as well as prevention of polymorphic light eruption (PLE). As understanding of phototherapy improves, new therapies (UV- and non-UV-based) are being developed that will modify regulatory T-cells (Treg), interact with (resident) memory T-cells and /or utilize agonists and antagonists as well as antibodies targeting soluble molecules such as cytokines and chemokines, transcription factors, and a variety of membrane-associated receptors.
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Affiliation(s)
- Pablo A Vieyra-Garcia
- Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, Graz A-8036, Austria.
| | - Peter Wolf
- Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, Graz A-8036, Austria.
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9
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Gupta M, Yamauchi PS, Bagot M, Szepietowski J, Bhatia S, Lotti T, Goldust M. Uncommon presentation of morphea related to interferon beta in a patient with concomitant multiple sclerosis and chronic hepatitis C: A case report. Clin Case Rep 2020; 8:1647-1650. [PMID: 32983469 PMCID: PMC7495805 DOI: 10.1002/ccr3.2971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/26/2020] [Accepted: 05/03/2020] [Indexed: 11/24/2022] Open
Abstract
Recombinant interferon beta-1b is one of the treatment options of multiple sclerosis (MS). Insertional biologics that are used in the treatment of MS may lead to skin adverse effects, for example, morphea.
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Affiliation(s)
| | - Paul S. Yamauchi
- Dermatology Institute and Skin Care CenterSanta MonicaCaliforniaUSA
- Division of DermatologyDavid Geffen School of Medicine at University of CaliforniaLos AngelesCaliforniaUSA
| | - Martine Bagot
- AP‐HP Dermatology DepartmentSaint‐Louis HospitalINSERM U976Université Paris Diderot‐Paris VIISorbonne Paris CitéParisFrance
| | - Jacek Szepietowski
- Department of Dermatology, Venereology and AllergologyWroclaw Medical UniversityWroclawPoland
| | - Shibani Bhatia
- Department of Dermatology, Venereology and LeprosyKasturba medical collegeManipal Manipal Academy of Higher EducationManipalIndia
| | | | - Mohamad Goldust
- Mazandaran University of Medical SciencesSariIran
- University of Rome G. MarconiRomeItaly
- Department of DermatologyUniversity Medical Center MainzMainzGermany
- Department of DermatologyUniversity Hospital BaselBaselSwitzerland
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10
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Arndt S, Lissner C, Unger P, Bäumler W, Berneburg M, Karrer S. Biological effects of a new ultraviolet A 1 prototype based on light-emitting diodes on the treatment of localized scleroderma. Exp Dermatol 2020; 29:1199-1208. [PMID: 32592187 DOI: 10.1111/exd.14135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/15/2020] [Accepted: 06/19/2020] [Indexed: 12/20/2022]
Abstract
Ultraviolet A1 (UVA1 ) phototherapy (spectral range 340-400 nm) is a well-established treatment option for various skin diseases such as localized scleroderma. Recent improvements of conventional UVA1 light sources (metal-halide or fluorescent lamps) have brought attention to a new light-emitting diode (LED) technology with remarkable advantages in handling and clinical routine. This study provides a preclinical histological and molecular evaluation of an LED-based UVA1 prototype with a narrower spectral range (360-400 nm) for treating localized scleroderma. Scleroderma mouse models and fibroblasts in vitro were exposed to LED-based UVA1 phototherapy or to irradiation with a commercially available metal-halide lamp emitting low-dose (20, 40 J/cm2 ), medium-dose (60 J/cm2 ) and high-dose (80, 100 J/cm2 ) UVA1 light. Both UVA1 light sources affected inflammatory genes (IL-1α and IL-6) and growth factors (TGFß-1 and TGFß-2). Increased collagen type 1 was reduced after UVA1 phototherapy. Matrix metalloproteinase-1 was more enhanced after a medium dose of LED-based UVA1 phototherapy than after conventional treatment. In vivo, dermal thickness and the amount of collagen were reduced after both treatment methods. Remarkably, myofibroblasts were more effectively reduced by a medium dose of LED-based UVA1 phototherapy. The study indicates that LED-based UVA1 phototherapy yields similar or even better results than conventional treatment. In terms of biosafety and patient comfort, LED-based UVA1 phototherapy offers clear advantages over conventional treatment because of the use of a narrower and less harmful UVA1 spectrum, less heat generation and shorter treatment times at the same irradiation intensity. Clinical studies are required to confirm these results in patients with localized scleroderma.
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Affiliation(s)
- Stephanie Arndt
- Department of Dermatology, University Medical Center Regensburg, Regensburg, Germany
| | - Clara Lissner
- Department of Dermatology, University Medical Center Regensburg, Regensburg, Germany
| | - Petra Unger
- Department of Dermatology, University Medical Center Regensburg, Regensburg, Germany
| | - Wolfgang Bäumler
- Department of Dermatology, University Medical Center Regensburg, Regensburg, Germany
| | - Mark Berneburg
- Department of Dermatology, University Medical Center Regensburg, Regensburg, Germany
| | - Sigrid Karrer
- Department of Dermatology, University Medical Center Regensburg, Regensburg, Germany
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11
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George R, George A, Kumar TS. Update on Management of Morphea (Localized Scleroderma) in Children. Indian Dermatol Online J 2020; 11:135-145. [PMID: 32477969 PMCID: PMC7247622 DOI: 10.4103/idoj.idoj_284_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Juvenile localized scleroderma (morphea) is the predominant scleroderma in childhood which affects the skin and may extend to the underlying fascia, muscle, joints and bone. The assessment of activity and damage can be done with a validated instrument like LoSCAT. Disease classified as “low severity” which includes superficial plaque morphea can be treated with topical mid potent- potent steroids, tacrolimus, calcipotriol or imiquimod in combination with phototherapy. Methotrexate is recommended for linear, deep and generalized morphea. Steroids are effective in the early inflammatory stage and used in combination with methotrexate. Methotrexate is continued for at least 12 months after adequate response is achieved. Mycophenolate mofetil is given in cases where methotrexate is contraindicated or for those who do not respond to methotrexate. There are also reports of improvement of disease with ciclosporine and hydroxychloroquine. In severe cases, recalcitrant to standard therapy there may be a role for biologics, JAK inhibitors, and IVIG. Supportive measures like physiotherapy and psychiatric counseling are also important in the management of morphea. Orthopedic surgery and other measures like autologous fat transfer may be advocated once the disease is inactive.
