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Memar EH, Safavi M, Moradinejad MH, Ziaee V. The First Presentation of Localized Scleroderma at Birth: Scleroderma as a Differential Diagnosis of Congenital Skin Lesion. JOURNAL OF CHILD SCIENCE 2022. [DOI: 10.1055/s-0041-1741055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Localized scleroderma is an uncommon autoimmune disease characterized by fibrosis of the skin and underlying tissue without involvement of blood vessels or internal organs. It usually affects children during later childhood, and early presentation of localized scleroderma during infancy is rare. In the current study, we report a child with localized scleroderma-related presentations occurring at birth. A 2-day-old male neonate presented with a firm, erythematous, and slightly pigmented plaque on his left thigh, leading to a change in the diameter of the affected foot and contracture of the left knee. At the age of 7 months, he was referred to our rheumatology clinic with normal growth and development. Laboratory studies, including urine and blood high-performance liquid chromatography assay, antinuclear antibodies, antitopoisomerase I, and rheumatic factor, were in the normal range. No signs of ocular involvement were noted during ophthalmological consultation. Skin biopsy showed mild acanthosis and collagen bundles, which replaced the fat around the sweat glands. A final diagnosis of localized scleroderma was made. Treatment was started with oral prednisolone, oral methotrexate (MTX), and colchicine. The skin lesion stopped progressing after 3 months of treatment. Steroid was then tapered over 6 months, while MTX and colchicine were continued for 2 years. Localized scleroderma during early infancy is a rare disease, but it should be considered as a differential in infants with erythematous and firm lesions on their body at birth because early treatment can prevent future complications.
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Affiliation(s)
- Elmira Hajiesmaeil Memar
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
- Children's Medical Center, Pediatric Center of Excellence, Tehran, Iran
| | - Moeinadin Safavi
- Children's Medical Center, Pediatric Center of Excellence, Tehran, Iran
- Department of Pathology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Hassan Moradinejad
- Children's Medical Center, Pediatric Center of Excellence, Tehran, Iran
- Pediatric Rheumatology Society of Iran, Tehran, Iran
| | - Vahid Ziaee
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
- Children's Medical Center, Pediatric Center of Excellence, Tehran, Iran
- Pediatric Rheumatology Society of Iran, Tehran, Iran
- Pediatric Rheumatology Research Group, Rheumatology Research Center, Tehran University of Medical Science, Tehran, Iran
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Yan M, Stans AA, Moran SL. Flap Reconstruction for Treatment of Pediatric Linear Scleroderma. Ann Plast Surg 2021; 87:533-536. [PMID: 34699432 DOI: 10.1097/sap.0000000000002887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Linear scleroderma is a rare connective tissue disease characterized by thickening of the skin due to excess collagen deposit. It is the most frequent type of localized scleroderma in the pediatric population (40%-70%), and it usually affects the extremities and head. Linear scleroderma can cause growth disturbances, extremity length discrepancy, and debilitating joint contractures. The aim of this study was to describe the surgical outcomes of microsurgical flap reconstruction of linear scleroderma in the pediatric population. METHODS A retrospective review of all children with linear scleroderma was performed at our institution. Patients less than 18 years of age with clinical diagnosis of linear scleroderma and who underwent microsurgical flap reconstruction for correction of their scleroderma were included. Fat grafting procedures were excluded. Patient demographics and surgical outcomes were collected. RESULTS A total 7 patients underwent microsurgical flap reconstruction for treatment of their linear scleroderma producing debilitating soft tissue contractures and preventing ambulation or elbow extension. Six patients had scleroderma involving the lower extremity and 1 involving the upper extremity. Three anterolateral thigh and 4 latissimus dorsi flaps were performed. The median age at surgery was 7 years (Q1-Q3, 5-11), and the median body mass index was 21.3 kg/m2 (Q1-Q3, 16.5-22.1). The median follow-up was 121.1 months (Q1-Q3, 43.2-187.4). All flaps survived, and no donor site complications were reported. Perioperative complications included wound infection that required debridement (n = 1), immediate postoperative bleeding requiring surgical intervention (n = 1), intraoperative venous congestion (n = 1), and scleroderma recurrence outside the flap (n = 2). When comparing anterolateral thigh and latissimus dorsi flaps, there was no statistically significant difference in the development of surgical complications, number of surgical revisions per patient [median, 4 (Q1-Q3, 4-7) vs 2.5 (Q1-Q3, 1.3, 3), P = 0.0916], or unplanned surgical interventions [median, 0 (Q1-Q3, 0-1) vs 1 (Q1-Q3, 0-1), P = 0.7228]. The reconstruction was successful in improving range of motion in 6 patients, 5 of which reached full weight-bearing. However, all patients had residual limb deformity, and 4 had remaining extremity length discrepancy. CONCLUSIONS Microsurgical flaps are a good option for functional improvement of severe pediatric linear scleroderma affecting the extremities. However, residual limb deformity is common, and patients are often required to undergo additional surgical revisions.
