Why, how, and when to use color Doppler ultrasound for improving precision in the diagnosis, assessment of severity and activity in morphea

High-frequency ultrasound evaluation of morphea: Retrospective analytical study

BACKGROUND

To date, there are no accepted outcome measures to monitor morphea, and consensus on specific monitoring criteria for morphea remains elusive. A few studies have assessed the criterion validity of skin ultrasound in morphea. So, in this study, we approach ultrasound findings in morphea lesions.

MATERIAL AND METHODS

This was a retrospective-analytical study conducted between December 2021 and May 2023. Patients were clinically evaluated at a dermatology outpatient clinic and then referred for high-frequency ultrasound (HF-US) evaluation and were selected to be included in this study. The lesions were confirmed by histopathology as well. Sonographic evaluations were performed on the lesion site and the symmetrical uninvolved other side. Dermal thickness and dermal echogenicities were recorded. Statistical analysis of group differences was performed by using the 2-tailed Student t-test. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Forty-one morphea lesions in the inflammatory phase of 27 patients were included in the study. The mean dermal thickness of morphea lesions was 1107.97 ± 414.3 and the mean dermal thickness of the control side was 1094.65 ± 331.06, The difference between these two variables was not statistically significant. The mean dermal density of lesions was 49.13 ± 18.97 and the mean dermal density of the control side was 52.22 ± 25.33. The difference between these two variables was not statistically significant.

CONCLUSION

This study shows that HF-US indicated increasing dermal thickness and reducing the dermal density of the morphea lesions in the inflammatory phase confirmed with the histopathology.

Role of Color Doppler Ultrasound in Cutaneous Inflammatory Conditions

Inflammatory cutaneous diseases can be challenging to diagnose and manage. Nowadays, the anatomical information provided by ultrasound is critical for detecting subclinical alterations and assessing the severity and activity of these conditions. Many of these entities can be clinically observed in dermatology and other specialties, such as rheumatology, plastic surgery, ophthalmology, and otolaryngology, among others. We review the ultrasonographic patterns of the most common inflammatory cutaneous conditions. In several cases, such as hidradenitis suppurativa, acne, and morphea, there are ultrasonographic staging systems of severity or activity that are pivotal in the management of these diseases. The early ultrasonographic diagnosis of these entities implies a proper management of the patients and, therefore, improve their quality of life. Thus, knowledge of the current use of ultrasound in this field seems essential.

How to Start on Dermatologic Ultrasound: Basic Anatomical Concepts, Guidelines, Technical Considerations, and Best Tips

Dermatologic ultrasound has grown exponentially during the last decades and has passed from the experimental phase to the routine daily practice in multiple countries. The performance of this imaging technique requires color Doppler ultrasound devices working with high-frequency probes, a trained operator on imaging and dermatologic conditions, and the performance of standardized protocols for obtaining the anatomical data properly. In this review, we analyze the ultrasonographic anatomy of the skin, hair, and nails, the technical requirements and considerations, the guidelines, and the recommended protocols, and provide the best tips for practicing this type of examination confidently.

Clinical and ultrasonographic evaluation of efficacy and safety of intralesional injection of autologous platelet-rich plasma in morphea: A comparative case series

Objective

To evaluate the efficacy and safety of platelet-rich plasma to restore skin changes in morphea by ultrasound and Localized Scleroderma Cutaneous Assessment Tool.

Methods

Nine morphea patients (21 lesions) were diagnosed clinically and by histopathology. Intradermal platelet-rich plasma was injected into morphea lesion once weekly for 12 sessions. The disease severity and damage were evaluated at baseline, after the last session (3 months later), and at 6 months follow-up using the LoSCAT and a high-resolution ultrasound. The healthy corresponding side was considered as a control.

Results

The Localized Scleroderma Cutaneous Assessment Tool score showed a significant improvement starting from 13 ± 7.28 up to 7.33 ± 6.82 after the therapeutic endpoint, reaching to 6.44 ± 7.09 after 6 months of follow-up with p value = 0.008 and 0.014, respectively. There was a significant positive correlation between the duration of the lesion and the improvement assessed by the ultrasound, with p value = 0.01. Regarding adverse effects, all patients reported having pain during platelet-rich plasma injection; transient edema of the face was reported by four patients (45%), and only two patients showed transient erythema.