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Affiliation(s)
- Renu George
- Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anju George
- Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu, India
| | - T Sathish Kumar
- Department of Child Health, Christian Medical College, Vellore, Tamil Nadu, India
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Pirrello R, Verro B, Grasso G, Ruscitti P, Cordova A, Giacomelli R, Ciccia F, Guggino G. Hyaluronic acid and platelet-rich plasma, a new therapeutic alternative for scleroderma patients: a prospective open-label study. Arthritis Res Ther 2019; 21:286. [PMID: 31836018 PMCID: PMC6911298 DOI: 10.1186/s13075-019-2062-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 11/12/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Systemic sclerosis is a systemic connective tissue disease characterized by endothelium damage, fibrosis, and subsequent atrophy of the skin. Perioral fibrosis produces a characteristic microstomia together with microcheilia, both of which cause severe difficulties and affects patients' daily life, such as eating and oral hygiene. Since there are no effective and specific therapies, we have aimed at evaluating the response to filler injections of hyaluronic acid together with platelet-rich plasma. METHODS Ten female patients aged between 18 and 70 were included in this study. Each patient was treated with three filler injections of hyaluronic acid and platelet-rich plasma at an interval of 15 to 20 days. Follow-up check-ups were recorded 1, 3, and 24 months after the end of the treatment. During the therapy and the subsequent follow-up, we evaluated the mouth's opening, freedom of movement of the lips, and skin elasticity. RESULTS After the treatment, patients had achieved good results already after the first injection and the improvement was maintained in the following months, up to 2 years. In particular, 8 (80%) patients showed a greater mouth's opening and increased upper lip's thickness during 1-month follow-up and maintained these results after 2 years (maximum mouth's opening T0 47.61; T3 49.23; T4 48.60 p < 0.0001. Upper lip's thickness T0 4.20; T3 4.75; T4 4.45 p < 0.0001). Moreover, distance between upper and lower incisors (T0 27.05; T3 29.03; T4 28.14 p < 0.0001), inter-commissural distance (T0 49.12; T3 51.44; T4 50.31: p < 0.0001), and lower lip's thickness (T0 3.80; T3 4.85, 5.10; T4 4.25; p < 0.0001) were increased in all of patients in 1-month follow-up, keeping these benefits after 24 months and having a significant increase of skin elasticity 1 month after the end of therapy. CONCLUSIONS Our study demonstrates that filler injections of hyaluronic acid and platelet-rich plasma represent an efficient local therapeutic alternative for patients affected by scleroderma. The treatment has significantly improved patients' quality of living.
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Affiliation(s)
- Roberto Pirrello
- Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sezione di Chirurgia Plastica e Ricostruttiva, Università di Palermo, Palermo, Italy
| | - Barbara Verro
- Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sezione di Chirurgia Plastica e Ricostruttiva, Università di Palermo, Palermo, Italy
| | - Giulia Grasso
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", Sezione di Reumatologia, University of Palermo, Palermo, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Palermo, Italy
| | - Adriana Cordova
- Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sezione di Chirurgia Plastica e Ricostruttiva, Università di Palermo, Palermo, Italy
| | - Roberto Giacomelli
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Palermo, Italy
| | - Francesco Ciccia
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", Sezione di Reumatologia, University of Palermo, Palermo, Italy
| | - Giuliana Guggino
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", Sezione di Reumatologia, University of Palermo, Palermo, Italy.
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周 志. Progress in the Treatment of Limited Scleroderma with Traditional Chinese and Western Medicine. ACTA ACUST UNITED AC 2019. [DOI: 10.12677/acm.2019.93053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Partl R, Regitnig P, Tauber G, Pötscher M, Bjelic-Radisic V, Kapp KS. Radiation-induced morphea-a rare but severe late effect of adjuvant breast irradiation : Case report and review of the literature. Strahlenther Onkol 2018; 194:1060-1065. [PMID: 30014236 PMCID: PMC6208943 DOI: 10.1007/s00066-018-1336-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/04/2018] [Indexed: 02/05/2023]
Abstract
Background Radiation-induced morphea (RIM) is a circumscribed localized scleroderma that occurs most often in the breast. After an asymptomatic period of one month to several years, the symptoms (circumscribed inflammation, edema, sclerosis) often arise suddenly and cannot be clinically distinguished from a local recurrence in the form of inflammatory carcinoma. Case We present a case of a 74-year-old woman who developed this rare and serious local side-effect in connective tissue following neoadjuvant CDK 4/6 inhibitor abemaciclib (Verzenio®) and aromatase inhibitor anastrozole (Arimidex®) therapy and subsequent radiation therapy of the breast. Conclusions Little is known about risk factors and pathogenesis of RIM. Here we describe the first case of RIM following immunotherapy. The diagnosis is based on clinical appearance and histopathological examination. Treatment should be initiated in the inflammatory stage in order to prevent or delay irreversible fibrosis and atrophy of the breast.
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Affiliation(s)
- Richard Partl
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria
| | - Peter Regitnig
- Institute of Pathology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 25, 8036, Graz, Austria
| | - Gerlinde Tauber
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria
| | - Michaela Pötscher
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria
| | - Vesna Bjelic-Radisic
- Division of Gynecology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 14, 8036, Graz, Austria
| | - Karin S Kapp
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria.