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Affiliation(s)
- Maria Yan
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery
| | - Anthony A Stans
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Vasquez-Canizares N, Li SC. Juvenile Localized Scleroderma: Updates and Differences from Adult-Onset Disease. Rheum Dis Clin North Am 2021; 47:737-755. [PMID: 34635302 DOI: 10.1016/j.rdc.2021.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Children and adolescents with localized scleroderma (LS) are at high risk for extracutaneous-related functional impairment including hemiatrophy, arthropathy, seizures, and vision impairment. Compared with adult-onset LS, pediatric disease has a higher likelihood for poor outcome, with extracutaneous involvement twice as prevalent in linear scleroderma, disease relapses more common, and disease duration more than double. Consensus among pediatric rheumatologists on treating patients at risk for significant morbidity with systemic immunosuppressants has led to major improvements in outcome. This review discusses recent progress in assessment and treatment strategies and in our understanding of key disease pathways.
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Affiliation(s)
- Natalia Vasquez-Canizares
- Department of Pediatrics, Division of Pediatric Rheumatology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA
| | - Suzanne C Li
- Department of Pediatrics, Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack Meridian School of Medicine, 30 Prospect Avenue, WFAN PC337, Hackensack, NJ 07601, USA.
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Li SC, O'Neil KM, Higgins GC. Morbidity and Disability in Juvenile Localized Scleroderma: The Case for Early Recognition and Systemic Immunosuppressive Treatment. J Pediatr 2021; 234:245-256.e2. [PMID: 33548257 DOI: 10.1016/j.jpeds.2021.01.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 12/29/2020] [Accepted: 01/28/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Suzanne C Li
- Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, NJ.
| | - Kathleen M O'Neil
- Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Gloria C Higgins
- Department of Pediatrics, Division of Rheumatology, The Ohio State University and Nationwide Children's Hospital, Columbus, OH
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Abatacept in the treatment of localized scleroderma: A pediatric case series and systematic literature review. Semin Arthritis Rheum 2020; 50:645-656. [DOI: 10.1016/j.semarthrit.2020.03.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 11/18/2022]
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Li SC, Zheng RJ. Overview of Juvenile localized scleroderma and its management. World J Pediatr 2020; 16:5-18. [PMID: 31786801 DOI: 10.1007/s12519-019-00320-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/26/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Juvenile localized scleroderma (JLS) is a rare pediatric disease characterized by inflammation and skin thickening. JLS is associated with deep tissue and extracutaneous involvement that often results in functional impairment and growth disturbances. This article provides an overview of the disease with a focus on active features and treatment. DATA SOURCES We searched databases including PubMed, Elsevier and MedLine and Wanfang, reviewing publications from 2013 to 2019. Selected earlier publications were also reviewed. RESULTS Linear scleroderma is the most common JLS subtype. Several lines of evidence suggest that JLS is an autoimmune disease. Extracutaneous involvement is common and can present before the onset of skin disease. Multiple skin features are associated with disease activity, and activity can also manifest as arthritis, myositis, uveitis, seizures, and growth impairment. Systemic immunosuppressive treatment, commonly methotrexate with or without glucocorticoids, greatly improves outcome and is recommended for treating JLS patients with active disease and moderate or higher severity. Long term monitoring is needed because of the disease's chronicity and the high frequency of relapses off of treatment. CONCLUSIONS JLS is associated with a risk for disabling and disfiguring morbidity for the growing child. Identifying active disease is important for guiding treatment, but often difficult because of the paucity of markers and lack of a universal skin activity feature. More studies of JLS pathophysiology are needed to allow the identification of biomarkers and therapeutic targets. Comparative effectiveness treatment studies are also needed to work towards optimizing care and outcome.
