Histological features of localized scleroderma ‘en coup de sabre ’: a study of 16 cases

Intraoral Involvement in Linear Scleroderma En Coup De Sabre: A Case Report

Localized scleroderma is a connective tissue disorder that causes excessive collagen deposition and skin fibrosis. It can be subdivided into morphea and linear scleroderma. En coup de sabre (ECDS) is a rare variant of linear scleroderma typically found among children. It is usually treated with methotrexate and corticotherapy in addition to folic acid supplements. To date, few cases of ECDS have been reported with oral involvement. This case report discusses a seven-year-old girl with linear scleroderma ECDS who was referred to the dental clinic to evaluate muscular hypotrophy on the floor of the mouth. Upon clinical and radiographic examination, the patient had hypotrophied mylohyoid muscle, reduced alveolar bone height on the affected side, and a deviated midline to the affected side as well. Furthermore, the patient was classified as having a high caries risk. After consultation with the primary physician regarding treatment modalities and options, the patient completed her comprehensive dental treatment at the Dental Department at King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia.

Oral Submucous Fibrosis and Scleroderma: A Review of the Etiopathogenesis, Clinicopathological Correlation, and Management Aspects

Oral submucous fibrosis (OSMF) is a chronic, progressive, insidious premalignant disease with multifactorial etiology affecting any part of the oral cavity and sometimes the pharynx by triggering a rapid onset of trismus and dysphagia due to stiffness at the lips, cheek, pharynx, and upper oesophageal region. Submucous fibrosis resembles many auto-immune, dermatological, mucocutaneous, and fibrotic lesions that include scleroderma, amyloidosis, iron deficiency anemia, and systemic or generalized fibromatosis clinically and histologically. Several authors established an association between oral submucous fibrosis and scleroderma with predominant oral manifestations on the basis of similarity in clinical and histological characteristics despite different pathogenesis and prognostic aspects. Scleroderma or systemic sclerosis is an autoimmune connective tissue disorder clinically manifested as fibrosis of the skin, blood vessels, and visceral organs with or without the involvement of the oral cavity. Thus, understanding the disease mechanism, appropriate early diagnosis, and clinical management of these two entities play an important role in disease prognosis and treatment outcomes. The present review was carried out to briefly present a concise overview of the etiopathogenesis, clinical, histological, diagnosis, and management aspects of OSMF and scleroderma based on the available literature, with special emphasis on similarities and differences between these two entities subsequently aiding in appropriate treatment planning.

Autologous Concentrated Growth Factor Used to Treat Linear Scleroderma En Coup de Sabre: A Case Report

Linear scleroderma en coup de sabre (LSCS) is a variant of localized scleroderma associated with band-like fibrotic lesions in the frontoparietal area. We report a case of LSCS in a woman who presented with progressive mild hyperchromia on the right side of her forehead, with dermal atrophy and hair and eyebrow loss. After the failure of conservative treatments, the patient responded dramatically to injection of autologous localized concentrated growth factor. After three treatments, the atrophy, stiffness, and angiotelectasis on the affected area had improved. No recurrence was detected 24 months after the last treatment. This is the first study describing the use of autologous concentrated growth factor injection to alleviate clinical symptoms of LSCS. This suggests that concentrated growth factor may be a treatment for LSCS in the clinic.

Epilepsy in Parry-Romberg syndrome and linear scleroderma en coup de sabre: Case series and systematic review including 140 patients

Parry-Romberg syndrome (PRS) and linear sclerosis en coup de sabre (LScs) are rare, related, autoimmune conditions of focal atrophy and sclerosis of head and face which are associated with the development of focal epilepsy. The scarcity of PRS and LScs cases has made an evidence-based approach to optimal treatment of seizures difficult. Here we present a large systematic review of the literature evaluating 137 cases of PRS or LScs, as well as three new cases with epilepsy that span the spectrum of severity, treatments, and outcomes in these syndromes. Analysis showed that intracranial abnormalities and epileptic foci localized ipsilateral to the external (skin, eye, mouth) manifestations by imaging or EEG in 92% and 80% of cases, respectively. Epilepsy developed before external abnormalities in 19% of cases and after external disease onset in 66% of cases, with decreasing risk the further from the start of external symptoms. We found that over half of individuals affected may achieve seizure freedom with anti-seizure medications (ASMs) alone or in combination with immunomodulatory therapy (IMT), while a smaller number of individuals benefitted from epilepsy surgery. Although analysis of case reports has the risk of bias or omission, this is currently the best source of clinical information on epilepsy in PRS/LScs-spectrum disease. The paucity of higher quality information requires improved case identification and tracking. Toward this effort, all data have been deposited in a Synapse.org database for case collection with the potential for international collaboration.