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Knobler R, Moinzadeh P, Hunzelmann N, Kreuter A, Cozzio A, Mouthon L, Cutolo M, Rongioletti F, Denton CP, Rudnicka L, Frasin LA, Smith V, Gabrielli A, Aberer E, Bagot M, Bali G, Bouaziz J, Braae Olesen A, Foeldvari I, Frances C, Jalili A, Just U, Kähäri V, Kárpáti S, Kofoed K, Krasowska D, Olszewska M, Orteu C, Panelius J, Parodi A, Petit A, Quaglino P, Ranki A, Sanchez Schmidt JM, Seneschal J, Skrok A, Sticherling M, Sunderkötter C, Taieb A, Tanew A, Wolf P, Worm M, Wutte NJ, Krieg T. European Dermatology Forum S1-guideline on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: localized scleroderma, systemic sclerosis and overlap syndromes. J Eur Acad Dermatol Venereol 2017; 31:1401-1424. [PMID: 28792092 DOI: 10.1111/jdv.14458] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 06/26/2017] [Indexed: 12/13/2022]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present guideline focuses on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, current strategies in the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this guideline provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes of systemic sclerosis with diseases of the rheumatological spectrum.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Moinzadeh
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - A Cozzio
- Department of Dermatology, Venereology and Allergology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - L Mouthon
- Service de Médecine Interne, Centre de référence maladies rares: vascularites et sclérodermie systémique, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - M Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - F Rongioletti
- Dermatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - C P Denton
- Division of Medicine, Centre for Rheumatology, University College London, London, UK
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L A Frasin
- Dermatology Unit, Hospital of Lecco, Lecco, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - A Gabrielli
- Department of Clinical and Molecular Science, Università Politecnica delle Marche, Ancona, Italy
| | - E Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - G Bali
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - J Bouaziz
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - A Braae Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - I Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - C Frances
- Department of Dermatology and Allergology, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - A Jalili
- Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - U Just
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - V Kähäri
- Department of Dermatology and Venereology, Turku University Hospital and University of Turku, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- Department of Dermato-Allergology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - D Krasowska
- Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Lublin, Poland
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - C Orteu
- Department of Dermatology, Connective Tissue Diseases Service, Royal Free Hospital, London, UK
| | - J Panelius
- Department of Dermatology, Allergology and Venereology, University of Helsinki, and Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - A Parodi
- Department of Dermatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - A Petit
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - P Quaglino
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - A Ranki
- Department of Dermatology, Allergology and Venereology, Inflammation Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J M Sanchez Schmidt
- Department of Dermatology, Hospital del Mar-Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - M Sticherling
- Department of Dermatology, University Hospital of Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Taieb
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Tanew
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Wolf
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Worm
- Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - N J Wutte
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - T Krieg
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
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Morphea - selected local treatment methods and their effectiveness. Reumatologia 2017; 55:305-313. [PMID: 29491539 PMCID: PMC5825969 DOI: 10.5114/reum.2017.72628] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/30/2017] [Indexed: 01/15/2023] Open
Abstract
Localised scleroderma is an uncommon connective tissue disease of multifactorial aetiology occurring in the paediatric and adult population. It is relatively difficult to conduct any research on the subject of this disease entity treatment due to the low number of patients suffering from morphea, a tendency of the disease to remit spontaneously, and not yet well recognised aetiology. Hence, there has been developed no causal treatment of well-proven effectiveness, and schedules of symptomatic therapy are not yet clearly determined. The paper depicts most widely used topical treatment methods in morphea therapy, which due to minor risk of systemic adverse effects seem to be a beneficial therapeutic alternative. The main aim of this article was to analyse different topical treatment options used in localised scleroderma therapy and to indicate the most appropriate, safe, and effective one.
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Balegar S, Mishra DK, Chatterjee S, Kumari S, Tiwary AK. Generalized Morphea following Radiotherapy for an Intracranial Tumor. Indian J Dermatol 2016; 61:581. [PMID: 27688464 PMCID: PMC5029261 DOI: 10.4103/0019-5154.190132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Morphea is a localized scleroderma variety which can be circumscribed or generalized and is characterized by sclerotic plaques developing on trunk and limbs. Surgery and radiation have been implicated as etiological factors for the development of morphea. Majority of the radiation-induced morphea cases have occurred in patients with breast cancer. The affected areas have been generally restricted to the area of radiation and nearby surrounding area in most of the reported cases. We hereby report a case of a 27-year-old male who developed radiation-induced progressive generalized morphea after getting radiotherapy for an intracranial tumor. His condition improved after dexamethasone-cyclophosphamide pulse therapy. With increased incidence of cancer worldwide and radiotherapy as a modality of treatment, it is imperative to follow the patient and look for the development of morphea which itself is a debilitating disease.
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Affiliation(s)
- Shrenik Balegar
- Department of Dermatology and Venereology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Dharmendra Kumar Mishra
- Department of Dermatology and Venereology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Sagarika Chatterjee
- Department of Dermatology and Venereology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Shweta Kumari
- Department of Dermatology and Venereology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Anup Kumar Tiwary
- Department of Dermatology and Venereology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
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Abstract
Systemic and localized scleroderma are difficult to manage diseases with no accepted gold standard of therapy to date. Phototherapeutic modalities for scleroderma show promise. A PubMed search of information on phototherapy for scleroderma was conducted. The information was classified into effects on pathogenesis and clinical outcomes. Studies on photopheresis were excluded. There were no randomized, double-blind, placebo-controlled studies, and only three controlled studies. The vast majority of identified studies evaluated ultraviolet A1 (UVA1) phototherapy. More rigorous studies are needed to evaluate phototherapy in the treatment of scleroderma. Based on the limited studies available, 20-50 J/cm2 of UVA1 therapy 3-4 times a week for 30 treatments is recommended.