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Affiliation(s)
- Suzanne C Li
- Department of Pediatrics, Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, 30 Prospect Avenue, Imus 337, Hackensack, 07601, NJ, USA.
- Department of Pediatrics, Hackensack Meridian School of Medicine at Seton Hall University, Clifton, 07110, NJ, USA.
| | - Rong-Jun Zheng
- Department of Rheumatology, Immunology, and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
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Torok KS, Li SC, Jacobe HM, Taber SF, Stevens AM, Zulian F, Lu TT. Immunopathogenesis of Pediatric Localized Scleroderma. Front Immunol 2019; 10:908. [PMID: 31114575 PMCID: PMC6503092 DOI: 10.3389/fimmu.2019.00908] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/09/2019] [Indexed: 01/03/2023] Open
Abstract
Localized scleroderma (LS) is a complex disease characterized by a mixture of inflammation and fibrosis of the skin that, especially in the pediatric population, also affects extracutaneous tissues ranging from muscle to the central nervous system. Although developmental origins have been hypothesized, evidence points to LS as a systemic autoimmune disorder, as there is a strong correlation to family history of autoimmune disease, the presence of shared HLA types with rheumatoid arthritis, high frequency of auto-antibodies, and elevated circulating chemokines and cytokines associated with T-helper cell, IFNγ, and other inflammatory pathways. This inflammatory phenotype of the peripheral blood is reflected in the skin via microarray, RNA Sequencing and tissue staining. Research is underway to identify the key players in the pathogenesis of LS, but close approximation of inflammatory lymphocytic and macrophage infiltrate with collagen and fibroblasts deposition supports the notion that LS is a disease of inflammatory driven fibrosis. The immune system is dynamic and undergoes changes during childhood, and we speculate on how the unique features of the immune system in childhood could potentially contribute to some of the differences in LS between children and adults. Interestingly, the immune phenotype in pediatric LS resembles to some extent the healthy adult cellular phenotype, possibly supporting accelerated maturation of the immune system in LS. We discuss future directions in better understanding the pathophysiology of and how to better treat pediatric LS.
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Affiliation(s)
- Kathryn S. Torok
- Division of Pediatric Rheumatology, Department of Pediatrics, Childrens's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Suzanne C. Li
- Division of Pediatric Rheumatology, Department of Pediatrics, Hackensack University Medical Center, Hackensack, NJ, United States
- Hackensack Meridian School of Medicine at Seton Hall University, Clifton, NJ, United States
| | - Heidi M. Jacobe
- Department of Dermatology, UT Southwestern Medical Center, Dallas, TX, United States
| | - Sarah F. Taber
- Division of Pediatric Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Anne M. Stevens
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Francesco Zulian
- Pediatric Rheumatology Unit, Department of Woman's and Child's Health, University of Padua, Padua, Italy
| | - Theresa T. Lu
- Division of Pediatric Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York, NY, United States
- HSS Research Institute, Hospital for Special Surgery, New York, NY, United States
- Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, United States
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Constantin T, Foeldvari I, Pain CE, Pálinkás A, Höger P, Moll M, Nemkova D, Weibel L, Laczkovszki M, Clements P, Torok KS. Development of minimum standards of care for juvenile localized scleroderma. Eur J Pediatr 2018; 177:961-977. [PMID: 29728839 DOI: 10.1007/s00431-018-3144-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/25/2018] [Accepted: 04/04/2018] [Indexed: 11/27/2022]
Abstract
UNLABELLED Juvenile localized scleroderma (jLS), also known as morphea, is an orphan disease. Pediatric guidelines regarding diagnosis, assessment, and management are lacking.Our objective was to develop minimum standards of care for diagnosis, assessment, and management of jLS. A systematic review was undertaken to establish the pediatric evidence for assessment and monitoring of jLS. An expert panel, including members of the Pediatric Rheumatology European Society (PRES) Scleroderma Working Group, were invited to a consensus meeting where recommendations were developed based on evidence graded by the systematic review and, where evidence was lacking, consensus opinion. A nominal technique was used where 75% consensus was taken as agreement. Recommendations for diagnosis, assessment, and management were developed. Due to a lack of pediatric evidence, these were primarily consensus driven. Careful assessment for extra-cutaneous manifestations including synovitis, brain involvement, and uveitis were key features together with joint assessments between Dermatology and Rheumatology to improve and standardize care. CONCLUSION Management of jLS is varied. These recommendations should help provide standardization of assessment and care for those with this rare and potentially debilitating condition. What is Known: • Children with juvenile localized scleroderma (jLS) are managed by a number of specialties including pediatric rheumatologists and dermatologists, sometimes in shared clinics. Studies have shown that management varies considerably and that there are notable differences between specialties [1]. • There is very little published guidance on management of jLS. What is new: • These recommendations aim to standardize diagnosis, assessment, and management through review of pediatric evidence and consensus agreement. • Joint review of patients by both pediatric rheumatologists and dermatologists is recommended.
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Affiliation(s)
| | - Ivan Foeldvari
- Hamburger Zentrum für Kinder- und Jugendrheumatologie, Hamburg, Germany
| | - Clare E Pain
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Peter Höger
- Department of Paediatric Dermatology, Catholic Children's Hospital Wilhelmstift, Hamburg, Germany
| | - Monika Moll
- University Childrens Hospital, Tuebingen, Germany
| | | | - Lisa Weibel
- Department of Dermatology, University Children's Hospital Zurich, Zurich, Switzerland
| | | | - Philip Clements
- David Geffen School of Medicine at UCLA, Division of Rheumatology, Los Angeles, CA, USA
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Bagri NK, Raj D, Kaur J, Punia H, Saini I, Lodha R, Kabra SK. Juvenile systemic sclerosis: experience from a tertiary care center from India. Rheumatol Int 2017; 37:1687-1691. [DOI: 10.1007/s00296-017-3793-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/09/2017] [Indexed: 10/19/2022]
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11
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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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Saracino AM, Denton CP, Orteu CH. The molecular pathogenesis of morphoea: from genetics to future treatment targets. Br J Dermatol 2017; 177:34-46. [PMID: 27553363 DOI: 10.1111/bjd.15001] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2016] [Indexed: 12/11/2022]
Abstract
A number of immunoinflammatory and profibrotic mechanisms are recognized in the pathogenesis of broad sclerotic skin processes and, more specifically, morphoea. However, the precise aetiopathogenesis is complex and remains unclear. Morphoea is clinically heterogeneous, with variable anatomical patterning, depth of tissue involvement and sclerotic, inflammatory, atrophic and dyspigmented morphology. Underlying mechanisms determining these reproducible clinical subsets are poorly understood but of great clinical and therapeutic relevance. Regional susceptibility mechanisms (e.g. environmental triggers, mosaicism and positional identity) together with distinct pathogenic determinants (including innate, adaptive and imbalanced pro- and antifibrotic signalling pathways) are likely implicated. In the age of genetic profiling and personalized medicine, improved characterization of the environmental, systemic, local, genetic and immunopathological factors underpinning morphoea pathogenesis may open the door to novel targeted therapeutic approaches.
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Affiliation(s)
- A M Saracino
- The Royal Free London NHS Foundation Trust, Department of Dermatology, London, U.K.,University College London, Centre for Rheumatology and Connective Tissue Diseases, Division of Medicine, London, U.K
| | - C P Denton
- University College London, Centre for Rheumatology and Connective Tissue Diseases, Division of Medicine, London, U.K.,The Royal Free London NHS Foundation Trust, Department of Rheumatology, London, U.K
| | - C H Orteu
- The Royal Free London NHS Foundation Trust, Department of Dermatology, London, U.K
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Lis-Święty A, Skrzypek-Salamon A, Ranosz-Janicka I, Brzezińska-Wcisło L. Localized scleroderma: clinical and epidemiological features with emphasis on adulthood- versus childhood-onset disease differences. J Eur Acad Dermatol Venereol 2017; 31:1595-1603. [DOI: 10.1111/jdv.14197] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/21/2017] [Indexed: 01/09/2023]
Affiliation(s)
- A. Lis-Święty
- Department of Dermatology; School of Medicine in Katowice; Medical University of Silesia; Katowice Poland
| | - A. Skrzypek-Salamon
- Department of Dermatology; School of Medicine in Katowice; Medical University of Silesia; Katowice Poland
| | - I. Ranosz-Janicka
- Department of Dermatology; School of Medicine in Katowice; Medical University of Silesia; Katowice Poland
| | - L. Brzezińska-Wcisło
- Department of Dermatology; School of Medicine in Katowice; Medical University of Silesia; Katowice Poland
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Zosteriform Morphea Without History of Herpes Zoster Infection. Arch Rheumatol 2016; 31:390-392. [PMID: 30375569 DOI: 10.5606/archrheumatol.2017.5902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 05/23/2016] [Indexed: 11/21/2022] Open
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Kacar SD, Ozuguz P, Polat S, Kacar E, Polat O, Tokyol C. Juvenile localized scleroderma with port wine stain: coincidental or possible common pathogenetic association. Indian J Dermatol 2015; 60:216. [PMID: 25814757 PMCID: PMC4372961 DOI: 10.4103/0019-5154.152579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Port wine stain and juvenile localized scleroderma are two different dermatoses usually encountered in pediatric age group. Up to now, there are reports of morphea patients initially diagnosed and treated as port wine stain. Coexistence of both diseases is not found yet. We herein present a case of juvenile localized scleroderma on the left side of trunk, with congenital port wine stain located on the ipsilateral face at V1-V2 distribution.
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Affiliation(s)
- Seval Dogruk Kacar
- Department of Dermatology, School of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey
| | - Pinar Ozuguz
- Department of Dermatology, School of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey
| | - Serap Polat
- Department of Dermatology, School of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey
| | - Emre Kacar
- Department of Radiology, School of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey
| | - Onur Polat
- Department of Opthalmology, School of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey
| | - Cigdem Tokyol
- Department of Pathology, School of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey
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Mixed connective tissue disease presenting with progressive scleroderma symptoms in a 10-year-old girl. Postepy Dermatol Alergol 2013; 30:329-36. [PMID: 24353496 PMCID: PMC3858664 DOI: 10.5114/pdia.2013.38365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 06/15/2013] [Accepted: 08/20/2013] [Indexed: 11/30/2022] Open
Abstract
Mixed connective tissue disease (MCTD) is a systemic inflammatory disease affecting connective tissue with the underlying autoimmunological mechanism. The core of MCTD is an appearance of symptoms of several other inflammatory diseases of connective tissue – systemic lupus erythematosus, systemic scleroderma, poly- or dermatomyositis, rheumatoid arthritis at the same time, accompanied by a high level of anti-ribonucleoprotein antibodies (anti-U1RNP). The disease was described more than 40 years ago by Sharp et al. During recent years, many efforts to better understand clinical and serological features of MCTD have been made. Diagnosis of MCTD can be difficult. Obligatory international diagnostic criteria are required to be fulfilled. Several versions of such criteria have been proposed, but the most widely used one was described by Kasukawa. There is no consensus about treatment – a choice of drugs depends on symptoms. We present a case of a 10-year-old girl with sclerodactyly and trophic damages of fingers accompanied by symptoms of Raynaud's phenomenon. After an almost 2-year course of the disease, a diagnosis of MCTD has been established.
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Noh JW, Kim J, Kim JW. Localized scleroderma: a clinical study at a single center in Korea. Int J Rheum Dis 2013; 16:437-41. [PMID: 23992265 DOI: 10.1111/1756-185x.12080] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Localized scleroderma (morphea) is a rare autoimmune disease limited to the skin, characterized by cutaneous fibrosing and obstructive vasculopathy. Localized scleroderma may invade into the subcutaneous fat layer and cause permanent functional disability. Because of its rarity, there have been few clinical surveys of patients with localized scleroderma in Korea. The aim of this study was to elucidate the clinical presentation, serological data, and clinical outcomes of localized scleroderma. METHODS This was a retrospective survey conducted by reviewing available medical records during a 7 year-period from 2004 to 2010 in a single medical center in Jeju Island, South Korea. In total 43 patients with localized scleroderma were included. RESULTS Localized scleroderma occurred primarily in females (female to male ratio 2.6 : 1.0). Most patients were between 10 and 29 years of age and the mean age at diagnosis was 26.2 years. Plaque (51.2%) and linear morphea (37.2%) were most common. No case was associated with systemic scleroderma (systemic sclerosis). The most common site of plaque morphea was the trunk (47.8%). In the linear type, the most common site was head-neck (52.9%). Fluorescent antinuclear antibody was positive in 23.3% of all cases. Treatment included systemic corticosteroids, colchicine, anti-malarial agents, D-penicillamine or intralesional triamcinolone injection. Clinical improvement, including significant and partial response, was seen in only 62.8% of treated patients. CONCLUSION Localized scleroderma is a chronic inflammatory condition confined to the skin. In order to exclude other conditions, thorough history taking, physical examination, serologic studies and histopathologic examinations should be conducted.
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Affiliation(s)
- Jung Won Noh
- Depatment of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
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Kura MM, Jindal SR. Disabling pansclerotic morphea of childhood with extracutaneous manifestations. Indian J Dermatol 2013; 58:159. [PMID: 23716826 PMCID: PMC3657236 DOI: 10.4103/0019-5154.108079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Disabling pansclerotic morphea (DPM) of childhood is a rare generalized type of localized scleroderma (LS) that is known to follow an aggressive course with pansclerotic lesions leading to severe joint contractures and consequent immobility. Mortality is due to complications of the disease such as bronchopneumonia, sepsis, or gangrene. There is no specific laboratory finding. Treatment protocols are still evolving for this severe recalcitrant disorder. Extracutaneous manifestations are rarely reported in DPM. We present the case of a 7-year-old girl with DPM with severe extracutaneous manifestations in the form of gastrointestinal and vascular disease, whose disease progressed rapidly. In spite of treatment with methotrexate, corticosteroids, and PUVA therapy, she ultimately succumbed to her illness due to sepsis.
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Affiliation(s)
- Mahendra M Kura
- Department of Dermatology, Venereology and Leprosy, Grant Medical College, Mumbai, India
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Amaral TN, Marques Neto JF, Lapa AT, Peres FA, Guirau CR, Appenzeller S. Neurologic involvement in scleroderma en coup de sabre. Autoimmune Dis 2012; 2012:719685. [PMID: 22319646 PMCID: PMC3272788 DOI: 10.1155/2012/719685] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 12/04/2011] [Indexed: 11/17/2022] Open
Abstract
Localized scleroderma is a rare disease, characterized by sclerotic lesions. A variety of presentations have been described, with different clinical characteristics and specific prognosis. In scleroderma en coup de sabre (LScs) the atrophic lesion in frontoparietal area is the disease hallmark. Skin and subcutaneous are the mainly affected tissues, but case reports of muscle, cartilage, and bone involvement are frequent. These cases pose a difficult differential diagnosis with Parry-Romberg syndrome. Once considered an exclusive cutaneous disorder, the neurologic involvement present in LScs has been described in several case reports. Seizures are most frequently observed, but focal neurologic deficits, movement disorders, trigeminal neuralgia, and mimics of hemiplegic migraines have been reported. Computed tomography and magnetic resonance imaging have aided the characterization of central nervous system lesions, and cerebral angiograms have pointed to vasculitis as a part of disease pathogenesis. In this paper we describe the clinical and radiologic aspects of neurologic involvement in LScs.
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Affiliation(s)
- Tiago Nardi Amaral
- Rheumatology Division, Faculty of Medical Science, State University of Campinas, 13083-970 Campinas, SP, Brazil
| | - João Francisco Marques Neto
- Rheumatology Division, Faculty of Medical Science, State University of Campinas, 13083-970 Campinas, SP, Brazil
| | - