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Knobler R, Geroldinger-Simić M, Kreuter A, Hunzelmann N, Moinzadeh P, Rongioletti F, Denton CP, Mouthon L, Cutolo M, Smith V, Gabrielli A, Bagot M, Olesen AB, Foeldvari I, Jalili A, Kähäri V, Kárpáti S, Kofoed K, Olszewska M, Panelius J, Quaglino P, Seneschal J, Sticherling M, Sunderkötter C, Tanew A, Wolf P, Worm M, Skrok A, Rudnicka L, Krieg T. Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes. J Eur Acad Dermatol Venereol 2024; 38:1251-1280. [PMID: 38456584 DOI: 10.1111/jdv.19912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/26/2024] [Indexed: 03/09/2024]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - M Geroldinger-Simić
- Department of Dermatology, Ordensklinikum Linz Elisabethinen, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - P Moinzadeh
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - F Rongioletti
- Vita Salute University IRCSS San Raffaele Hospital, Milan, Italy
| | - C P Denton
- Center for Rheumatology, Royal Free and University College Medical School, London, UK
| | - L Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, APHP-CUP, Hôpital Cochin, Paris, France
- Institut Cochin, Université de Paris Cité, Paris, France
| | - M Cutolo
- Laboratories for Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University Medical School of Genoa, IRCCS San Martino Genoa, Genoa, Italy
| | - V Smith
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - A Gabrielli
- Fondazione di Medicina Molecolare e Terapia Cellulare, Università Politecnica delle Marche, Ancona, Italy
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - A B Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - I Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - A Jalili
- Dermatology & Skin Care Clinic, Buochs, Switzerland
| | - V Kähäri
- Department of Dermatology and Venereology, University of Turku and Turku University Hospital, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- The Skin Clinic, Copenhagen, Denmark
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - J Panelius
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, CNRS, Immuno CencEpT, UMR 5164, Bordeaux, France
| | - M Sticherling
- Department of Dermatology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Tanew
- Private Practice, Vienna, Austria
| | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - M Worm
- Division of Allergy and Immunology, Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - T Krieg
- Department of Dermatology and Venereology, and Translational Matrix Biology, University of Cologne, Cologne, Germany
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Foeldvari I, Torok KS, Antón J, Blakley M, Constantin T, Cutolo M, Denton CP, Fligelstone K, Hinrichs B, Li SC, Maillard S, Marrani E, Moinzadeh P, Orteu CH, Pain CE, Pauling JD, Pilkington C, Rosser F, Smith V, Furst DF. Best clinical practice in the treatment of juvenile systemic sclerosis: expert panel guidance - the result of the International Hamburg Consensus Meeting December 2022. Expert Rev Clin Immunol 2024; 20:387-404. [PMID: 38149621 DOI: 10.1080/1744666x.2023.2298354] [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: 09/06/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of 3 in 1,000,000 children. Currently there is only one consensus treatment guideline concerning skin, pulmonary and vascular involvement for jSSc, the jSSc SHARE (Single Hub and Access point for pediatric Rheumatology in Europe) initiative, which was based on data procured up to 2014. Therefore, an update of these guidelines, with a more recent literature and expert experience, and extension of the guidance to more aspects of the disease is needed. AREAS COVERED Treatment options were reviewed, and opinions were provided for most facets of jSSc including general management, some of which differs from adult systemic sclerosis, such as the use of corticosteroids, and specific organ involvement, such as skin, musculoskeletal, pulmonary, and gastroenterology. EXPERT OPINION We are suggesting the treat to target strategy to treat early to prevent cumulative disease damage in jSSc. Conclusions are derived from both expert opinion and available literature, which is mostly based on adult systemic sclerosis (aSSc), given shared pathophysiology, extrapolation of results from aSSc studies was judged reasonable.