Conclusion

Autologous platelet-rich plasma is a safe technique with great aesthetic outcomes for filling up the contour defects and correcting both hyper and hypopigmentation, in addition to softening the indurated lesions.

Ultrasound Morphea Activity Scoring (US-MAS): Modified US-MAS

Morphea, an autoimmune connective tissue disease that affects the skin, can be supported by color Doppler ultrasound in its diagnosis and assessment of activity. To date, there are no reliable laboratory parameters to track activity, and ultrasound presents a higher axial spatial resolution than magnetic resonance imaging and computed tomography, which is critical for studying the superficial layers. The quality of the ultrasonographic assessment of activity in morphea depends on the standardization and features of the acquisition of the anatomical data. We propose a detailed ultrasound morphea activity scoring called modified US-MAS (mUS-MAS) that could allow us to systematically register the cutaneous abnormalities in the corporal regions and their subregions. The selection of the scanning sites will depend on the corporal regions of involvement and their adjacent segments. Through systematic and sequential ultrasound data analysis, we propose that this scoring system can better support description and activity tracking accuracy.

Color Doppler Ultrasound Assessment of Subclinical Activity With Scoring of Morphea

BACKGROUND

Detection of activity in morphea is paramount for adequately managing the disease. Subclinical ultrasound involvement on inactive lesions or healthy skin areas adjacent to morphea has not been described to date.

OBJECTIVES

The study aimed to detect morphea's subclinical activity by Color Doppler ultrasound not identified with the clinical scorings.

MATERIALS & METHODS

This cross-sectional retrospective study was done from January 2014 to July 2019 in patients with a clinicopathological diagnosis of morphea. The modified Localized Scleroderma Skin Severity Index (mLoSSI) and The Ultrasound Morphea Activity Score (US-MAS) were used to correlate clinical and subclinical activity.

RESULTS

A total of 36 patients met the inclusion criteria. 54% of cases presented subclinical activity in areas adjacent to the clinically active lesion, 23% in nonadjacent regions, and 23% demonstrated activity at a clinically inactive lesion site.100% of patients with morphea "en coup de sabre" involving the frontal region of the face concomitantly presented both subclinical activities of morphea on the frontal facial region and the scalp following the same axis.A positive relationship was observed between the degree of clinical activity measured by mLoSSI and US-MAS scoring.The main limitations of our study were the low number of patients and the inability to detect alterations < 0.1 mm.

CONCLUSIONS

Subclinical activity is frequent in morphea, can extend beyond the lesional areas, including apparently noninvolved adjacent and distant corporal regions, and can be detected by color Doppler ultrasound.

Key Points to Select a Device for Dermatologic Ultrasound

What points to consider when selecting a device for practicing dermatologic ultrasound is an excellent question. After we met the requisites published in the guidelines for practicing dermatologic ultrasound, it is necessary to consider the main objective of the use because it is not the same to be focused mostly on the avoidance of the puncture of important facial vessels such as the case of injectors of cosmetic fillers in comparison to the use of operators that need to deal with the diagnosis and monitoring of a wide range of dermatologic pathologies. Currently, a broad variety of ultrasound devices meets the minimum requirements for practicing these examinations in the market. Thus, small, portable, and high-end devices may present advantages and limitations that must be balanced according to the primary purposes and the budget. Moreover, the shape and footprint of the probes can make difficult or facilitate a dermatologic procedure. Other points to consider are the type of storage and the need for technical service. In summary, there are key points that we need to consider when we select a dermatologic ultrasound device in dermatology or aesthetics.

