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Kreuter A, Moinzadeh P, Kinberger M, Horneff G, Worm M, Werner RN, Hammacher A, Krieg T, Wenzel J, Oeschger M, Weibel L, Müllegger R, Hunzelmann N. S2k guideline: Diagnosis and therapy of localized scleroderma. J Dtsch Dermatol Ges 2024; 22:605-620. [PMID: 38426689 DOI: 10.1111/ddg.15328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 03/02/2024]
Abstract
The updated S2k guideline deals with the diagnosis and therapy of localized scleroderma (LoS). LoS represents a spectrum of sclerotic skin diseases in which, depending on the subtype and localisation, structures such as adipose tissue, muscles, joints, and bones may also be affected. Involvement of internal organs or progression to systemic sclerosis does not occur. LoS can be classified into four main forms: limited, generalized, linear, and mixed forms, with some additional subtypes. For cases of limited skin involvement, the guideline primarily recommends therapy with topical corticosteroids. UV therapy can also be recommended. In subtypes with severe skin or musculoskeletal involvement, systemic therapy with methotrexate is recommended. During the active phase of the disease, systemic glucocorticosteroids can be used additionally. In cases of methotrexate and steroid refractory courses, contraindications, or intolerance, mycophenolate mofetil, mycophenolic acid, or abatacept can be considered as second-line systemic therapies. In the case of linear LoS, autologous adipose-derived stem cell transplantation can also be performed for correcting soft tissue defects.
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Affiliation(s)
- Alexander Kreuter
- Department of Dermatology, Venereology and Allergology, Helios St. Elisabeth Hospital Oberhausen, Oberhausen, Germany
- Department of Dermatology, Venereology and Allergology, Helios St. Johannes Hospital Duisburg, Duisburg, Germany
| | - Pia Moinzadeh
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Maria Kinberger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Division of Evidence-Based Medicine (dEBM), Berlin, Germany
| | - Gerd Horneff
- Department of General Pediatrics, Asklepios Hospital, St. Augustin, Germany
| | - Margitta Worm
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Berlin, Germany
| | - Ricardo N Werner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Division of Evidence-Based Medicine (dEBM), Berlin, Germany
| | | | - Thomas Krieg
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Jörg Wenzel
- Department of Dermatology and Allergology, University Bonn, Bonn, Germany
| | | | - Lisa Weibel
- University Children's Hospital Zurich, Zurich, Switzerland
| | - Robert Müllegger
- Department of Dermatology and Venereology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Nicolas Hunzelmann
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
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Kreuter A, Moinzadeh P, Kinberger M, Horneff G, Worm M, Werner RN, Hammacher A, Krieg T, Wenzel J, Oeschger M, Weibel L, Müllegger R, Hunzelmann N. S2k‐Leitlinie: Diagnostik und Therapie der zirkumskripten Sklerodermie. J Dtsch Dermatol Ges 2024; 22:605-621. [PMID: 38574014 DOI: 10.1111/ddg.15328_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 04/06/2024]
Abstract
ZusammenfassungDie vorliegende aktualisierte S2k‐Leitlinie befasst sich mit der Diagnostik und der Therapie der zirkumskripten Sklerodermie (ZS). Diese umfasst ein Spektrum sklerotischer Erkrankungen der Haut mit, je nach Subtyp und Lokalisation, möglicher Beteiligung von hautnahen Strukturen wie Fettgewebe, Muskulatur, Gelenke und Knochen. Ein Befall innerer Organe oder ein Übergang in eine systemische Sklerodermie treten nicht auf. Eingeteilt werden kann die ZS in die vier Hauptformen der limitierten, generalisierten, linearen und gemischten Form. Teilweise existieren weitere Unterformen. Bei limitiertem Hautbefall empfiehlt die Leitlinie primär eine Therapie mit topischen Kortikosteroiden. Eine UV‐Therapie kann ebenfalls sinnvoll sein. Bei Subtypen mit schwerem Hautbefall oder muskuloskelettalem Befall wird eine systemische Therapie mit Methotrexat empfohlen. In der aktiven Phase der Erkrankung können ergänzend systemische Glukokortikosteroide eingesetzt werden. Bei MTX‐ und Steroid‐refraktären Verläufen, Kontraindikation oder Unverträglichkeit sollten Mycophenolat‐Mofetil, Mycophenolsäure oder Abatacept als Systemtherapie der zweiten Wahl eingesetzt werden. Bei einer linearen ZS kann zudem eine autologe Fettstammzelltransplantation zur Korrektur von Weichteildefekten erfolgen.
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Affiliation(s)
- Alexander Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Hospital Oberhausen, Oberhausen, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Johannes Hospital Duisburg, Duisburg, Deutschland
| | - Pia Moinzadeh
- Klinik und Poliklinik für Dermatologie und Venerologie, Uniklinik Köln, Köln, Deutschland
| | - Maria Kinberger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Berlin, Deutschland
| | - Gerd Horneff
- Allgemeine Kinder- und Jugendmedizin, Asklepios Klinik St. Augustin, St. Augustin, Deutschland
| | - Margitta Worm
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Dermatologie, Venerologie und Allergologie, Berlin, Deutschland
| | - Ricardo N Werner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Berlin, Deutschland
| | | | - Thomas Krieg
- Klinik und Poliklinik für Dermatologie und Venerologie, Uniklinik Köln, Köln, Deutschland
| | - Jörg Wenzel
- Klinik und Poliklinik für Dermatologie und Allergologie, Universität Bonn, Bonn, Deutschland
| | | | - Lisa Weibel
- Universitäts-Kinderspital Zürich, Zürich, Schweiz
| | - Robert Müllegger
- Abteilung für Dermatologie und Venerologie am Landesklinikum Wiener Neustadt, Wiener Neustadt, Österreich
| | - Nicolas Hunzelmann
- Klinik und Poliklinik für Dermatologie und Venerologie, Uniklinik Köln, Köln, Deutschland
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Al-Gburi S, Kreuter A, Moinzadeh P. [Localized scleroderma]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:197-207. [PMID: 38363312 DOI: 10.1007/s00105-024-05297-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/17/2024]
Abstract
Localized scleroderma (LS), also called circumscribed scleroderma or morphea, comprises a heterogeneous group of diseases that can be classified into four subtypes: limited, linear, generalized, and mixed LS. All manifestations are primarily due to chronic progressive fibrosis of the skin or structures close to the skin. Involvement of internal organs or the transition to systemic sclerosis is excluded by definition. A distinction is made between forms that primarily affect the skin (up to the dermis) or that severely involve subcutaneous fat tissue, muscle fascia or muscles. A detailed examination is required for clinical diagnosis. In order to improve comparability of findings, photo documentation and the use of clinical scores should be carried out. For superficial subtypes the use of topical glucocorticosteroids, calcineurin inhibitors or phototherapy is initially recommended, whereas for severe forms with deep involvement or overall therapy refractoriness, the diagnosis should first be expanded and systemic therapy initiated at an early stage. Especially, in cross joint or extremity-dominant forms of linear LS or in cases with head and neck involvement, such as en coup de sabre, Parry-Romberg syndrome and other subtypes with a prominent musculoskeletal affection, an MRI examination should be arranged. Depending on location, an ophthalmological, neurological, orthodontic, rheumatological or orthopedic consultation may be necessary. For systemic therapy, methotrexate alone or in combination with systemic glucocorticosteroids as pulse therapy is recommended as first-line treatment.