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Affiliation(s)
- Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - Kathryn S Torok
- University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jordi Antón
- Department of Pediatric Rheumatology. Hospital Sant Joan de Déu and Universitat de Barcelona, Barcelona, Spain
| | - Michael Blakley
- Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tamás Constantin
- Unit of Pediatric Rheumatology, Tűzoltó Street Department, Pediatric Centre, Semmelweis University, Budapest, Hungary
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology-Department of Internal Medicine and Specialties, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | | | - Kim Fligelstone
- Scleroderma & Raynaud's United Kindgom (SRUK) (Research Subcommittee, Patient Research Partner), FESCA, London, UK
| | - Bernd Hinrichs
- Children's pulmonology, Asklepios Klinik Nord - Heidberg, Hamburg, Germany
| | - Suzanne C Li
- Hackensack University Medical Center, Hackensack, NJ, USA
| | | | - Edoardo Marrani
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Pia Moinzadeh
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Catherine H Orteu
- UCL Institute of Immunity and Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Clare E Pain
- Alder Hey Children's Foundation NHS Trust, Liverpool, UK
| | - John D Pauling
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium and ERN ReCONNET
| | | | - Franziska Rosser
- University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Vanessa Smith
- University of California, Los Angeles, CA, USA
- University of Washington, Seattle, WA, USA
- University of Florence, Florence, Italy
| | - Daniel F Furst
- Division of Rheumatology Fellow, Geffen School of Medicine at the University of California in Los Angeles, Los Angeles, CA, USA
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Teske N, Fett N. Recent Advances in Treatment of Systemic Sclerosis and Morphea. Am J Clin Dermatol 2024; 25:213-226. [PMID: 38087156 DOI: 10.1007/s40257-023-00831-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 02/16/2024]
Abstract
Systemic sclerosis (SSc) and morphea are autoimmune sclerosing diseases that cause significant morbidity, and in the case of SSc, mortality. The pathogenesis of both SSc and morphea share vascular dysfunction, auto-reactive T cells and Th2-associated cytokines, such as interleukin 4, and overproduction of transforming growth factor beta (TGFβ). TGFβ stimulates fibroblast collagen and extra-cellular matrix production. Although morphea and SSc have similar pathogenic pathways and histological findings, they are distinct diseases. Recent advances in treatment of morphea, skin sclerosis in SSc, and interstitial lung disease in SSc are focused on targeting known pathogenic pathways.
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Affiliation(s)
- Noelle Teske
- Department of Dermatology, Oregon Health and Science University, 3303 SW Bond Avenue, Portland, OR, 97239, USA
| | - Nicole Fett
- Department of Dermatology, Oregon Health and Science University, 3303 SW Bond Avenue, Portland, OR, 97239, USA.
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Petty AJ, Emge DA, Blanchard SK, Selim MA, Scoggins K, Liu B, Green CL, Cardones AR. Pilot, open-label, single-arm clinical trial evaluating the efficacy of topical crisaborole for steroid refractory morphea. J Am Acad Dermatol 2023; 89:390-392. [PMID: 37054813 DOI: 10.1016/j.jaad.2023.03.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/23/2023] [Accepted: 03/25/2023] [Indexed: 04/15/2023]
Affiliation(s)
- Amy J Petty
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Drew A Emge
- Department of Dermatology, Duke University, Durham, North Carolina
| | | | - Maria Angelica Selim
- Division of Dermatopathology, Department of Pathology, Duke University, Durham, North Carolina
| | - Kim Scoggins
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Adela R Cardones
- Division of Dermatology, Department of Internal Medicine, University of Kansas, Medical Center, Kansas City, Kansas.
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Papara C, De Luca DA, Bieber K, Vorobyev A, Ludwig RJ. Morphea: The 2023 update. Front Med (Lausanne) 2023; 10:1108623. [PMID: 36860340 PMCID: PMC9969991 DOI: 10.3389/fmed.2023.1108623] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/18/2023] [Indexed: 02/15/2023] Open
Abstract
Morphea, also known as localized scleroderma, is a chronic inflammatory connective tissue disorder with variable clinical presentations, that affects both adults and children. It is characterized by inflammation and fibrosis of the skin and underlying soft tissue, in certain cases even of the surrounding structures such as fascia, muscle, bone and central nervous system. While the etiology is still unknown, many factors may contribute to disease development, including genetic predisposition, vascular dysregulation, TH1/TH2 imbalance with chemokines and cytokines associated with interferon-γ and profibrotic pathways as well as certain environmental factors. Since the disease may progress to permanent cosmetic and functional sequelae, it is crucial to properly assess the disease activity and to initiate promptly the adequate treatment, thus preventing subsequent damage. The mainstay of treatment is based on corticosteroids and methotrexate. These, however, are limited by their toxicity, especially if applied long-term. Furthermore, corticosteroids and methotrexate often do not sufficiently control the disease and/or the frequent relapses of morphea. This review presents the current understanding of morphea by discussing its epidemiology, diagnosis, management and prognosis. In addition, it will describe recent pathogenetic findings, thus proposing potential novel targets for therapeutic development in morphea.
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Affiliation(s)
- Cristian Papara
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany,*Correspondence: Cristian Papara, ✉
| | - David A. De Luca
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Artem Vorobyev
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Ralf J. Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Szczepanek M, Frątczak A, Polak K, Lis-Święty A. Narrow-band reflectance spectrophotometry and infrared thermography for assessment of skin lesions in localized scleroderma. J Eur Acad Dermatol Venereol 2022; 36:2451-2458. [PMID: 35925826 DOI: 10.1111/jdv.18483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 07/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Infrared thermography (IRT) is a useful method to detect activity/inflammation in localized scleroderma (LoS), however inactive skin lesions with a severe degree of dermal and subcutaneous atrophy may show false positive results. Narrow-band reflectance spectrophotometry (NBRS) is an objective, noninvasive technique of measuring erythema and hyperpigmentation severity, yet has not been extensively studied in LoS. OBJECTIVES The aim of this research was to compare the spectrophotometric results with thermographic examination of LoS lesions. METHODS The lesions were assessed using the Localized Scleroderma Assessment Tool (LoSCAT), Dyspigmentation, Induration, Erythema, and Telangiectasias (DIET) score, NBRS and IRT. The difference of the erythema index (ΔEI), melanin index (ΔMI) and average temperature Tavg (ΔTavg) were calculated between each lesion and its normal control. RESULTS Fifty-five patients with 49 active and 64 inactive LoS lesions were examined. The ΔEI strongly correlated with the erythema (rs =0.62, p <0.0000002) and DIET score (rs = 0.66, p <0.0000001) and moderately correlated with the telangiectasias score (rs =0.58, p <0.00001). ΔMI showed strong correlation with the dyspigmentation score (rs =0.65, p <0.0000001). There was a strong correlation between the ΔTavg and the erythema score (rs =0.7, p <0.000001). A moderate correlation between the Δ EI and ΔTavg was found in active LoS lesions (rs =0.53 p <0.0001). CONCLUSION NBRS may be a complementary method for determining erythema in LoS active lesions, although this technique remains inferior to IRT, because is unable to distinct between active and inactive lesions. However, NBRS enables to evaluate the severity of hyperpigmentation and telangiectasias, and it can be useful for the assessment of disease severity which is poorly evaluated by IRT.