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Affiliation(s)
- John Hassani
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
| | - Steven R Feldman
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Dyer BA, Hodges MG, Mayadev JS. Radiation-Induced Morphea: An Under-Recognized Complication of Breast Irradiation. Clin Breast Cancer 2016; 16:e141-3. [DOI: 10.1016/j.clbc.2016.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 04/04/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
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Abstract
Phototherapy is an effective treatment strategy for a variety of sclerosing skin conditions. There are a number of phototherapeutic modalities used for the treatment of sclerosing skin conditions, including ultraviolet (UV)A1, broadband UVA, psoralen plus UVA, and narrowband UVB phototherapy. As controlled trials with validated outcome measures are lacking for these therapies, existing evidence is largely level II for morphea and is even more minimal for scleroderma and other sclerosing disorders (scleroderma, lichen sclerosus, and chronic graft-versus-host disease, among others). Studies do suggest that phototherapy may be effective for many of these disorders, including those that have been unresponsive to other therapies. Phototherapy remains an attractive therapeutic option for patients due to its efficacy and favorable risk-versus-benefit profile. Phototherapy also offers a therapeutic alternative to systemic immunosuppressives for patients who cannot tolerate these medications.
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Affiliation(s)
- Noelle M Teske
- Department of Dermatology, University of Texas at Southwestern Medical Center, Dallas, TX
| | - Heidi T Jacobe
- Department of Dermatology, University of Texas at Southwestern Medical Center, Dallas, TX.
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Nisar MF, Parsons KSG, Bian CX, Zhong JL. UVA irradiation induced heme oxygenase-1: a novel phototherapy for morphea. Photochem Photobiol 2014; 91:210-20. [PMID: 25207998 DOI: 10.1111/php.12342] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 08/21/2014] [Indexed: 12/21/2022]
Abstract
Long wave UVA radiation (340-400 nm) causes detrimental as well as beneficial effects on human skin. Studies of human skin fibroblasts irradiated with UVA demonstrate increased expression of both antifibrotic heme oxygenase-1 (HO-1) and matrix metalloproteinase 1 (MMP-1). The use of UVA-induced MMP-1 is well-studied in treating skin fibrotic conditions such as localized scleroderma, now called morphea. However, the role that UVA-induced HO-1 plays in phototherapy of morphea has not been characterized. In the present manuscript, we have illustrated and reviewed the biological function of HO-1 and the use of UVA1 wavebands (340-400 nm) for phototherapy; the potential use of HO-1 induction in UVA therapy of morphea is also discussed.
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Affiliation(s)
- Muhammad Farrukh Nisar
- The Base of "111 Project" for Biomechanics & Tissue Repair Engineering, Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, China
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Wollina U, Buslau M, Petrov I, Pramatarov K. Disabling pansclerotic morphea of childhood. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.2.6.775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Transforming growth factor-β1 in plaque morphea. Postepy Dermatol Alergol 2013; 30:337-42. [PMID: 24493995 PMCID: PMC3907897 DOI: 10.5114/pdia.2013.39431] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/21/2013] [Accepted: 09/17/2013] [Indexed: 11/17/2022] Open
Abstract
Introduction Morphea (localized scleroderma) is a rare cutaneous disease characterized by skin fibrosis of unknown pathogenesis. Transforming growth factor-β (TGF-β) is a potent profibrotic factor. The role of TGF-β in morphea remains unclear. Aim The goal of this study was to estimate the expression level of TGF-β1 in skin and peripheral blood mononuclear cells as well as the plasma levels of TGF-β1 in plaque morphea (MEP). Material and methods The study involved 20 MEP patients. Three control groups were involved: 1 – plasma: 36 healthy volunteers; 2 – PBMC: 47 healthy volunteers; 3 – skin biopsies: 13 samples collected during mastectomy (breast cancer was not skin involved). The analysis of TGF-β1 plasma levels was performed with the use an adequate ELISA kit, while real-time polymerase chain reaction was employed for the expression of TGF-β1 in peripheral blood mononuclear cells (PBMC) and skin. Results In our study we have not detected differences in TGF-β 1 expression in PBMC, skin, nor in plasma levels of TGF-β1 between MEP patients and healthy controls, regardless of disease activity and its duration. Conclusions The results of our study contradict the claim of the substantial role of TGF-β1 in the most common morphea subtype – MEP.
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Updates on morphea: role of vascular injury and advances in treatment. Autoimmune Dis 2013; 2013:467808. [PMID: 24319593 PMCID: PMC3844232 DOI: 10.1155/2013/467808] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 09/18/2013] [Indexed: 01/23/2023] Open
Abstract
Morphea and systemic sclerosis are fibrosing disorders of the skin that share common inflammatory and immunologic pathways that are responsible for the vascular changes, increased collagen production, and extracellular matrix proliferation seen in both conditions. Recent advances in molecular biology techniques have furthered our knowledge of the potential underlying pathogenic mechanisms and offer new and provocative areas of research for novel diagnostic and therapeutic interventions. This review focuses on the role of vascular injury in the development of morphea, the use of ultrasonography as a diagnostic modality, and well-established and newly proposed treatments.
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Gupta A, Avci P, Dai T, Huang YY, Hamblin MR. Ultraviolet Radiation in Wound Care: Sterilization and Stimulation. Adv Wound Care (New Rochelle) 2013; 2:422-437. [PMID: 24527357 DOI: 10.1089/wound.2012.0366] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Indexed: 01/09/2023] Open
Abstract
SIGNIFICANCE Wound care is an important area of medicine considering the increasing age of the population who may have diverse comorbidities. Light-based technology comprises a varied set of modalities of increasing relevance to wound care. While low-level laser (or light) therapy and photodynamic therapy both have wide applications in wound care, this review will concentrate on the use of ultraviolet (UV) radiation. RECENT ADVANCES UVC (200-280 nm) is highly antimicrobial and can be directly applied to acute wound infections to kill pathogens without unacceptable damage to host tissue. UVC is already widely applied for sterilization of inanimate objects. UVB (280-315 nm) has been directly applied to the wounded tissue to stimulate wound healing, and has been widely used as extracorporeal UV radiation of blood to stimulate the immune system. UVA (315-400 nm) has distinct effects on cell signaling, but has not yet been widely applied to wound care. CRITICAL ISSUES Penetration of UV light into tissue is limited and optical technology may be employed to extend this limit. UVC and UVB can damage DNA in host cells and this risk must be balanced against beneficial effects. Chronic exposure to UV can be carcinogenic and this must be considered in planning treatments. FUTURE DIRECTIONS New high-technology UV sources, such as light-emitting diodes, lasers, and microwave-generated UV plasma are becoming available for biomedical applications. Further study of cellular signaling that occurs after UV exposure of tissue will allow the benefits in wound healing to be better defined.
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Affiliation(s)
- Asheesh Gupta
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
- Defense Institute of Physiology and Allied Sciences (DIPAS), Delhi, India
| | - Pinar Avci
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Tianhong Dai
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Ying-Ying Huang
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Guangxi Medical University, Nanning, China
| | - Michael R. Hamblin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
- Harvard–MIT Division of Health Sciences and Technology, Cambridge, Massachusetts
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27
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Bielsa Marsol I. Actualización en la clasificación y el tratamiento de la esclerodermia localizada. ACTAS DERMO-SIFILIOGRAFICAS 2013. [DOI: 10.1016/j.ad.2012.10.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Pavlotsky F, Sakka N, Lozinski A, Barzilai A. Bath psoralen-UVA photochemotherapy for localized scleroderma: experience from a single institute. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2013; 29:247-52. [DOI: 10.1111/phpp.12063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/13/2013] [Indexed: 11/29/2022]
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Bielsa Marsol I. Update on the classification and treatment of localized scleroderma. ACTAS DERMO-SIFILIOGRAFICAS 2013; 104:654-66. [PMID: 23948159 DOI: 10.1016/j.adengl.2012.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/07/2012] [Indexed: 01/26/2023] Open
Abstract
Morphea or localized scleroderma is a distinctive inflammatory disease that leads to sclerosis of the skin and subcutaneous tissues. It comprises a number of subtypes differentiated according to their clinical presentation and the structure of the skin and underlying tissues involved in the fibrotic process. However, classification is difficult because the boundaries between the different types of morphea are blurred and different entities frequently overlap. The main subtypes are plaque morphea, linear scleroderma, generalized morphea, and pansclerotic morphea. With certain exceptions, the disorder does not have serious systemic repercussions, but it can cause considerable morbidity. In the case of lesions affecting the head, neurological and ocular complications may occur. There is no really effective and universal treatment so it is important to make a correct assessment of the extent and severity of the disease before deciding on a treatment approach.
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Affiliation(s)
- I Bielsa Marsol
- Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Barcelona, Spain.
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Ju M, Chen K, Chang B, Gu H. UVA1 irradiation inhibits fibroblast proliferation and alleviates pathological changes of scleroderma in a mouse model. J Biomed Res 2013; 26:135-42. [PMID: 23554742 PMCID: PMC3597330 DOI: 10.1016/s1674-8301(12)60023-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 11/07/2011] [Accepted: 12/18/2011] [Indexed: 01/13/2023] Open
Abstract
The purpose of the present study was to compare the effects of different doses of ultraviolet radiation A1 (UVA1) on human fibroblast proliferation and collagen level in a mouse model of scleroderma, so as to identify appropriate irradiation doses for clinical treatment of scleroderma. Monolayer from human fibroblasts was cultured in vitro, and a mouse model of scleroderma was established by subcutaneous injection of 100 µL of 400 µg/mL bleomycin into the back of BALB/c mice for 4 weeks. The mouse models and human fibroblasts were divided into UVA1-exposed (100, 60 and 20 J/cm2) and UVA-unexposed groups. At 0, 24 and 48 h after exposure, cell proliferation and levels of hydroxyproline and collagen were detected. UVA1 irradiation was performed 3 times weekly for 10 weeks, and the pathological changes of skin tissues, skin thickness and collagen level were observed after phototherapy. Cell proliferation and the levels of hydroxyproline and collagen were inhibited after phototherapy, and there was a significant difference between the UVA1-exposed cells and UVA1-unexposed cells (P < 0.001). In addition, UVA1 phototherapy improved dermal sclerosis and softened the skin, and there were significant differences between the high-dose UVA1 group and the model group, and the negative group (P < 0.05). It is concluded that UVA1 radiation can reduce cell proliferation, and decrease hydroxyproline and collagen levels in a dose-dependent manner in vitro. High-dose UVA1 phototherapy has marked therapeutic effect on scleroderma in the mouse model. Decreased collagen level may be related to the reduced number and activity of cells, as well as inhibition of collagen synthesis.
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Affiliation(s)
| | | | | | - Heng Gu
- Corresponding author: Heng Gu, M.D., Institute of Dermatology, Chinese Academy of Medical Sciences, 12 Jiangwangmiao Street Nanjing 210042, China. Tel/Fax: +86-2585478969/+86-2585478969, E-mail:
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31
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Abstract
This article outlines the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment of childhood morphea. Also known as localized scleroderma, morphea is a fibrosing disorder of the skin and subcutaneous tissues. Morphea is differentiated from systemic sclerosis (scleroderma) based on the absence of sclerodactyly, Raynaud phenomenon, and nail-fold capillary changes. Confusion may occur because patients with morphea often have systemic symptoms such as malaise, fatigue, arthralgias, myalgias, and positive autoantibodies. Unlike morphea, systemic sclerosis has organ involvement, particularly gastrointestinal, pulmonary, and renal.