Transcriptomic Evaluation of Juvenile Localized Scleroderma Skin With Histologic and Clinical Correlation

OBJECTIVE

Juvenile localized scleroderma (LS) is an autoimmune disease of the skin whose pathogenesis is not well understood due to the rarity of the disease. This study was undertaken to determine the skin transcriptome in skin biopsy tissue from children with juvenile LS compared to pediatric healthy controls, with identification of significant molecular targets using RNA sequencing (RNA-Seq). In this study, differentially expressed genes (DEGs) were assessed for correlations with histopathologic and clinical features in children with juvenile LS, and were used to group the children into distinct genetic clusters based on immunophenotype.

METHODS

RNA-Seq was performed on sections of paraffin-embedded skin tissue obtained from 28 children with juvenile LS and 10 pediatric healthy controls. RNA-Seq was carried out using an Illumina HTS TruSeq RNA Access library prep kit, with data aligned using STAR and data analysis using a DESeq2 platform. A standardized histologic scoring system was used to score skin sections for the severity of inflammation and levels of collagen deposition. Histologic scoring was completed by 2 pathologists who were blinded with regard to the status of each sample. Spearman's rank correlation coefficients were used to assess significant correlations between DEG expression profiles and skin histologic findings in patients with juvenile LS.

RESULTS

We identified 589 significant DEGs in children with juvenile LS as compared to healthy controls. Hierarchical clustering was used to demonstrate 3 distinct juvenile LS immunophenotype clusters. The histologic scores of skin inflammation (based on numbers and categories of inflammatory cell infiltrates) were significantly correlated with the expression levels of HLA-DPB1, HLA-DQA2, HLA-DRA, and STAT1 genes (r_s > 0.5, P < 0.01). Collagen thickness correlated with the expression levels of collagen organization genes as well as with genes found to be correlated with the severity of inflammation, including genes for major histocompatibility complex (MHC) class I, MHC class II, and interferon-γ signaling.

CONCLUSION

Among children with juvenile LS, 3 distinct genetic signatures, or clusters, were identified. In one cluster, inflammation-related pathways were up-regulated, corresponding to the histologic skin inflammation score. In the second cluster, fibrosis-related pathways were up-regulated. In the third cluster, gene expression in the skin corresponded to the patterns seen in healthy controls. Up-regulation of HLA class II genes was observed within the first cluster (characterized by predominant inflammation), a feature that has also been observed in the peripheral blood of patients with morphea and in the skin of patients with systemic sclerosis.

Adult-onset en coup de sabre scleroderma in a patient with linear localized scleroderma profunda: A case report and literature review

The en coup de sabre variant of linear scleroderma typically occurs in children. We report a unique case of adult-onset en coup de sabre scleroderma in a patient with linear localized scleroderma profunda. The patient was treated with oral steroids and oral methotrexate improving her cutaneous disease. This case highlights the importance of a thorough cutaneous examination as this adult patient developed an entity traditionally believed to occur in childhood.

Histopathologic Spectrum of Morphea

ABSTRACT

Morphea is an autoimmune skin disease with protean clinical manifestations. Histologic features are similarly variable, and skin biopsies may be nondiagnostic. A single-institution retrospective cohort study was conducted. Morphea patients who had a biopsy in 2005-2015 were included, and a histopathological review was conducted by 2 pathologists. There were 51 biopsy specimens from 40 subjects. The most common histologic features were dermal sclerosis (90%), dermal thickening (78%), collagen homogenization (86%), a superficial and deep infiltrate (76%), a moderate-abundant inflammatory infiltrate (73%), and periadnexal fat loss/decreased skin appendages (71%). Twenty-four specimens were not diagnostic of morphea. In these specimens, the main clues to diagnosis included the presence of dermal sclerosis (79%), subtle collagen homogenization (75%), dermal thickening (58%), moderate-to-abundant plasma cells (50%), and perineural inflammation (50%). There were no statistically significant differences between active and inactive lesions, nor untreated and treated lesions. The histopathologic features of morphea are variable and a high proportion of biopsies are not diagnostic. Clinicians and pathologists should have a high degree of suspicion to correctly make the diagnosis of morphea.

Alopecia as a systemic disease

Alopecia is a skin condition of great social and psychologic impact. Primary alopecia originates from the hair follicles and usually does not have systemic manifestations; however, secondary alopecia can affect the hair follicles in the setting of systemic diseases, medications, and external trauma. Connective tissue diseases, granulomatous diseases, bullous diseases, infections, and tumors are some of the systemic diseases that will be covered in this review. Trichoscopy is a useful noninvasive tool that can help with the diagnosis in the office and can guide the selection of the optimal site for the scalp biopsy. Histopathology is the ultimate tool for the diagnosis in most cases of secondary alopecia and can be performed on vertical and horizontal sections. In most cases, treating the underlying condition is the single most important strategy, but topical treatments for the alopecia are also applied.

Linear Patch of Alopecia in a Child: Trichoscopy Reveals the Actual Diagnosis

Linear scleroderma en coup de sabre (LSCS) is a clinical variant of morphea that presents with a linear alopecic patch over the frontal scalp. Linear alopecia areata may present as a close differential in the incipient stages of LSCS in the pediatric population, especially when the binding down and pigmentary changes characteristic of LSCS have not developed. Histopathology may also be noncontributory in such scenarios. We hereby report a case of linear alopecia in a 5-year-old Indian girl and highlight the role of trichoscopic evaluation in clinching the diagnosis. This emphasizes the importance of clinicodermoscopic-pathological correlation over clinicopathological correlation for cutaneous diagnosis.

Diagnostic criteria, severity classification and guidelines of localized scleroderma

We established diagnostic criteria and severity classification of localized scleroderma because there is no established diagnostic criteria or widely accepted severity classification of the disease. Also, there has been no clinical guideline for localized scleroderma, so we established its clinical guideline ahead of all over the world. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of localized scleroderma.

Serum levels of genomic DNA of α1(I) collagen are elevated in scleroderma patients

Recent studies have indicated that various nucleic acids are present in human sera, and attracted attention for their potential as novel disease markers in many human diseases. In this study, we tried to evaluate the possibility that DNA and RNA of collagens exist in human sera, and determined whether their serum levels can be useful biomarkers in scleroderma patients. The RNA or DNA of collagens were purified from sera, and detected by polymerase chain reaction or quantitated by real-time polymerase chain reaction. Among approximately 18 360 bases of full-length α1(I) collagen DNA, various regions were detected by polymerase chain reaction in human sera. However, α2(I) collagen DNA, α1(I) collagen RNA or α2(I) collagen RNA were not detectable. α1(I) Collagen DNA in sera was quantitative using our method. The levels of serum α1(I) collagen DNA were significantly increased in scleroderma patients compared with healthy control subjects or systemic lupus erythematosus patients. According to the receiver-operator curve analysis, serum α1(I) collagen DNA levels were shown to be effective as a diagnostic marker of scleroderma. Furthermore, when we determined the association of serum α1(I) collagen DNA levels with clinical/laboratory features in scleroderma patients, those with elevated α1(I) collagen DNA levels showed significantly higher prevalence of pitting scars/ulcers. In summary, elevation of serum α1(I) collagen DNA levels in scleroderma patients may be useful as the diagnostic marker, reflecting the presence of vasculopathy.

Morphea "en coup de sabre": An unusual oral presentation

Morphea, or localized scleroderma, is an inflammatory disease that leads to sclerosis of the skin and underlying tissues due to excessive collagen deposition. Oral involvement is unusual and it may produce white linear fibrotic areas with a scar-like appearance, atrophy of tongue papillae, gingival recession and alveolar bone resorption. We report a case of a 13-year-old girl who consulted for progressive recession on the attached gingiva of her upper left incisors. She also presented a hypopigmented line on the left side skin of her upper lip, which continued through the vermilion and the lip mucosa, including the gingiva of the affected teeth. Clinical examination, blood tests, computerized axial tomography, echo-Doppler ultrasound and histopathological evaluation confirmed the diagnosis of morphea. Treatment with methotrexate and systemic corticosteroids was conducted. After 24 months, no other lesions appeared. No adverse side effects have been reported so far.

Key words:Localized scleroderma, oral morphea, linear scleroderma, oral involvement, intraoral lesions.

Linear Morphea Mimicking Lichen Striatus in Its Early Presentation

Linear morphea and lichen striatus are distinct conditions that have been linked in only one previous case report. We describe two patients with facial lichen striatus preceding linear morphea at the same site. A possible pathogenic relationship is discussed.