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Affiliation(s)
- Suzan Al-Gburi
- Klinik und Poliklinik für Dermatologie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Alexander Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Klinik Oberhausen, Oberhausen, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Johannes Klinik Duisburg, Duisburg, Deutschland
| | - Pia Moinzadeh
- Klinik und Poliklinik für Dermatologie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
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Strauss T, Günther C, Brück N. [Juvenile localized scleroderma]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:208-213. [PMID: 38240812 DOI: 10.1007/s00105-023-05293-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 02/24/2024]
Abstract
Juvenile scleroderma, often referred to as juvenile localized scleroderma or "morphea", is a rare inflammatory disease of the skin and skin-related structures, accompanied by local sclerosis and tissue fibrosis. Depending on the clinical manifestation, four different subtypes can be defined: limited, generalized, linear, and mixed. To prevent possible sequelae of the disease, the diagnosis should be made as early as possible and therapy should be initiated at specialized centers in multiprofessional pediatric and dermatologic collaboration. In this review, we present the main clinical, laboratory, and therapeutic characteristics of juvenile localized scleroderma and summarize recommendations.
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Affiliation(s)
- Timmy Strauss
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Claudia Günther
- Klinik und Poliklinik für Dermatologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - Normi Brück
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
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Parra-Cares J, Wortsman X, Alfaro-Sepúlveda D, Mellado-Francisco G, Ramírez-Cornejo C, Vera-Kellet C. Color Doppler Ultrasound Assessment of Subclinical Activity With Scoring of Morphea. J Cutan Med Surg 2023; 27:454-460. [PMID: 37533149 DOI: 10.1177/12034754231191474] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
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.
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Affiliation(s)
- Julio Parra-Cares
- Department of Dermatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ximena Wortsman
- Department of Dermatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Imaging, Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, Santiago, Chile
| | | | - Gonzalo Mellado-Francisco
- Department of Dermatology, Pontificia Universidad Católica de Chile, Connective Tissue Diseases Unit, Santiago, Chile
| | - Cristian Ramírez-Cornejo
- Department of Dermatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristián Vera-Kellet
- Department of Dermatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Dermatology, Pontificia Universidad Católica de Chile, Connective Tissue Diseases Unit, Santiago, Chile
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Khorasanizadeh F, Kalantari Y, Etesami I. Role of imaging in morphea assessment: A review of the literature. Skin Res Technol 2023; 29:e13410. [PMID: 37522502 PMCID: PMC10318382 DOI: 10.1111/srt.13410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 06/24/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Localized scleroderma, known as morphea, is a connective tissue disorder characterized by inflammation and fibrosis of the skin and the soft tissue. There exist no universally accepted validated outcome measures in order to monitor the disease activity. Besides clinical scores to evaluate outcome measures, imaging modalities are increasingly utilized in assessing patients with morphea, such as high-frequency ultrasonography (US), shear-wave elastography (SWE), and magnetic resonance imaging (MRI). However, the accuracy of these imaging modalities in monitoring morphea activity is not yet clear. AIMS To review the literature regarding the role of imaging modalities in assessing patients with morphea. MATERIALS & METHODS In this study, we searched the PubMed/Medline database for articles published from inception until February 2023. RESULTS A total number of 23 original articles in three categories of US, elastography, and MRI were included. DISCUSSION Regarding US, criteria, including increased dermal thickness, increased echogenicity of the subcutaneous tissue, and decreased dermal echogenicity, were indicators of active morphea lesions when using high frequencies probe (18-20 MHz) color Doppler sonography. Moreover, studies evaluating SWE, a novel method to quantitatively assess tissue stiffness, demonstrated increased dermal stiffness in active lesions. CONCLUSION Studies showed that MRI can help to determine the depth of disease, particularly as a first-line and follow-up diagnostic tool, especially in generalized and deep morphea. In addition, brain MRI may be useful for patients with localized craniofacial scleroderma experiencing new or worsening neurological symptoms.
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Affiliation(s)
| | - Yasamin Kalantari
- Department of DermatologyRazi HospitalTehran University of Medical SciencesTehranIran
| | - Ifa Etesami
- Department of DermatologyRazi HospitalTehran University of Medical SciencesTehranIran
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Shajil C, Sathishkumar D, Babu JS, Babu R, Kumar S. Spontaneous crateriform indentation in a child. Pediatr Dermatol 2023; 40:715-717. [PMID: 37440194 DOI: 10.1111/pde.15241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 12/19/2022] [Indexed: 07/14/2023]
Affiliation(s)
- Chandana Shajil
- Departments of Dermatology, Christian Medical College and Hospital, Vellore, India
| | | | - Jyoti Sureka Babu
- Departments of Radiology, Christian Medical College and Hospital, Vellore, India
| | - Ramesh Babu
- Departments of Pathology, Christian Medical College and Hospital, Vellore, India
| | - Sathish Kumar
- Pediatric Rheumatology Unit, Department of Pediatrics, Christian Medical College and Hospital, Vellore, India
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Abbas LF, Joseph AK, Day J, Cole NA, Hallac R, Derderian C, Jacobe HT. Measuring asymmetry in facial morphea via 3-dimensional stereophotogrammetry. J Am Acad Dermatol 2023; 88:101-108. [PMID: 35643243 DOI: 10.1016/j.jaad.2022.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 05/05/2022] [Accepted: 05/08/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Objectively determining tissue loss in craniofacial morphea is challenging. However, 3-dimensional (3D) stereophotogrammetry is a noninvasive modality that may be a useful adjunct. OBJECTIVE To prospectively evaluate 3D stereophotogrammetry in the assessment of craniofacial linear morphea. METHODS Participants underwent clinical, quality-of-life, and 3D-stereophotogrammetry assessments. Traditional photographs and 3D-stereophotogrammetry images were rated as mild, moderate, or severe by 2 experts and 2 nonexperts. In addition, interrater and intrarater reliability (on delayed rescoring) were calculated. RESULTS Of 23 patients with craniofacial morphea, 3D stereophotogrammetry detected pathologic asymmetry in 14 (20.6%) patients. Providers rated patients as more severely affected when using 3D stereophotogrammetry versus when using traditional photographs (19% severe on 3D stereophotogrammetry vs 0% severe on traditional photographs, P = .004). Qualitative ratings of both traditional and 3D images showed high inter- and intrarater reliability between experts and nonexperts alike. Physicians' Global Assessment of Damage scores correlated with mouth asymmetry (P = .0021), cheek asymmetry (P = .04), and 3D-stereophotogrammetry ratings (median, mild: 27.5 vs moderate: 46.5 vs severe: 64, P = .0152). Lower face asymmetry correlated with worse quality-of-life scores (P = .013). LIMITATIONS Small sample size and cross-sectional design. CONCLUSION 3D stereophotogrammetry can reliably detect and quantify asymmetry in craniofacial morphea with greater sensitivity than that observed with traditional assessment alone. 3D stereophotogrammetry may be a useful adjunct to clinical examination.