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Affiliation(s)
- John C Browning
- Division of Dermatology and Cutaneous Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
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Abstract
Localized scleroderma (also called morphea) is a term encompassing a spectrum of sclerotic autoimmune diseases that primarily affect the skin, but also might involve underlying structures such as the fat, fascia, muscle, and bones. Its exact pathogenesis is still unknown, but several trigger factors in genetically predisposed individuals might initially lead to an immunologically triggered release of pro-inflammatory cytokines, resulting in a profound dysregulation of the connective tissue metabolism and ultimately to induction of fibrosis. To date, there are no specific serological markers available for localized scleroderma. Within the last years, several validated clinical scores have been introduced as potential outcome measures for the disease. Given the rarity of localized scleroderma, only few evidence-based therapeutical treatment options exist. So far, the most robust data is available for ultraviolet A1 phototherapy in disease that is restricted to the skin, and methotrexate alone or in combination with systemic corticosteroids in more severe disease that additionally affects extracutaneous structures. This practical review summarizes relevant information on the epidemiology, pathogenesis, clinical subtypes and classifications, differential diagnoses, clinical scores and outcome measures, and current treatment strategies of localized scleroderma.
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Affiliation(s)
- Alexander Kreuter
- Department of Dermatology, Venerology and Allergology, Ruhr-University Bochum, Bochum, Germany.
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33
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Walker D, Jacobe H. Phototherapy in the Age of Biologics. ACTA ACUST UNITED AC 2011; 30:190-8. [DOI: 10.1016/j.sder.2011.08.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 08/07/2011] [Indexed: 11/29/2022]
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34
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A systematic review of morphea treatments and therapeutic algorithm. J Am Acad Dermatol 2011; 65:925-41. [DOI: 10.1016/j.jaad.2010.09.006] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 07/27/2010] [Accepted: 09/09/2010] [Indexed: 11/23/2022]
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Laetsch B, Hofer T, Lombriser N, Lautenschlager S. Irradiation-induced morphea: x-rays as triggers of autoimmunity. Dermatology 2011; 223:9-12. [PMID: 21865672 DOI: 10.1159/000330324] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 05/19/2011] [Indexed: 11/19/2022] Open
Abstract
We report on 3 females with breast cancer who developed morphea at the site of post-surgery radiotherapy. One was suffering from other autoimmune skin diseases before the diagnosis and treatment of breast cancer. Postirradiation morphea is a potential complication after radiotherapy, particularly radiotherapy for cancer. This troublesome skin disease can occur months to years after treatment, and is associated with remarkable morbidity and pain, and also cosmetic aspects. Therefore, it is crucial to be aware of this condition, and to try to identify patients who might be at an increased risk of developing morphea.
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Affiliation(s)
- B Laetsch
- Department of Dermatology, Triemli Hospital, Zurich, Switzerland
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36
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Wernicke AG, Goltser Y, Trichter S, Sabbas A, Gaan J, Swistel AJ, Magro CM. Morphea as a consequence of accelerated partial breast irradiation. Clin Breast Cancer 2011; 11:67-70. [PMID: 21421525 DOI: 10.3816/cbc.2011.n.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Morphea is a localized form of scleroderma usually unaccompanied by the typical systemic stigmata that characterize progressive systemic scleroderma. It rarely manifests at the site of whole breast external-beam radiation therapy. We present an unusual case of radiation-induced morphea (RIM) that occurred after accelerated partial breast irradiation (APBI) using intracavitary Contura brachytherapy. A 65-year-old white woman was treated for stage IIA invasive ductal carcinoma of the left breast with APBI to a dose of 34 Gy in 3.4-Gy fractions twice daily over the course 5 days with intracavitary brachytherapy. At 1.5 years after completion of APBI, the patient developed an area of tenderness, erythema, and induration at the site of irradiation. A skin biopsy was consistent with morphea. To our knowledge, this is the first case of RIM confined to the area of APBI.
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Affiliation(s)
- A Gabriella Wernicke
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, NY 10065, USA.
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Fett N, Werth VP. Update on morphea: part II. Outcome measures and treatment. J Am Acad Dermatol 2011; 64:231-42; quiz 243-4. [PMID: 21238824 DOI: 10.1016/j.jaad.2010.05.046] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 05/19/2010] [Accepted: 05/25/2010] [Indexed: 10/18/2022]
Abstract
Morphea is a rare fibrosing disorder of the skin and underlying tissues. The underlying pathogenesis of morphea is not completely understood at this time, but ultimately results in an imbalance of collagen production and destruction. Evidence-based treatment options of morphea are limited secondary to the rarity of the disease, and the lack of universally used validated outcome measures. The most commonly used outcome measures are skin scores, computerized surface area measurement, durometer, cutometer, thermography, and ultrasound measurements. The Localized Scleroderma Cutaneous Assessment Tool is a promising recently validated skin scoring tool that allows differentiation between activity and damage, is sensitive to change, and requires no additional equipment. The most robust data in the treatment of morphea exists for methotrexate in combination with systemic steroids and ultraviolet A1.
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Affiliation(s)
- Nicole Fett
- Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Zhou YD, Fang XF, Cui ZJ. UVA-induced calcium oscillations in rat mast cells. Cell Calcium 2009; 45:18-28. [PMID: 18602157 DOI: 10.1016/j.ceca.2008.05.003] [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: 12/14/2007] [Revised: 04/27/2008] [Accepted: 05/20/2008] [Indexed: 02/07/2023]
Abstract
UVA is a major bio-active component in solar irradiation, and is shown to have immunomodulatory and anti-inflammatory effects. The detailed molecular mechanism of UVA action in regard to calcium signaling in mast cells, however, is not fully understood. In this study, it was found that UVA induced ROS formation and cytosolic calcium oscillations in individual rat mast cells. Exogenously added H2O2 and hypoxanthine/xanthine oxidase (HX/XOD) mimicked UVA effects on cytosolic calcium increases. Regular calcium oscillation induced by UVA irradiation was inhibited completely by the phosphatidylinositol-specific phospholipase C inhibitor U73122, but U73343 was without effect. Tetrandrine, a calcium entry blocker, or calcium-free buffer abolished UVA-induced calcium oscillations. L-type calcium channel blocker nifedipine and stores-operated calcium channel blocker SK&F96365 had no such inhibitory effect. ROS induction by UVA was abolished after pre-incubation with anti-oxidant NAC or with NAD(P)H oxidase inhibitor DPI; such treatment also made UVA-induced calcium oscillation to disappear. UVA irradiation did not increase mast cell diameter, but it made mast cell structure more granular. Spectral confocal imaging revealed that the emission spectrum of the endogenous fluorophore in single mast cell contained a sizable peak which corresponded to that of NAD(P)H. Taken together, these data suggest that UVA in rat mast cells could activate NAD(P)H oxidase, to produce ROS, which in turn activates phospholipase C signaling, to trigger regular cytosolic calcium oscillation.
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Affiliation(s)
- Yan Dong Zhou
- Institute of Cell Biology, Beijing Normal University, Beijing 100875, China
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39
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Badea I, Taylor M, Rosenberg A, Foldvari M. Pathogenesis and therapeutic approaches for improved topical treatment in localized scleroderma and systemic sclerosis. Rheumatology (Oxford) 2008; 48:213-21. [PMID: 19022832 DOI: 10.1093/rheumatology/ken405] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
SSc is a chronic progressive disorder of unknown aetiology characterized by excess synthesis and deposition of collagen and other extracellular matrix components in a variety of tissues and organs. Localized scleroderma (LS) differs from SSc in that with LS only skin and occasionally subcutaneous tissues are involved. Although rarely life threatening, LS can be disfiguring and disabling and, consequently, can adversely affect quality of life. There is no known effective treatment for LS, and various options, including, as examples, corticosteroids and other immunomodulatory agents, ultraviolet radiation and vitamin D analogues, are of unproven efficacy. Clinical trials evaluating combination therapy such as corticosteroids with MTX or UVA1 exposure with psoralens have not been established as consistently effective. New immunomodulators such as tacrolimus and thalidomide are also being evaluated. A better understanding of the molecular and cellular mechanisms of LS has led to evaluation of new treatments that modulate profibrotic cytokines such as TGF-beta and IL-4, regulate assembly and deposition of extracellular matrix components, and restore Th1/Th2 immune balance by administering IL-12 or IFN-gamma. IFN-gamma acts by directly inhibiting collagen synthesis and by restoring immune balance. In this review, we evaluate current and future treatment options for LS and cutaneous involvement in SSc. Recent advances in therapy focus mainly on anti-fibrotic agents. Delivery of these drugs into the skin as the target tissue might be a key factor in developing more effective and safer therapy.
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Affiliation(s)
- I Badea
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
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40
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Kroft EBM, Berkhof NJG, van de Kerkhof PCM, Gerritsen RMJP, de Jong EMGJ. Ultraviolet A phototherapy for sclerotic skin diseases: a systematic review. J Am Acad Dermatol 2008; 59:1017-30. [PMID: 18835066 DOI: 10.1016/j.jaad.2008.07.042] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2008] [Revised: 07/13/2008] [Accepted: 07/24/2008] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Elisabeth B M Kroft
- Department of Dermatology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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41
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Autoantibodies against matrix metalloproteinase-1 in patients with localized scleroderma. J Dermatol Sci 2008; 52:47-54. [DOI: 10.1016/j.jdermsci.2008.04.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 04/04/2008] [Accepted: 04/11/2008] [Indexed: 11/22/2022]
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42
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Jacobe H, Cayce R, Nguyen J. UVA1 phototherapy is effective in darker skin: a review of 101 patients of Fitzpatrick skin types I-V. Br J Dermatol 2008; 159:691-6. [DOI: 10.1111/j.1365-2133.2008.08672.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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43
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Cheah NLC, Wong DWY, Chetiyawardana AD. Radiation-induced morphea of the breast: a case report. J Med Case Rep 2008; 2:136. [PMID: 18447904 PMCID: PMC2390574 DOI: 10.1186/1752-1947-2-136] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2007] [Accepted: 04/30/2008] [Indexed: 11/10/2022] Open
Abstract
Radiation-induced morphea (RIM) of the breast is a rare complication of radiotherapy. It is disfiguring, painful and defeats the purpose of achieving a good cosmesis in breast-conservation surgery. This report describes a severe case of RIM in a breast cancer patient together with photographic illustrations of the serial changes over time and histopathology slides. A review of the literature is provided.
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Affiliation(s)
- Nellie LC Cheah
- Cancer Centre, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham B15 2TH, UK
| | - Daniel WY Wong
- Cancer Centre, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham B15 2TH, UK
| | - Anula D Chetiyawardana
- Cancer Centre, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham B15 2TH, UK
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44
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Zulian F. Systemic Sclerosis and Localized Scleroderma in Childhood. Rheum Dis Clin North Am 2008; 34:239-55; ix. [DOI: 10.1016/j.rdc.2007.11.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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45
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Gambichler T, Skrygan M, Tomi NS, Breuksch S, Altmeyer P, Kreuter A. Significant downregulation of transforming growth factor-? signal transducers in human skin following ultraviolet-A1 irradiation. Br J Dermatol 2007; 156:951-6. [PMID: 17381457 DOI: 10.1111/j.1365-2133.2007.07802.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite the significant role of the transforming growth factor (TGF)-beta/Smad pathway in cell growth and extracellular matrix regulation, relatively little is known regarding the effect of ultraviolet (UV) radiation on the TGF-beta/Smad signalling in human skin. OBJECTIVES We aimed to investigate the impact of UVA1 and UVB on the mRNA and protein expression of TGF-beta/Smad signal transducers in human skin in vivo. METHODS Fifteen subjects were exposed to 1.5 minimal erythema doses (MED) (4.5 MED cumulative) of UVA1 and UVB over a 3-day period. Skin biopsies were obtained at 24 and 72 h after the last UV exposure. Real-time reverse transcription-polymerase chain reaction and immunohistology were performed. RESULTS In the UVA1-exposed sites (24 h, 72 h), mRNA expression of TGF-beta1 and Smad3/4/7 was significantly downregulated as compared with nonirradiated skin sites (P < 0.05). At 24 h, immunohistology revealed significantly reduced TGF-beta1 protein levels in fibroblasts (P < 0.05). However, mRNA and protein expression of TGF-beta/Smad proteins observed in UVB-irradiated sites did not differ significantly from control sites (P > 0.05). CONCLUSIONS In contrast to UVB, UVA1 significantly downregulates the expression of TGF-beta/Smad proteins in human skin in vivo. The extent to which the acute effects of TGF-beta/Smad signalling reported in the present paper are related to the beneficial effect of UVA1-based phototherapy of fibrotic skin conditions and/or to the chronic effects of UV that result in photoaging and cancer remains to be established.
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Affiliation(s)
- T Gambichler
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, Bochum, Germany.
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46
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Abstract
PURPOSE OF REVIEW Localized scleroderma, also known as morphoea, has a variety of clinical manifestations that can include systemic involvement. Early recognition, diagnosis and treatment may improve the long-term outcome. RECENT FINDINGS A large multicentre study coordinated by the Pediatric Rheumatology European Society has yielded important information on the epidemiology and clinical manifestations of juvenile localized scleroderma, especially as it pertains to systemic manifestations. Previous results using methotrexate and corticosteroids have been confirmed. Studies on phototherapy have also demonstrated efficacy. A new immunomodulator, imiquimod, has shown promise in an initial case series. SUMMARY Studies over the past year highlight the wide range of extracutaneous manifestations and different forms of localized scleroderma and suggest that treatment may be beneficial.
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Affiliation(s)
- Ronald M Laxer
- Department of Paediatrics and Medicine, University of Toronto, Vice President, Education and Quality, The Hospital for Sick Children, Toronto, Canada.
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47
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Tuchinda C, Kerr HA, Taylor CR, Jacobe H, Bergamo BM, Elmets C, Rivard J, Lim HW. UVA1 phototherapy for cutaneous diseases: an experience of 92 cases in the United States. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2006; 22:247-53. [PMID: 16948826 DOI: 10.1111/j.1600-0781.2006.00245.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The efficacy and safety of UVA1 (340-400 nm) phototherapy were established by studies from European countries. PURPOSE Evaluate experience with UVA1 phototherapy for patients with cutaneous diseases in the United States. METHODS A retrospective analysis of 92 cases of UVA1-treated cutaneous conditions from four medical centers in the United States was performed. RESULTS Two-third of the patients showed a fair to good response (26-100% improvement) and one-third of the patients showed a poor response (0-25% improvement). Diseases with a moderate to good response (51-100% improvement) included scleredema adultorum, hand or foot dermatitis, atopic dermatitis, morphea (medium or medium- to high-dose UVA1), systemic sclerosis, and urticaria pigmentosa. Besides tanning, other adverse effects were found in 15% of patients, which include pruritus, erythema, tenderness, and burning sensation. Patients with skin types I-III responded better that those with a darker skin type. CONCLUSION UVA1 phototherapy is a useful and well-tolerated treatment option for a variety of skin conditions.
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48
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Breuckmann F, Gambichler T, Altmeyer P, Kreuter A. UVA/UVA1 phototherapy and PUVA photochemotherapy in connective tissue diseases and related disorders: a research based review. BMC DERMATOLOGY 2004; 4:11. [PMID: 15380024 PMCID: PMC521488 DOI: 10.1186/1471-5945-4-11] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Accepted: 09/20/2004] [Indexed: 11/10/2022]
Abstract
BACKGROUND Broad-band UVA, long-wave UVA1 and PUVA treatment have been described as an alternative/adjunct therapeutic option in a number of inflammatory and malignant skin diseases. Nevertheless, controlled studies investigating the efficacy of UVA irradiation in connective tissue diseases and related disorders are rare. METHODS Searching the PubMed database the current article systematically reviews established and innovative therapeutic approaches of broad-band UVA irradiation, UVA1 phototherapy and PUVA photochemotherapy in a variety of different connective tissue disorders. RESULTS Potential pathways include immunomodulation of inflammation, induction of collagenases and initiation of apoptosis. Even though holding the risk of carcinogenesis, photoaging or UV-induced exacerbation, UVA phototherapy seems to exhibit a tolerable risk/benefit ratio at least in systemic sclerosis, localized scleroderma, extragenital lichen sclerosus et atrophicus, sclerodermoid graft-versus-host disease, lupus erythematosus and a number of sclerotic rarities. CONCLUSIONS Based on the data retrieved from the literature, therapeutic UVA exposure seems to be effective in connective tissue diseases and related disorders. However, more controlled investigations are needed in order to establish a clear-cut catalogue of indications.
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Affiliation(s)
- Frank Breuckmann
- Department of Dermatology, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Thilo Gambichler
- Dermatology Out-Patient Clinic, Oldchurch Hospital, Romford RM7 OBE, Greater London, UK
| | - Peter Altmeyer
- Department of Dermatology, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Alexander Kreuter
- Department of Dermatology, Ruhr-University Bochum, 44791 Bochum, Germany
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