Morphea After Liposuction Ultrasonography

Liposuction is a common aesthetic procedure; however, to date, liposuction has not been linked to morphea. The aim was to review cases with a history of liposuction that presented active morphea lesions in the same surgery regions and were confirmed by ultrasound and histology. A retrospective descriptive analysis of the clinical, ultrasonographic, and pathology database took place (2014-2020). Eleven patients met the criteria. Ultrasound supported the diagnosis, and the ultrasonographic signs of activity in these cases matched the features described in the literature in 100% of cases. In summary, morphea may appear after liposuction and ultrasound can support its early detection.

Skin sonography in children: a review

Skin lesions are not uncommon in children, and most of them are benign. However, they can be a matter of concern. Although in most cases the diagnosis can be suspected based on clinical history and physical examination, in some cases clinical findings are nonspecific. High-frequency color Doppler US is a noninvasive technique that can play a relevant role in these cases and give important anatomical information for final clinical management. US can be helpful to avoid unnecessary surgery, plan a surgical excision and avoid advanced imaging studies such as MRI and CT, which have a lower resolution for the skin. Different lesions can look similar on US, and clinical correlation is always important. The purpose of this article is to show a variety of skin lesions that occur in children, emphasizing clinical-sonographic correlation, and to familiarize pediatric radiologists with the US technique and sonographic appearance of common skin lesions in children.

Sun Sign in the Ultrasound Diagnosis and Activity Assessment of Morphea

Morphea, a localized form of scleroderma, is a chronic inflammatory autoimmune disease of the skin. Color Doppler Ultrasound has been reported as a reliable tool to assess the activity of the disease. With histologically confirmed cases, this case series describes a new ultrasound sign consisting of a hyperechoic halo surrounding superficial subcutaneous veins of the extremities in transverse view, named the sun sign. This sign can help diagnose morphea in the inflammatory phase and correlate in pathology with perivascular infiltrates surrounding superficial subcutaneous veins.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Practical applications of ultrasound in dermatology

Ultrasound has evolved in dermatology from an experimental phase to a daily practice imaging technique. Its several advantages include its safety, good balance between penetration and resolution, high definition, and the detection of blood flow in real time. Its applications are growing and include the support of the diagnosis and extent in all axes, including depth, vascularity patterns, staging, and follow up of multiple cutaneous diseases-benign cutaneous tumors, vascular anomalies, nail lesions, skin cancer, inflammatory cutaneous diseases, and aesthetics complications.

Usefulness of high-frequency ultrasonography in the evaluation and monitoring of sclerosing dermatoses: a cohort study

BACKGROUND

Monitoring of disease activity in sclerosing dermatoses (SD) can be challenging and tools to support clinical decision-making are lacking.

AIM

To analyse the impact of high-frequency ultrasonography (HFUS) on the clinical management of SD and to describe the US characteristics of disease activity.

METHODS

This was a cohort study of patients with various SD [morphoea, systemic sclerosis (SS) and chronic graft-versus-host disease (cGvHD)] who underwent HFUS between January 2017 and August 2019. HFUS criteria for diagnosing active SD were increased Doppler vascularity and/or meeting all B-mode greyscale US signs of activity. Discordance in SD activity between HFUS and clinical examination was evaluated at the time of the first US assessment. Changes in patient management were instituted after HFUS were recorded.

RESULTS

In total, 72 patients (31 with morphoea, 19 with SS and 22 with cGvHD), who underwent 163 HFUS sessions in total, were included. All HFUS-active morphoea lesions exhibited increased vascularity, and all HFUS-active SS exhibited dermal thickening and dermal hypoechogenicity. HFUS-active cGvHD displayed increased dermal thickness and loss of definition of the dermal-hypodermal junction, and there were signs of panniculitis in 80% of cases and of increased vascularity in 70%. Discordance in disease activity between clinical and HFUS evaluation was found in 17 (23.6%) patients. Changes in clinical management after HFUS were made for 14 (19.4%) patients: treatment discontinuation for 6 patients (42.9%), treatment initiation for 5 (35.7%), medication change for 2 (14.3%) and skin biopsy taken for 1 (7.1%).

CONCLUSION

HFUS seems an efficacious support tool in the monitoring of SD activity with a notable impact on clinical management. Further studies are warranted to evaluate the impact of HFUS-supported management changes on SD outcomes.