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Affiliation(s)
- Laila F Abbas
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adrienne K Joseph
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jennifer Day
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Naomi A Cole
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rami Hallac
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Derderian
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heidi T Jacobe
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Fan W, Obiakor B, Jacobson R, Haemel A, Gandelman J. Clinical and therapeutic course in head variants of linear morphea in adults: a retrospective review. Arch Dermatol Res 2022; 315:1161-1170. [DOI: 10.1007/s00403-022-02478-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 10/31/2022] [Accepted: 11/16/2022] [Indexed: 12/05/2022]
Abstract
AbstractParry Romberg Syndrome (PRS) and en coup de sabre (ECDS) are head variants of linear morphea with functional and structural implications. This study describes the clinical course, autoimmune co-morbidities, complications, and treatment of adults with PRS/ECDS at a tertiary referral center. We retrospectively reviewed the records of all 34 adult patients with PRS/ECDS identified through billing code search and seen by dermatologists at our institution between 2015 and 2021. Eight patients (23.5%) had ECDS, 8 (23.5%) had PRS, and 18 (52.9%) had overlap. Twenty-six patients (76.5%) reported ocular, oral, and/or neurologic symptoms, and 8 (23.5%) had concomitant autoimmune/inflammatory conditions. Sixteen patients (47.1%) had a skin biopsy, and 25 (73.5%) had imaging. Forty-six MRIs were obtained, of which 6 (13.0%) reported intracranial findings and 25 (54.3%) reported disease-related connective tissue damage. Twenty-four patients (70.6%) underwent systemic treatment during their disease course per available clinical records. Seventeen patients (70.8%) had improved or stable disease upon treatment completion, with an average duration of 22.2 months. Ten patients (41.7%) reported recurrence of disease following the treatment course. To address changes to facial contour, 6 patients (17.6%) opted for procedural treatments. One patient (16.7%) experienced morphea reactivation following a filler injection performed off-immunosuppression. Compared to findings in children, our study suggests adults with PRS/ECDS are more likely to have oral and ocular complications but experience less severe neurologic symptoms. While systemic treatments appear beneficial in most adult patients with PRS/ECDS, disease may recur following discontinuation.
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Dańczak-Pazdrowska A, Cieplewicz P, Żaba R, Adamski Z, Polańska A. Controversy around the morphea. Postepy Dermatol Alergol 2021; 38:716-720. [PMID: 34849114 PMCID: PMC8610066 DOI: 10.5114/ada.2021.106242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/23/2021] [Indexed: 11/24/2022] Open
Abstract
Morphea, also known as localized scleroderma, is a chronic, autoimmune disease of connective tissue. It is characterized by a typical clinical feature. In morphea, there is no Raynaud's phenomenon, no sclerodactyly or no ulcerations on the fingertips. Although morphea and systemic sclerosis have been perceived as separate disease entities for years, they are still confused both by patients (which is a source of unnecessary stress) and doctors. This may be due to, in part, misunderstood terminology. The controversy around morphea also concerns the division of this disease entity, including its less common subtypes, such as eosinophilic fasciitis. Discussions also revolve around the diagnostic aspects and possible treatment options. The paper attempts to present the debatable aspects regarding nomenclature, classification, diagnosis and treatment of morphea.
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Affiliation(s)
| | - Paulina Cieplewicz
- Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Ryszard Żaba
- Department of Dermatology and Venereology, Poznan University of Medical Sciences, Poznan, Poland
| | - Zygmunt Adamski
- Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Adriana Polańska
- Department of Dermatology and Venereology, Poznan University of Medical Sciences, Poznan, Poland
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Sink JR, Chiu YE. Pediatric morphea state-of-the-art literature review: Reframing morphea as a systemic disease. Pediatr Dermatol 2021; 38:1020-1031. [PMID: 34272748 DOI: 10.1111/pde.14688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric morphea is an inflammatory, fibrosing dermatologic disorder. Although morphea may be localized to the skin and subcutaneous tissues, differentiating it from systemic sclerosis, there is increasing evidence that morphea is a manifestation of a systemic inflammatory process, with the potential to involve many organ systems. Given the potential risk for irreversible sequelae, pediatric morphea should be treated early and aggressively. Long-term disease monitoring is essential.
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Affiliation(s)
- Jacquelyn R Sink
- Department of Dermatology, Northwestern Medicine Regional Medical Group, Winfield, IL, USA
| | - Yvonne E Chiu
- Departments of Dermatology (Section of Pediatric Dermatology) and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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Kolb M, Peisen F, Ekert K, Xenitidis T, Fritz J, Ioanoviciu SD, Henes J, Horger M. Shear Wave Elastography for Assessment of Muscular Abnormalities Related to Systemic Sclerosis. Acad Radiol 2021; 28:1118-1124. [PMID: 32527706 DOI: 10.1016/j.acra.2020.04.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 12/16/2022]
Abstract
RATIONALE AND OBJECTIVES To assess muscular abnormalities related to systemic sclerosis (SSc) using shear wave elastography and correlate results with those of clinical tests. MATERIALS AND METHODS We evaluated 55 patients (mean age: 50.4 years; range: 18-88; 34 female) with SSc before treatment and choose muscle groups based on cutaneous involvement and functional impairment [forearms (9); thighs (41); thenar/hypothenar (5)]. We performed shear wave elastography in two orientations to access heterogeneity using virtual touch IQ and mean shear wave velocity values (SWV) and measured skin and fascia thickness. We compared SWVs to the modified Rodnan skin score (mRSS). Twenty-two healthy controls (mean age: 52.0; range: 19-88; 7 female) underwent the same protocol. RESULTS SWV pattern analysis (homogeneous vs heterogeneous) detected SSc with sensitivity/specificity/negative predictive value/positive predictive value0.79/0.81/0.91/0.62 in transverse and 0.75/0.18/0.91/0.56 in longitudinal orientation. In patients we found poor correlation between SWVs and mRSS but a cutoff of mRSSE = 20 separated them significantly (p < 0.01). Skin and muscle fascia were significantly thicker in patients vs. controls (p < 0.001). CONCLUSION SSc involves more than increased skin and fascial thickness which is not fully represented by mRSS. Elasticity differs in muscles with and without SSc. The former shows higher SWV and increased heterogeneity in transversal planes of muscular fibers.
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Affiliation(s)
- Manuel Kolb
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany.
| | - Felix Peisen
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany
| | - Kaspar Ekert
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany
| | - Theodoros Xenitidis
- Department of Internal Medicine II, Eberhard-Karls-University, Tuebingen, Germany
| | - Jan Fritz
- Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiological Science, Baltimore, MD
| | | | - Jörg Henes
- Department of Internal Medicine II, Eberhard-Karls-University, Tuebingen, Germany
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany
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13
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Abbas L, Joseph A, Kunzler E, Jacobe HT. Morphea: progress to date and the road ahead. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:437. [PMID: 33842658 PMCID: PMC8033330 DOI: 10.21037/atm-20-6222] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Morphea is a rare autoimmune condition causing inflammation and sclerosis of the skin and underlying soft tissue. It is characterized by periods of activity (inflammation admixed with fibrosis), ultimately resulting in permanent damage (pigment change and tissue loss). Damage resulting from unchecked activity can lead to devastating, permanent cosmetic and functional sequelae including hair loss; cutaneous, soft tissue and bony atrophy; joint contractures; and growth restriction of the affected body site in children. This makes the early identification of activity and initiation of appropriate treatment crucial to limiting damage in morphea. To this end, recent investigative work has focused on validation of clinical, biomarker, imaging, and histologic outcomes aimed at accurately quantifying activity and damage. Despite promising results, further work is needed to better validate these measures before they can be used in the clinic and research settings. Although there has been recent approval of less toxic, targeted therapies for many inflammatory skin conditions, none have been systematically investigated in morphea. The mainstays of treatment for active morphea are corticosteroids and methotrexate. These are often limited by substantial toxicity. The paucity of new treatments for morphea is the result of a lack of studies examining its pathogenesis, with many reviews extrapolating from research in systemic sclerosis. Recent studies have demonstrated the role of dysregulated immune and fibrotic pathways in the pathogenesis of morphea, particularly interferon (IFN) gamma related pathways. Active morphea lesions have been found to display an inflammatory morphea signature with CXCR3 receptor ligands, as well as a distinct fibrotic signature reflecting fibroblast activation and collagen production. CXCL9 and 10 have been associated with increased measures of disease activity. While immune dysfunction is thought to play the primary role in morphea pathogenesis, there are other factors that may also contribute, including genetic predisposition, environmental factors, and vascular dysregulation. There remains an essential need for further research to elucidate the pathogenesis of morphea and the mode of action of dysregulated upstream and downstream immune and fibrotic pathways. These studies will allow for the discovery of novel biomarkers and targets for therapeutic development.
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Affiliation(s)
- Laila Abbas
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Adrienne Joseph
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elaine Kunzler
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Heidi T Jacobe
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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14
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Quintana-Castanedo L, Sánchez-Orta A, Nuno-Gonzalez A, Herranz-Pinto P. Usefulness of cutaneous ultrasound in the management of Parry Romberg syndrome. Skin Res Technol 2021; 27:644-645. [PMID: 33638229 DOI: 10.1111/srt.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/04/2021] [Accepted: 01/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Alba Sánchez-Orta
- Department of Dermatology, La Paz University Hospital, Madrid, Spain
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15
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Abbas LF, O'Brien JC, Goldman S, Pezeshk P, Chalian M, Chhabra A, Jacobe HT. A Cross-sectional Comparison of Magnetic Resonance Imaging Findings and Clinical Assessment in Patients With Morphea. JAMA Dermatol 2020; 156:590-592. [PMID: 32236514 PMCID: PMC7113827 DOI: 10.1001/jamadermatol.2020.0036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Laila F Abbas
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas
| | - Jack C O'Brien
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas
| | - Shauna Goldman
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas
| | - Parham Pezeshk
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas
| | - Majid Chalian
- Department of Musculoskeletal Radiology, University of Washington, Seattle
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas
| | - Heidi T Jacobe
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas
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16
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Pérez M, Zuccaro J, Mohanta A, Tijerin M, Laxer R, Pope E, Doria AS. Feasibility of Using Elastography Ultrasound in Pediatric Localized Scleroderma (Morphea). ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:3218-3227. [PMID: 32951932 DOI: 10.1016/j.ultrasmedbio.2020.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 06/11/2023]
Abstract
Assessment and monitoring of inflammation and tissue damage is crucial in localized scleroderma (LS), but validated diagnostic tools are lacking. We aimed to determine the feasibility of using acoustic radiation force imaging ultrasound elastography in the assessment of pediatric-onset LS lesions. Conventional ultrasound and shear-wave elastography (SWE) imaging were used to characterize changes in pre-assigned LS lesions in 13 prospectively recruited participants. Contralateral sites were used as controls. Mean SWE values were compared. LS lesions were significantly stiffer than control sites in the dermis and the hypodermis using both parametric and non-parametric tests, before and after skin-thickness normalization. We show that SWE imaging is a feasible way to discriminate between normal skin and LS lesions in the pediatric population.
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Affiliation(s)
- Manuela Pérez
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
| | - Jennifer Zuccaro
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arun Mohanta
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Marta Tijerin
- Radiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ronald Laxer
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Section of Dermatology, Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elena Pope
- Section of Dermatology, Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Andrea S Doria
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada; Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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17
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Jones KM, Tan JK, Alomari AI, Son MB, Vleugels RA, Mulliken JB, Liang MG. Early Features of Progressive Hemifacial Atrophy-Clinical and Imaging Findings. JAMA Dermatol 2020; 156:1376-1379. [PMID: 32697295 DOI: 10.1001/jamadermatol.2020.2593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Krystal M Jones
- Dermatology Program, Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer K Tan
- Dermatology Program, Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Ahmad I Alomari
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mary Beth Son
- Rheumatology Program, Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ruth Ann Vleugels
- Dermatology Program, Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Dermatology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - John B Mulliken
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marilyn G Liang
- Dermatology Program, Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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18
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Morris MS, Matcuk G, DeClerk BK, Arkfeld D, Stevanovic M. Linear Morphea With Inflammatory Myositis. J Hand Surg Am 2020; 45:782.e1-782.e5. [PMID: 31801651 DOI: 10.1016/j.jhsa.2019.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 10/07/2019] [Indexed: 02/02/2023]
Abstract
Morphea is an autoimmune disorder characterized by sclerosis and inflammation of the skin and soft tissues. Early diagnosis and treatment are essential to minimize morbidity such as joint contracture. In this report, we present the case of a 19-year-old man with linear morphea with inflammatory myositis who presented to our clinic 1 year after symptom onset with severe elbow flexion contracture. Through reviewing this rare disorder, it is hoped that early diagnosis will lead to better outcomes in the future.
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Affiliation(s)
| | | | | | - Daniel Arkfeld
- Department of Rheumatology, Keck School of Medicine, University of Southern California, Los Angeles, CA
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19
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Cruz-Diaz CN, Haemel AK. At the Leading Edge in Morphea—New Insights Into Disease Course and Management Options. JAMA Dermatol 2020; 156:495-496. [DOI: 10.1001/jamadermatol.2020.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Anna K. Haemel
- Department of Dermatology, University of California, San Francisco
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20
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Navallas M, Inarejos Clemente EJ, Iglesias E, Rebollo-Polo M, Antón J, Navarro OM. Connective Tissue Disorders in Childhood: Are They All the Same? Radiographics 2020; 39:229-250. [PMID: 30620697 DOI: 10.1148/rg.2019180078] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Systemic connective tissue disorders are characterized by the presence of autoantibodies and multiorgan system involvement. Juvenile systemic lupus erythematosus with or without associated antiphospholipid syndrome; juvenile dermatomyositis; sclerodermiform syndromes, including systemic and localized sclerodermas and eosinophilic fasciitis; mixed connective tissue disease; and Sjögren syndrome are the disorders that affect children most frequently. Diagnosis is difficult, because the clinical presentation of patients is diverse, from mild to severe disease. In addition, all organs may be affected. However, a variety of imaging techniques are now available to investigate rheumatic disease in children. These imaging modalities offer the potential for earlier diagnosis and improved assessment of therapeutic response. This article reviews the main connective tissue disorders that affect children, highlighting their key imaging features on images acquired with different diagnostic imaging modalities and correlating these features with clinical and pathologic findings, when available. ©RSNA, 2019.
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Affiliation(s)
- María Navallas
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Emilio J Inarejos Clemente
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Estíbaliz Iglesias
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Mónica Rebollo-Polo
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Jordi Antón
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Oscar M Navarro
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
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21
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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: 4] [Impact Index Per Article: 1.0] [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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22
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Flores Quispe SKJ, Cavaliere A, Weber M, Stramare R, Zuliani M, Quaia E, Zulian F, Giraudo C. Sarcopenia in juvenile localized scleroderma: new insights on deep involvement. Eur Radiol 2020; 30:4091-4097. [PMID: 32144460 DOI: 10.1007/s00330-020-06764-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Juvenile localized scleroderma (JLS) is a rare chronic autoimmune disease which can also affect bones and muscles. Nevertheless, muscle loss was not previously investigated in patients with JLS. Thus, the aim of this study was to retrospectively evaluate deep involvement and assess and quantify sarcopenia in JLS patients using magnetic resonance imaging (MRI). METHODS Fourteen children with JLS (nine females, mean age ± SD, 7.1 ± 3.6 years) referring to our tertiary center from January 2012 to January 2018 who underwent at least one MRI examination including axial T1-weighted and short tau inversion recovery images were included. Two readers assessed in consensus superficial and deep involvement. Muscle edema, muscle fatty infiltration, and sarcopenia were independently scored (absent, moderate, or severe) and the Cohen's kappa coefficient computed. Skin perimeter, subcutaneous area, muscle area, and muscle volume were independently measured using the contralateral unaffected extremity as reference (paired Student's t test, p < 0.05). The intraclass correlation coefficient (ICC) was used to investigate the reliability of the measurements. RESULTS All patients showed superficial involvement with subcutaneous fat atrophy being the most common finding (13 patients). Bone marrow edema occurred in five patients. Muscle edema affected ten children (moderate in seven, severe in three; k = 0.89), muscle fatty replacement occurred in one case (severe; k = 1.00), and sarcopenia was detected in eight patients (severe in two; k = 0.78). All quantitative parameters were lower on the affected side than on the unaffected contralateral limb (p < 0.05, each) and all measurements showed a high reliability (ICC > 0.750, each). CONCLUSION Patients with JLS can be affected by sarcopenia and quantitative analyses allow a robust characterization of such finding. KEY POINTS • Deep involvement in juvenile localized scleroderma is frequently characterized by sarcopenia. • In juvenile localized scleroderma, muscle edema and sarcopenia are mostly moderate while fatty infiltration, even if rare, can be severe. • Sarcopenia can be reliably quantified in children with juvenile localized scleroderma using MRI.
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Affiliation(s)
| | - Annachiara Cavaliere
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Roberto Stramare
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Monica Zuliani
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Emilio Quaia
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | | | - Chiara Giraudo
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy.
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23
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Sethu C, Wong KY, Slade-Sharman D. Morphea masquerading as cellulitis. BMJ Case Rep 2019; 12:12/8/e230816. [PMID: 31420439 DOI: 10.1136/bcr-2019-230816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A case of morphea postbreast reconstruction is presented. It is a rare condition that can be easily mistaken for other inflammatory conditions or infection.
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Affiliation(s)
- Claire Sethu
- Plastic & Reconstructive Surgery, John Radcliffe Hospital, Oxford, UK
| | - Kai Yuen Wong
- Plastic & Reconstructive Surgery, Health Sciences Centre, Winnipeg, Canada
| | - Diana Slade-Sharman
- Plastic & Reconstructive Surgery, Salisbury District Hospital, Salisbury, UK
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24
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Hsieh M, Tokoro S, Ugajin T, Namiki T, Miura K, Yokozeki H. Ultrasonography as an auxiliary diagnostic tool for morphea profunda: A case report. J Dermatol 2019; 46:626-630. [PMID: 31149739 DOI: 10.1111/1346-8138.14922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 04/16/2019] [Indexed: 12/24/2022]
Abstract
Morphea profunda is a rare subtype of localized scleroderma and it is difficult to evaluate the conditions of sclerotic changes at an early stage. Studies using ultrasonography to evaluate localized scleroderma are limited and, to date, the characteristic findings of morphea profunda assessed by ultrasonography have never been reported. Here, we present a case of morphea profunda diagnosed with the assistance of ultrasonography. A 69-year-old Japanese woman with a past history of morphea en plaque on her lower abdomen presented with skin indurations of her bilateral lower back and thighs. To evaluate the stiffness of the subcutis, fascia and muscle, we utilized ultrasonography and found an unexpected hyperechogenicity not only of the dermis but also in the deeper tissue. The diagnosis was revised to morphea profunda after we performed a deep skin biopsy, including the muscle tissue. From this case, we assert that ultrasonography is a useful alternative tool to assist in the differential diagnosis of morphea profunda.
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Affiliation(s)
- Minghsiu Hsieh
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shown Tokoro
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsukasa Ugajin
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeshi Namiki
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiko Miura
- Department of Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroo Yokozeki
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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25
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Li SC, Li X, Pope E, Stewart K, Higgins GC, Rabinovich CE, O’Neil KM, Haines KA, Laxer RM, Punaro M, Jacobe H, Andrews T, Wittkowski K, Nyirenda T, Foeldvari I, Torok KS. New Features for Measuring Disease Activity in Pediatric Localized Scleroderma. J Rheumatol 2018; 45:1680-1688. [DOI: 10.3899/jrheum.171381] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2018] [Indexed: 11/22/2022]
Abstract
Objective.To identify clinical features that define disease activity in pediatric localized scleroderma (LS), and determine their specificity and importance.Methods.We conducted a multicenter prospective study of patients with active and inactive LS skin lesions. A standardized evaluation of a single designated study lesion per subject was performed at 3 visits. We evaluated the pattern and correlation between assessed features and physician’s global assessments of activity (PGA-A).Results.Ninety of 103 subjects had evaluable data; 66 had active and 24 inactive disease. Subjects had similar age of onset, sex, and disease patterns. Linear scleroderma was the most common subtype. Features specific for active disease included erythema, violaceous color, tactile warmth, abnormal skin texture, and disease extension. Scores for these variables changed over time and correlated with PGA-A of the lesion. Active and inactive lesions could not be distinguished by the presence or level of skin thickening, either of lesion edge or center. However, in active lesions, skin thickening scores did correlate with PGA–A scores. Regression analysis identified the combination of erythema, disease extension, violaceous color, skin thickening, and abnormal texture as predictive of PGA-A at study entry. Damage features were common irrespective of activity status.Conclusion.We identified variables strongly associated with disease activity, expanding upon those used in current measures, and determined their relative importance in physician activity scoring. Skin thickening was found to lack specificity for disease activity. These results will help guide development of a sensitive, responsive activity tool to improve care of patients with LS.
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26
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Martini G, Fadanelli G, Agazzi A, Vittadello F, Meneghel A, Zulian F. Disease course and long-term outcome of juvenile localized scleroderma: Experience from a single pediatric rheumatology Centre and literature review. Autoimmun Rev 2018; 17:727-734. [DOI: 10.1016/j.autrev.2018.02.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/11/2018] [Indexed: 12/20/2022]
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27
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Agazzi A, Fadanelli G, Vittadello F, Zulian F, Martini G. Reliability of LoSCAT score for activity and tissue damage assessment in a large cohort of patients with Juvenile Localized Scleroderma. Pediatr Rheumatol Online J 2018; 16:37. [PMID: 29914516 PMCID: PMC6006585 DOI: 10.1186/s12969-018-0254-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/08/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To assess reliability of the two indexes of Localized Scleroderma Cutaneous Assessment Tool (LoSCAT), the modified Localized Scleroderma Skin Severity Index (mLoSSI) and the Localized Scleroderma Skin Damage Index (LoSDI), when applied by clinicians with different experience in scoring and managing patients with JLS. Secondary aim was to compare LoSCAT and infrared thermography (IRT) in monitoring lesions over time. METHODS Consecutive children with Juvenile Localized Scleroderma (JLS) were blindly evaluated by three examiners with different experience in Paediatric Rheumatology and with no experience in LoSCAT use. At each visit, patients were assessed by LoSCAT and IRT. Sensitivity to change of LoSCAT and IRT was assessed in a group of patients 3-6 months later. Inter-rater reliability was assessed by Intraclass Correlation Coefficient (ICC) and variance analysis (ANOVA). FINDINGS Forty-seven patients (129 lesions) entered the study, and 26 (79 lesions) were re-evaluated with same modality after 4.5 (SD 1.5) months. mLoSSI showed excellent inter-rater reliability expressed by ICC 0.965 confirmed by ANOVA. Similarly, inter-rater reliability for LoSDI was good (ICC = 0.774) but worse concordance among examiners was observed. A comparable improvement of mLoSSI in all anatomic sites was noted by all examiners in 79 lesions examined in two subsequent visits and was consistent with thermography. CONCLUSIONS Different clinical experience in JLS did not influence clinical judgement in mLoSSI which showed excellent concordance, whereas LoSDI is less precise in damage assessment and not completely reliable in monitoring skin changes. Infrared thermography confirms to be a helpful tool for detecting disease activity and reliable in monitoring lesions over time.
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Affiliation(s)
- Anna Agazzi
- 0000 0004 1757 3470grid.5608.bPaediatric Rheumatology Unit, Department of Woman and Child Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Gloria Fadanelli
- 0000 0004 1763 6494grid.415176.0Paediatric Unit, Santa Chiara Hospital, Trento, Italy
| | - Fabio Vittadello
- 0000 0004 1757 3470grid.5608.bPaediatric Rheumatology Unit, Department of Woman and Child Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Francesco Zulian
- 0000 0004 1757 3470grid.5608.bPaediatric Rheumatology Unit, Department of Woman and Child Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Giorgia Martini
- Paediatric Rheumatology Unit, Department of Woman and Child Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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Morfea en la infancia: actualización. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:312-322. [DOI: 10.1016/j.ad.2017.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 06/12/2017] [Accepted: 06/25/2017] [Indexed: 10/18/2022] Open
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Clinical Usefulness of Magnetic Resonance Imaging in Four Children With Scleroderma. Arch Rheumatol 2017; 33:230-235. [PMID: 30207558 DOI: 10.5606/archrheumatol.2018.6498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/31/2017] [Indexed: 11/21/2022] Open
Abstract
Children with localized scleroderma may have more serious sequelae than adults with the disease. In this case report, we analyzed four girls with localized scleroderma (generalized morphea) to evaluate the clinical usefulness of magnetic resonance imaging in facilitating disease control and investigating patient responsiveness to various treatments. Two of the children had flexion contracture, and two displayed a clear high-intensity area in the bone marrow under the sclerotic skin on magnetic resonance imaging. Two girls had different bilateral circumferences of the legs or forearms. These abnormalities were detected without any obvious changes in blood chemistry. Our results demonstrated that magnetic resonance imaging is useful for the evaluation of treatment effects for localized scleroderma in children.
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Mendes AL, Miot HA, Haddad V. Diabetes mellitus and the skin. An Bras Dermatol 2017; 92:8-20. [PMID: 28225950 PMCID: PMC5312172 DOI: 10.1590/abd1806-4841.20175514] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 06/29/2016] [Indexed: 11/22/2022] Open
Abstract
Several dermatoses are routinely associated with diabetes mellitus, especially in patients with chronic disease. This relationship can be easily proven in some skin disorders, but it is not so clear in others. Dermatoses such necrobiosis lipoidica, granuloma annulare, acanthosis nigricans and others are discussed in this text, with an emphasis on proven link with the diabetes or not, disease identification and treatment strategy used to control those dermatoses and diabetes.
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Affiliation(s)
- Adriana Lucia Mendes
- Department of Clinical Medicine - Faculdade de Medicina de Botucatu - Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP) - Botucatu (SP), Brazil
| | - Helio Amante Miot
- Department of Dermatology and Radiotherapy - Faculdade de Medicina de Botucatu - Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP) -Botucatu (SP), Brazil
| | - Vidal Haddad
- Department of Dermatology and Radiotherapy - Faculdade de Medicina de Botucatu - Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP) -Botucatu (SP), Brazil
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Zulian F. Scleroderma in children. Best Pract Res Clin Rheumatol 2017; 31:576-595. [DOI: 10.1016/j.berh.2018.02.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 11/27/2017] [Accepted: 12/06/2017] [Indexed: 12/15/2022]
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Early- and late-stage morphea subtypes with deep tissue involvement is treatable with Abatacept (Orencia). Semin Arthritis Rheum 2017; 46:775-781. [DOI: 10.1016/j.semarthrit.2016.08.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 08/22/2016] [Accepted: 08/30/2016] [Indexed: 11/21/2022]
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Musculoskeletal MRI findings of juvenile localized scleroderma. Pediatr Radiol 2017; 47:442-449. [PMID: 28091699 DOI: 10.1007/s00247-016-3765-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 10/17/2016] [Accepted: 12/06/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Juvenile localized scleroderma comprises a group of autoimmune conditions often characterized clinically by an area of skin hardening. In addition to superficial changes in the skin and subcutaneous tissues, juvenile localized scleroderma may involve the deep soft tissues, bones and joints, possibly resulting in functional impairment and pain in addition to cosmetic changes. OBJECTIVE There is literature documenting the spectrum of findings for deep involvement of localized scleroderma (fascia, muscles, tendons, bones and joints) in adults, but there is limited literature for the condition in children. We aimed to document the spectrum of musculoskeletal magnetic resonance imaging (MRI) findings of both superficial and deep juvenile localized scleroderma involvement in children and to evaluate the utility of various MRI sequences for detecting those findings. MATERIALS AND METHODS Two radiologists retrospectively evaluated 20 MRI studies of the extremities in 14 children with juvenile localized scleroderma. Each imaging sequence was also given a subjective score of 0 (not useful), 1 (somewhat useful) or 2 (most useful for detecting the findings). RESULTS Deep tissue involvement was detected in 65% of the imaged extremities. Fascial thickening and enhancement were seen in 50% of imaged extremities. Axial T1, axial T1 fat-suppressed (FS) contrast-enhanced and axial fluid-sensitive sequences were rated most useful. CONCLUSION Fascial thickening and enhancement were the most commonly encountered deep tissue findings in extremity MRIs of children with juvenile localized scleroderma. Because abnormalities of the skin, subcutaneous tissues and fascia tend to run longitudinally in an affected limb, axial T1, axial fluid-sensitive and axial T1-FS contrast-enhanced sequences should be included in the imaging protocol.
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Walker D, Susa JS, Currimbhoy S, Jacobe H. Histopathological changes in morphea and their clinical correlates: Results from the Morphea in Adults and Children Cohort V. J Am Acad Dermatol 2017; 76:1124-1130. [PMID: 28285783 DOI: 10.1016/j.jaad.2016.12.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 12/07/2016] [Accepted: 12/11/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Histopathological features in morphea (localized scleroderma) and their clinical correlates are poorly described. OBJECTIVE We sought to systematically describe histologic changes of morphea in a large, well-annotated cohort and determine the association between histopathology and clinical features. METHODS This was a cross-sectional study of 83 patients enrolled in the Morphea in Adults and Children cohort. The main outcome measure was the association of microanatomical location and degree of sclerosis and inflammation seen on histologic samples with patient-reported symptoms and physician-based measures of severity. RESULTS Pattern of sclerosis was associated with morphea subtype, the presence of patient-reported symptoms, and functional limitation. A bottom-heavy pattern of sclerosis was associated with pain and tightness (P = .0039 and .001, respectively). These symptoms were not associated with a top-heavy pattern. Severe inflammation may be associated with pain and functional limitation (P = .073 for both). LIMITATIONS Small sample size limits ability to detect associations, particularly in subgroups. CONCLUSIONS Histopathological examination of morphea may assist in identifying patients who may require additional monitoring and treatment. Features such as patterns of sclerosis and severity of inflammation should be included in pathology reports to help aid in clinical management.
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Affiliation(s)
- Daniel Walker
- Department of Dermatology, University of Arkansas, Fayetteville, Arkansas
| | - Joseph S Susa
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sharif Currimbhoy
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heidi Jacobe
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Kreuter A, Krieg T, Worm M, Wenzel J, Moinzadeh P, Kuhn A, Aberer E, Scharffetter-Kochanek K, Horneff G, Reil E, Weberschock T, Hunzelmann N. German guidelines for the diagnosis and therapy of localized scleroderma. J Dtsch Dermatol Ges 2016; 14:199-216. [PMID: 26819124 DOI: 10.1111/ddg.12724] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Localized scleroderma designates a heterogeneous group of sclerotic skin disorders. Depending on the subtype, severity, and site affected, adjacent structures such as adipose tissue, muscles, joints, and bones may be involved. This is an update of the existing German AWMF (Association of the Scientific Medical Societies in Germany) guidelines (classification: S2k). These guidelines provide an overview of the definition, epidemiology, classification, pathogenesis, laboratory workup, histopathology, clinical scoring systems, as well as imaging and device-based workup of localized scleroderma. Moreover, consensus-based recommendations are given on the management of localized scleroderma depending on its clinical subtype. Treatment recommendations are presented in a therapeutic algorithm. No financial support was given by any pharmaceutical company. The guidelines are valid until July 2019.