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Affiliation(s)
- M Szczepanek
- Chair and Department of Dermatology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - A Frątczak
- Chair and Department of Dermatology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - K Polak
- Doctoral School, Medical University of Silesia, Katowice, Poland
| | - A Lis-Święty
- Chair and Department of Dermatology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
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LaChance AH, Goldman N, Kassamali B, Vleugels RA. Immunologic underpinnings and treatment of morphea. Expert Rev Clin Immunol 2022; 18:461-483. [DOI: 10.1080/1744666x.2022.2063841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Avery H. LaChance
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nathaniel Goldman
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
- New York Medical College School of Medicine, Valhalla, NY
| | - Bina Kassamali
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Ruth Ann Vleugels
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
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Soluble Factors and Receptors Involved in Skin Innate Immunity-What Do We Know So Far? Biomedicines 2021; 9:biomedicines9121795. [PMID: 34944611 PMCID: PMC8698371 DOI: 10.3390/biomedicines9121795] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/25/2021] [Accepted: 11/27/2021] [Indexed: 12/25/2022] Open
Abstract
The pattern recognition receptors, complement system, inflammasomes, antimicrobial peptides, and cytokines are innate immunity soluble factors. They sense, either directly or indirectly, the potential threats and produce inflammation and cellular death. High interest in their modulation has emerged lately, acknowledging they are involved in many cutaneous inflammatory, infectious, and neoplastic disorders. We extensively reviewed the implication of soluble factors in skin innate immunity. Furthermore, we showed which molecules target these factors, how these molecules work, and how they have been used in dermatological practice. Cytokine inhibitors have paved the way to a new era in treating moderate to severe psoriasis and atopic dermatitis.
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Abstract
PURPOSE OF REVIEW Treatment of scleroderma in children is challenging since little is known about its pathogenesis. Herein, we review the most recent evidence regarding the treatment of juvenile scleroderma. RECENT FINDINGS According to the recent recommendations for Pediatric Rheumatology in Europe (SHARE), systemic treatment in localized scleroderma is needed when there is a risk for disability, such as in generalized or pansclerotic morphea and progressive linear scleroderma. In juvenile systemic sclerosis, the introduction of the severity score, J4S, has standardized the assessment of the patients in the daily practice and allowed a more tailored therapeutic approach. Since, to date, no clinical trial is available in JSSc, due to its rarity, the treatment is based on adults' experience. The recent recommendations for juvenile scleroderma represent an important instrument to standardize the treatment approach, confirm the role of methotrexate, and open new windows for effective experimental treatments, such as mycophenolate mofetil and biological agents, for severe or refractory cases.
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Affiliation(s)
- Francesco Zulian
- Department of Woman's and Child's Health, University of Padua, Via Giustiniani 3, 35128, Padua, Italy.
| | - Francesca Tirelli
- Department of Woman's and Child's Health, University of Padua, Via Giustiniani 3, 35128, Padua, Italy
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Weibel L, Theiler M, Howell K, Denton C, Waelchli R, Atherton D, Woo P, Harper J. Prospective evaluation of treatment response and disease reversibility of paediatric localized scleroderma (morphoea) to steroids and methotrexate using multi‐modal imaging. J Eur Acad Dermatol Venereol 2020; 34:1609-1616. [DOI: 10.1111/jdv.16308] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
- L. Weibel
- Department of Dermatology Pediatric Skin Center University Children's Hospital Zurich Zurich Switzerland
| | - M. Theiler
- Department of Dermatology Pediatric Skin Center University Children's Hospital Zurich Zurich Switzerland
| | - K.J. Howell
- Microvascular Diagnostics Royal Free Hospital Institute of Immunity and Transplantation London UK
| | - C.P. Denton
- Centre for Rheumatology and Connective Tissue Disease UCL Division of Medicine Royal Free London NHS Foundation Trust London UK
| | - R. Waelchli
- Department of Dermatology Pediatric Skin Center University Children's Hospital Zurich Zurich Switzerland
| | - D. Atherton
- Department of Dermatology Great Ormond Street Hospital for Children London UK
| | - P. Woo
- Centre for Adolescent Rheumatology University College London London UK
| | - J.I. Harper
- Department of Dermatology Great Ormond Street Hospital for Children London UK
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Albuquerque JVD, Andriolo BNG, Vasconcellos MRA, Civile VT, Lyddiatt A, Trevisani VFM. Interventions for morphea. Cochrane Database Syst Rev 2019; 7:CD005027. [PMID: 31309547 PMCID: PMC6630193 DOI: 10.1002/14651858.cd005027.pub5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Morphea (morphoea) is an immune-mediated disease in which excess synthesis and deposition of collagen in the skin and underlying connective tissues results in hardened cutaneous areas. Morphea has different clinical features according to the subtype and stage of evolution of the disease. There is currently no consensus on optimal interventions for morphea. OBJECTIVES To assess the effects of treatments for people with any form of morphea. SEARCH METHODS We searched the following databases up to July 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, and five trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials. SELECTION CRITERIA Randomised controlled trials of topical, intralesional, or systemic treatments (isolated or combined) in anyone who has been clinically diagnosed by a medical practitioner with any form of morphea. Eligible controls were placebo, no intervention, any other treatment, or different doses or duration of a treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcomes were global improvement of disease activity or damage assessed by a medical practitioner or by participants, and adverse effects. Secondary outcomes were improvement of disease activity and improvement of disease damage. We used GRADE to assess the quality of the evidence for each outcome. MAIN RESULTS We included 14 trials, with a total of 429 randomised participants, aged between 3 and 76 years. There were juvenile and adult participants; over half were female, and the majority had circumscribed morphea, followed by linear scleroderma. The settings of the studies (where described) included a dermatologic centre, a national laboratory centre, paediatric rheumatology and dermatology centres, and a university hospital or medical centre.The studies evaluated heterogenous therapies for different types of morphea, covering a wide range of comparisons. We were unable to conduct any meta-analyses. Seven studies investigated topical medications, two evaluated intralesional medications, and five investigated systemic medications. The study duration ranged from seven weeks to 15 months from baseline.We present here results for our primary outcomes for our four key comparisons. All of these results are based on low-quality evidence.The included studies were at high risk of performance, detection, attrition, and reporting bias.Global improvement of disease activity or damage after treatment may be higher with oral methotrexate (15 mg/m², maximum 20 mg, once a week, for 12 months or until disease flare) plus oral prednisone (1 mg/kg a day, maximum of 50 mg, in a single morning dose, for three months, and one month with gradually decreased dose until discontinuation) than with placebo plus oral prednisone in children and adolescents with active morphea (linear scleroderma, generalised morphea or mixed morphea: linear and circumscribed) (risk ratio (RR) 2.31, 95% confidence interval (CI) 1.20 to 4.45; number needed to treat for an additional beneficial outcome (NNTB) 3; 1 randomised controlled trial (RCT); 70 participants, all juvenile). This outcome was measured 12 months from the start of treatment or until flare of the disease. Data were not available separately for each morphea type. There may be little or no difference in the number of participants experiencing at least one adverse event with oral methotrexate (26/46) or placebo (11/24) (RR 1.23, 95% CI 0.75 to 2.04; 1 RCT; 70 participants assessed during the 12-month follow-up). Adverse events related to methotrexate included alopecia, nausea, headache, fatigue and hepatotoxicity, whilst adverse events related to prednisone (given in both groups) included weight gain (more than 5% of body weight) and striae rubrae.One three-armed RCT compared the following treatments: medium-dose (50 J/cm²) UVA-1; low-dose (20 J/cm²) UVA-1; and narrowband UVB phototherapy. There may be little or no difference between treatments in global improvement of disease activity or damage, as assessed through the modified skin score (where high values represent a worse outcome): medium-dose UVA-1 phototherapy versus low-dose UVA-1 group: MD 1.60, 95% CI -1.70 to 4.90 (44 participants); narrowband UVB phototherapy versus medium-dose UVA-1 group: MD -1.70, 95% CI -5.27 to 1.87 (35 participants); and narrowband UVB versus low-dose UVA-1 group: MD -0.10, 95% CI -2.49 to 2.29 (45 participants). This RCT included children and adults with active morphea (circumscribed morphea, linear scleroderma (with trunk/limb variant and head variant), generalised morphea, or mixed morphea), who received phototherapy five times a week, for eight weeks. Outcomes were measured at eight weeks from the start of treatment.Safety data, measured throughout treatment, from the same RCT (62 participants) showed that treatment with UVA-1 phototherapy may cause mild tanning compared to narrowband UVB: narrowband UVB versus medium-dose UVA-1: RR 0.03, 95% CI 0.00 to 0.42; 35 participants; narrowband UVB versus low-dose UVA-1: RR 0.03, 95% CI 0.00 to 0.41; 45 participants. However, there may be no difference in the number of participants reporting mild tanning when comparing medium and low dose UVA-1 phototherapy (RR 1.00, 95% CI 0.91 to 1.10; 44 participants). Transient erythema was reported in three participants with narrowband UVB and no participants in the low- or medium-dose UVA-1 groups. AUTHORS' CONCLUSIONS Compared to placebo plus oral prednisone, oral methotrexate plus oral prednisone may improve disease activity or damage in juvenile active morphea (linear scleroderma, generalised morphea or mixed morphea: linear and circumscribed), but there may be a slightly increased chance of experiencing at least one adverse event.When medium-dose UVA-1 (50 J/cm²), low-dose UVA-1 (20 J/cm²), and narrowband UVB were compared against each other in treating children and adults with active morphea (circumscribed morphea, linear scleroderma, generalised morphea and mixed morphea), there may be little or no difference between these treatments on global improvement of disease activity or damage. UVA-1 phototherapy may cause more mild tanning than narrowband UVB, but there may be no difference between medium- and low-dose UVA-1 phototherapy. These results are based on low-quality evidence.Limitations of data and analyses include risk of bias and imprecision (small number of participants or events and wide confidence intervals). We encourage multicentre RCTs to increase sample size and evaluate, with validated tools, different treatment responses according to the subtypes of morphea and age groups.
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Affiliation(s)
- Julia V de Albuquerque
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Brenda NG Andriolo
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Monica RA Vasconcellos
- Universidade Federal de São PauloDepartment of DermatologyPedro de Toledo St. 508São PauloBrazil04039‐001
| | - Vinicius T Civile
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Anne Lyddiatt
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Virginia FM Trevisani
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
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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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Sng MK, Chan JSK, Teo Z, Phua T, Tan EHP, Wee JWK, Koh NJN, Tan CK, Chen JP, Pal M, Tong BMK, Tnay YL, Ng XR, Zhu P, Chiba S, Wang X, Wahli W, Tan NS. Selective deletion of PPARβ/δ in fibroblasts causes dermal fibrosis by attenuated LRG1 expression. Cell Discov 2018; 4:15. [PMID: 29619245 PMCID: PMC5880809 DOI: 10.1038/s41421-018-0014-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/04/2018] [Indexed: 01/04/2023] Open
Abstract
Connective tissue diseases of the skin are characterized by excessive collagen deposition in the skin and internal organs. Fibroblasts play a pivotal role in the clinical presentation of these conditions. Nuclear receptor peroxisome-proliferator activated receptors (PPARs) are therapeutic targets for dermal fibrosis, but the contribution of the different PPAR subtypes are poorly understood. Particularly, the role of fibroblast PPARβ/δ in dermal fibrosis has not been elucidated. Thus, we generated a mouse strain with selective deletion of PPARβ/δ in the fibroblast (FSPCre-Pparb/d-/-) and interrogated its epidermal and dermal transcriptome profiles. We uncovered a downregulated gene, leucine-rich alpha-2-glycoprotein-1 (Lrg1), of previously unknown function in skin development and architecture. Our findings suggest that the regulation of Lrg1 by PPARβ/δ in fibroblasts is an important signaling conduit integrating PPARβ/δ and TGFβ1-signaling networks in skin health and disease. Thus, the FSPCre-Pparb/d-/- mouse model could serve as a novel tool in the current gunnery of animal models to better understand dermal fibrosis.
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Affiliation(s)
- Ming Keat Sng
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551 Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Novena Campus, 11 Mandalay Road, Singapore, 308232 Singapore
| | - Jeremy Soon Kiat Chan
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551 Singapore
| | - Ziqiang Teo
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551 Singapore
| | - Terri Phua
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551 Singapore
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Nobels väg 16, 17177 Stockholm, Sweden
| | - Eddie Han Pin Tan
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551 Singapore
| | - Jonathan Wei Kiat Wee
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551 Singapore
| | - Nikki Jun Ning Koh
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551 Singapore
| | - Chek Kun Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Novena Campus, 11 Mandalay Road, Singapore, 308232 Singapore
| | - Jia Peng Chen
- Lee Kong Chian School of Medicine, Nanyang Technological University, Novena Campus, 11 Mandalay Road, Singapore, 308232 Singapore
| | - Mintu Pal
- Biological Sciences and Technology Division, CSIR-North East Institute of Science and Technology, Jorhat, Assam 785006 India
| | - Benny Meng Kiat Tong
- School of Physical and Mathematical Sciences, Nanyang Technological University, Singapore, 637371 Singapore
| | - Ya Lin Tnay
- School of Physical and Mathematical Sciences, Nanyang Technological University, Singapore, 637371 Singapore
| | - Xuan Rui Ng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Novena Campus, 11 Mandalay Road, Singapore, 308232 Singapore
| | - Pengcheng Zhu
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551 Singapore
| | - Shunsuke Chiba
- School of Physical and Mathematical Sciences, Nanyang Technological University, Singapore, 637371 Singapore
| | - Xiaomeng Wang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Novena Campus, 11 Mandalay Road, Singapore, 308232 Singapore
- Institute of Molecular and Cell Biology, Agency for Science Technology & Research, 61 Biopolis Drive, Proteos, Singapore, 138673 Singapore
- Department of Cell Biology, Institute of Ophthalmology, University College London, London, UK
- Singapore Eye Research Institute, Singapore, 169856 Singapore
| | - Walter Wahli
- Lee Kong Chian School of Medicine, Nanyang Technological University, Novena Campus, 11 Mandalay Road, Singapore, 308232 Singapore
- INRA ToxAlim, Chemin de Tournefeuille, Toulouse Cedex 3, UMR1331 France
- Center for Integrative Genomics, University of Lausanne, Le Genopode, Lausanne, Switzerland
| | - Nguan Soon Tan
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore, 637551 Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Novena Campus, 11 Mandalay Road, Singapore, 308232 Singapore
- Institute of Molecular and Cell Biology, Agency for Science Technology & Research, 61 Biopolis Drive, Proteos, Singapore, 138673 Singapore
- KK Research Centre, KK Women’s and Children Hospital, 100 Bukit Timah Road, Singapore, 229899 Singapore
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Abstract
Morphea, also known as localized scleroderma, encompasses a group of idiopathic sclerotic skin diseases. The spectrum ranges from relatively mild phenotypes, which generally cause few problems besides local discomfort and visible disfigurement, to subtypes with severe complications such as joint contractures and limb length discrepancies. Eosinophilic fasciitis (EF, Shulman syndrome) is often regarded as belonging to the severe end of the morphea spectrum. The exact driving mechanisms behind morphea and EF pathogenesis remain to be elucidated. However, extensive extracellular matrix formation and autoimmune dysfunction are thought to be key pathogenic processes. Likewise, these processes are considered essential in systemic sclerosis (SSc) pathogenesis. In addition, similarities in clinical presentation between morphea and SSc have led to many theories about their relatedness. Importantly, morphea may be differentiated from SSc based on absence of sclerodactyly, Raynaud’s phenomenon, and nailfold capillary changes. The diagnosis of morphea is often based on characteristic clinical findings. Histopathological evaluation of skin biopsies and laboratory tests are not necessary in the majority of morphea cases. However, full-thickness skin biopsies, containing fascia and muscle tissue, are required for the diagnosis of EF. Monitoring of disease activity and damage, especially of subcutaneous involvement, is one of the most challenging aspects of morphea care. Therefore, data harmonization is crucial for optimizing standard care and for comparability of study results. Recently, the localized scleroderma cutaneous assessment tool (LoSCAT) has been developed and validated for morphea. The LoSCAT is currently the most widely reported outcome measure for morphea. Care providers should take disease subtype, degree of activity, depth of involvement, and quality-of-life impairments into account when initiating treatment. In most patients with circumscribed superficial subtypes, treatment with topical therapies suffices. In more widespread disease, UVA1 phototherapy or systemic treatment with methotrexate (MTX), with or without a systemic corticosteroid combination, should be initiated. Disappointingly, few alternatives for MTX have been described and additional research is still needed to optimize treatment for these debilitating conditions. In this review, we present a state-of-the-art flow chart that guides care providers in the treatment of morphea and EF.
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Morphea - selected local treatment methods and their effectiveness. Reumatologia 2017; 55:305-313. [PMID: 29491539 PMCID: PMC5825969 DOI: 10.5114/reum.2017.72628] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/30/2017] [Indexed: 01/15/2023] Open
Abstract
Localised scleroderma is an uncommon connective tissue disease of multifactorial aetiology occurring in the paediatric and adult population. It is relatively difficult to conduct any research on the subject of this disease entity treatment due to the low number of patients suffering from morphea, a tendency of the disease to remit spontaneously, and not yet well recognised aetiology. Hence, there has been developed no causal treatment of well-proven effectiveness, and schedules of symptomatic therapy are not yet clearly determined. The paper depicts most widely used topical treatment methods in morphea therapy, which due to minor risk of systemic adverse effects seem to be a beneficial therapeutic alternative. The main aim of this article was to analyse different topical treatment options used in localised scleroderma therapy and to indicate the most appropriate, safe, and effective one.
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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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Zaslavsky DV, Chuprov IN, Sidikov AA, Wolkensteyn PIER, Sadykov AI, Sibgatullin RR, Koval YG, Skrek SV. Application of a preparation of imiquimod in а dosage form of ointment 5% in therapy of basal cell carcinoma. VESTNIK DERMATOLOGII I VENEROLOGII 2015. [DOI: 10.25208/0042-4609-2015-91-6-67-74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Objective. To estimate efficiency and safety of application of a preparation of Aldara (imiquimod, 5% external application cream) it is independent or in combination with cryotherapy in therapy of the basal cell carcinoma of the skin (BCC). Material and methods. Research included 78 patients (22 women and 56 men) with various forms of a basal cell carcinoma of the skin. All patients were divided into 3 groups: the main group (n = 30) the patients receiving therapy by Aldara (imiquimod, 5% external application cream) made, second (n = 21) - the patients receiving therapy by Aldara’s, and also 1 course of cryotherapy, and the group of comparison (n = 27) receiving therapy of placebo in the form of external application cream. Therapy was carried out 3 times a week, within 16 weeks. Research was conducted in some stages with histologic confirmation of the diagnosis, and also an assessment of efficiency of therapy and undesirable effects. Results. At 27 of 30 patients of the first group (90%) and at 21 of 21 patients of the second group (100%) receiving treatment by Aldara’s absolute clinical recovery is reached. In group of comparison of clinical recovery at all 27 patients it wasn’t observed. It is expedient to note that at all patients of the second group (100%) already to 75 ± to the 2nd day of therapy (the 4th visit) clinical recovery while at 27 of 30 patients of the first group (90%) the total disappearance (clinical recovery) came for 105 and more days (the 5th and 6th visits) was noted. Recurrence of a disease after the end of therapy it wasn’t observed. Conclusion. Aldara (imiquimod, 5% external application cream) possesses high efficiency at therapy of various forms and sizes of BCC. Undesirable effects of therapy are easily resolved at cancellation of a preparation and not observed at its renewal. Unlike other immunomodulatory preparations (corticosteroids, retinoid, cyclosporin) Aldar’s application doesn’t promote suppression of cellular immunity.
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