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Affiliation(s)
- Alexander Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, Oberhausen, Germany
| | - Thomas Krieg
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology, and Allergology, Charité - University Medical Center Berlin, Berlin, Germany
| | - Jörg Wenzel
- Department of Dermatology and Allergology, University Hospital Bonn, Bonn, Germany
| | - Pia Moinzadeh
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Annegret Kuhn
- Interdisciplinary Center for Clinical Studies (IZKS), University Medical Center Mainz, Mainz, Germany
| | - Elisabeth Aberer
- Department of Dermatology and Venereology, University Hospital Graz, Graz, Austria
| | | | - Gerd Horneff
- Department of General Pediatrics, Asklepios Hospital, St. Augustin, Germany
| | - Emma Reil
- Emma Reil, Scleroderma Support Group, Heilbronn, Germany
| | - Tobias Weberschock
- Department of Dermatology, Venereology, und Allergology, University Hospital Frankfurt and Work Group EbM Frankfurt, Institute for General Medicine, Johann Wolfgang Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Nicolas Hunzelmann
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
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Abstract
Localized scleroderma (LoS) comprises a heterogeneous spectrum of fibrotic diseases that primarily affect the skin with inflammation and skin thickening. The extent of skin involvement and manifestation at extra-cutaneous structures characterizes the specific subset. Fat tissue, fascia, and sometimes muscle, and bones might be involved, and in rare cases the central nervous or ocular system. A worldwide accepted classification system for LoS is still lacking. The latest guidelines have proposed a distinction of limited, generalized, linear, deep, and mixed types. The exact pathophysiology of LoS is not fully understood yet, but it is thought that an externally triggered release of pro-inflammatory cytokines leads to a dysregulation of the connective tissue metabolism. LoS is diagnosed according to typical clinical features. Further diagnostic procedures are helpful to characterize the subtype and to define the extent of inflammation and fibrosis. Due to the heterogeneity of LoS, therapeutic strategies should always be selected depending on the respective subtype. The stage of tissue inflammation and sclerosis has to be considered. Treatment options such as topical corticosteroids, calcipotriol, and calcineurin inhibitors as well as phototherapy are well established. In subsets with severe wide-spread skin manifestation and/or extra-cutaneous involvement, methotrexate monotherapy or a combination of methotrexate and systemic corticosteroids need to be considered. Physical treatment should always be added to the topical and systemic treatment to prevent significant disabilities due to LoS. This article provides an updated review on the epidemiology, pathophysiology, clinical classification and treatment options for patients suffering from LoS.
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Lis-Święty A, Janicka I, Skrzypek-Salamon A, Brzezińska-Wcisło L. A systematic review of tools for determining activity of localized scleroderma in paediatric and adult patients. J Eur Acad Dermatol Venereol 2016; 31:30-37. [PMID: 27401109 DOI: 10.1111/jdv.13790] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 04/26/2016] [Indexed: 01/04/2023]
Abstract
Localized scleroderma (LoS) is a rare inflammatory skin disorder that affects the dermis and sometimes subcutaneous tissues. LoS can have very long periods of quiescence followed by reactivation, but the progression or activity of the disease is difficult to measure. To review the measuring tools used for the evaluation of LoS activity, to choose the most appropriate technique to facilitate progress towards properly assessing the disease, a systematic review of the literature was carried out using the PubMed MEDLINE. Sixty-three studies describing groups of children, adults or both were reviewed and included in the analysis. Case reports were excluded. The analysed papers were published between June 1986 and February 2016. Data were extracted with a focus on instruments measuring the clinical signs of LoS, health-related quality of life (HRQoL), laboratory tests and imaging techniques. Perusal of the literature confirmed that clinical characteristics of the lesions were used to identify activity and scoring systems that focused on a series of signs, and were initially validated in cases of childhood-onset disease; however, there were no data concerning the adult-onset form of the disease. Adult patients with LoS scored lower on HDLQI than those with paediatric-onset LoS. No validated biological markers were available as correlative laboratory parameters of LoS activity. For infrared thermography, ultrasound and other imaging techniques, the features of active lesions were described, but were only useful with appropriate clinical correlation. Measuring tools have not been prospectively validated yet. Summarizing, scoring methods seem to provide the most adequate assessment of LoS and deserve to be further investigated. Combined imaging techniques create optimal conditions for the proper interpretation of the temperature at the skin surface, as well as the structure and vascularity of LoS lesions. Additional scores, musculoskeletal or neuroimaging techniques and laboratory parameters are needed for the specific disease subtypes to monitor extracutaneous manifestations.
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Affiliation(s)
- A Lis-Święty
- School of Medicine in Katowice, Chair and Department of Dermatology, Medical University of Silesia, Katowice, Poland
| | - I Janicka
- School of Medicine in Katowice, Chair and Department of Dermatology, Medical University of Silesia, Katowice, Poland
| | - A Skrzypek-Salamon
- School of Medicine in Katowice, Chair and Department of Dermatology, Medical University of Silesia, Katowice, Poland
| | - L Brzezińska-Wcisło
- School of Medicine in Katowice, Chair and Department of Dermatology, Medical University of Silesia, Katowice, Poland
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Kreuter A, Krieg T, Worm M, Wenzel J, Moinzadeh P, Kuhn A, Aberer E, Scharffetter-Kochanek K, Horneff G, Reil E, Weberschock T, Hunzelmann N. Deutsche Leitlinie zur Diagnostik und Therapie der zirkumskripten Sklerodermie. J Dtsch Dermatol Ges 2016. [DOI: 10.1111/ddg.130_12724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alexander Kreuter
- Klinik für Dermatologie; Venerologie und Allergologie; HELIOS St. Elisabeth Hospital Oberhausen
| | - Thomas Krieg
- Klinik und Poliklinik für Dermatologie und Venerologie; Uniklinik Köln
| | - Margitta Worm
- Klinik für Dermatologie; Venerologie und Allergologie; Charité - Universitätsmedizin; Berlin
| | - Jörg Wenzel
- Klinik und Poliklinik für Dermatologie und Allergologie; Universität Bonn
| | - Pia Moinzadeh
- Klinik und Poliklinik für Dermatologie und Venerologie; Uniklinik Köln
| | - Annegret Kuhn
- Interdisziplinäres Zentrum Klinische Studien (IZKS); Universitätsmedizin Mainz
| | - Elisabeth Aberer
- Universitätsklinik für Dermatologie und Venerologie; Medizinische Universität Graz
| | | | - Gerd Horneff
- Allgemeine Kinder- und Jugendmedizin; Asklepios Klinik; St. Augustin
| | - Emma Reil
- Emma Reil; Sklerodermie Selbsthilfe e.V.; Heilbronn
| | - Tobias Weberschock
- Klinik für Dermatologie; Venerologie und Allergologie; Universitätsklinikum Frankfurt und Arbeitsgruppe EbM Frankfurt; Institut für Allgemeinmedizin; Johann Wolfgang Goethe-Universität; Frankfurt am Main
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Distler O, Cozzio A. Systemic sclerosis and localized scleroderma--current concepts and novel targets for therapy. Semin Immunopathol 2015; 38:87-95. [PMID: 26577237 DOI: 10.1007/s00281-015-0551-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 11/06/2015] [Indexed: 11/28/2022]
Abstract
Systemic sclerosis (SSc) is a chronic autoimmune disease with a high morbidity and mortality. Skin and organ fibrosis are key manifestations of SSc, for which no generally accepted therapy is available. Thus, there is a high unmet need for novel anti-fibrotic therapeutic strategies in SSc. At the same time, important progress has been made in the identification and characterization of potential molecular targets in fibrotic diseases over the recent years. In this review, we have selected four targeted therapies, which are tested in clinical trials in SSc, for in depths discussion of their preclinical characterization. Soluble guanylate cyclase (sGC) stimulators such as riociguat might target both vascular remodeling and tissue fibrosis. Blockade of interleukin-6 might be particularly promising for early inflammatory stages of SSc. Inhibition of serotonin receptor 2b signaling links platelet activation to tissue fibrosis. Targeting simultaneously multiple key molecules with the multityrosine kinase-inhibitor nintedanib might be a promising approach in complex fibrotic diseases such as SSc, in which many partially independent pathways are activated. Herein, we also give a state of the art overview of the current classification, clinical presentation, diagnostic approach, and treatment options of localized scleroderma. Finally, we discuss whether the novel targeted therapies currently tested in SSc could be used for localized scleroderma.
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Affiliation(s)
- Oliver Distler
- Division of Rheumatology, University Hospital Zurich, Gloriastr. 25, 8091, Zurich, Switzerland.
| | - Antonio Cozzio
- Division of Dermatology, University Hospital Zurich, Zurich, Switzerland
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Kirchgesner T, Dallaudière B, Omoumi P, Malghem J, Vande Berg B, Lecouvet F, Houssiau F, Galant C, Larbi A. Eosinophilic fasciitis: Typical abnormalities, variants and differential diagnosis of fasciae abnormalities using MR imaging. Diagn Interv Imaging 2015; 96:341-8. [DOI: 10.1016/j.diii.2014.06.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/11/2014] [Accepted: 06/23/2014] [Indexed: 01/14/2023]
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Abstract
PURPOSE OF REVIEW Scleroderma, in its localized and systemic presentation, represents the third most frequent rheumatic condition in childhood after juvenile idiopathic arthritis and systemic lupus erythematosus. Early diagnosis, appropriate assessment and effective treatment are crucial to improve the long-term outcome. RECENT FINDINGS Recent studies, concerning histopathology and clinical associations with other conditions, open new horizons on the etiopathogenesis of scleroderma. New developments have been also reached in the field of outcome measures. In juvenile localized scleroderma (JLS), new techniques such as Doppler and laser Doppler imaging have shown their usefulness for the daily monitoring of the patients. In juvenile systemic sclerosis (JSSc), a new severity score has been developed and needs to be validated in future trials. Finally, a randomized, double-blind controlled trial, a multicenter consensus statement and long-term follow-up studies have confirmed the important role of methotrexate (MTX) for the treatment of JLS. SUMMARY Studies over recent years highlighted the role of imaging as outcome measures for JLS and introduced a severity score for JSSc. New studies on MTX confirmed its important role for the treatment of JLS.
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Porta F, Kaloudi O, Garzitto A, Prignano F, Nacci F, Falcini F, Matucci Cerinic M. High frequency ultrasound can detect improvement of lesions in juvenile localized scleroderma. Mod Rheumatol 2013; 24:869-73. [DOI: 10.3109/14397595.2013.844301] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kelsey CE, Torok KS. The Localized Scleroderma Cutaneous Assessment Tool: responsiveness to change in a pediatric clinical population. J Am Acad Dermatol 2013; 69:214-20. [PMID: 23562760 DOI: 10.1016/j.jaad.2013.02.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 01/24/2013] [Accepted: 02/03/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Lack of agreement on how to accurately capture disease outcomes in localized scleroderma (LS) has hindered the development of efficacious treatment protocols. The LS Cutaneous Assessment Tool (LoSCAT), consisting of the modified LS Skin Severity Index (mLoSSI) and the LS Damage Index, has potential for use in clinical trials. OBJECTIVE The goal of this article is to further evaluate the clinical responsiveness of the LoSCAT. Based on the modifiable nature of disease activity versus damage, we expected the mLoSSI to be responsive to change. METHODS At 2 study visits, a physician completed the LoSCAT and Physician Global Assessment (PGA) of Disease Activity and of Disease Damage for 29 patients with LS. Spearman correlations were used to examine the relationships between the change in the LoSCAT and the PGA scores. To evaluate contrasted group validity, patients were grouped according to disease activity classification and change scores of groups were compared. Minimal clinically important differences were calculated and compared with the standard error of measurement. RESULTS Change in the mLoSSI score correlated strongly with change in the PGA of Disease Activity score, whereas change in the LS Damage Index score correlated weakly with change in the PGA of Disease Damage score. The mLoSSI and PGA of Disease Activity exhibited contrasted group validity. Minimal clinically important differences for the activity measures were greater than the respective standard errors of measurement. LIMITATIONS Only 2 study visits were included in analysis. CONCLUSION This study gives further evidence that the LoSCAT, specifically the mLoSSI, is a responsive, valid measure of activity in LS and should be used in future treatment studies.
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Affiliation(s)
- Christina E Kelsey
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15224, USA.
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Hiller N, Zlotogorski A, Simanovsky N, Ingber A, Ramot Y, Molho-Pessach V. The spectrum of radiological findings in H syndrome. Clin Imaging 2013; 37:313-9. [DOI: 10.1016/j.clinimag.2012.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 05/11/2012] [Accepted: 05/24/2012] [Indexed: 12/15/2022]
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Schanz S, Henes J, Ulmer A, Kötter I, Fierlbeck G, Claussen CD, Horger M. Magnetic resonance imaging findings in patients with systemic scleroderma and musculoskeletal symptoms. Eur Radiol 2012; 23:212-21. [PMID: 22843057 DOI: 10.1007/s00330-012-2584-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 06/20/2012] [Accepted: 06/22/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To explore the role of whole-body magnetic resonance imaging (MRI) in detecting musculoskeletal involvement in patients with systemic scleroderma and musculoskeletal symptoms. METHODS Eighteen consecutive patients (8 men, 10 women) with systemic scleroderma (median age 46 years) presenting with musculoskeletal complaints underwent whole-body MRI at 1.5 T. Images were evaluated for abnormal signal intensity and/or thickening of subcutaneous fatty tissue septa, muscular fasciae, intramuscular perifascial septa, muscle signal intensity and articular or tendon sheath synovial abnormalities on STIR and post-gadolinium scans. Additionally, C-reactive protein, creatinine kinase and the modified Rodnan skin score were determined. RESULTS MRI indicated evidence of fasciitis, articular synovial inflammation, and subcutaneous thickening in 16 (89 %) patients. MRI findings were compatible with myopathy or myositis in 14 (78 %) patients, tenosynovitis in 11 (61 %) patients and enthesitis in 10 (56 %) patients. Typically, these manifestations were distributed symmetrically and mostly generalised. We only found few correlations with modified Rodnan skin score, C-reactive protein and creatinine kinase. CONCLUSION In patients with systemic scleroderma experiencing musculoskeletal symptoms, whole-body MRI is able to detect involvement of muscles, fasciae, joints and entheses more confidently compared with clinical and laboratory parameters.
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Affiliation(s)
- Stefan Schanz
- Department of Dermatology, Eberhard Karls University Tuebingen, Liebermeister-Str. 25, 72076, Tuebingen, Germany
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Abstract
Pediatric scleroderma includes 2 major groups of clinical entities, systemic sclerosis (SSc) and localized scleroderma (LS). Although both share a common pathophysiology, their clinical manifestations differ. LS is typically confined to the skin and underlying subcutis, with up to a quarter of patients showing extracutaneous disease manifestations such as arthritis and uveitis. Vascular, cutaneous, gastrointestinal, pulmonary, and musculoskeletal involvement are most commonly seen in children with SSc. Treatment of both forms targets the active inflammatory stage and halts disease progression; however, progress needs to be made toward the development of more effective antifibrotic therapy to help reverse disease damage.
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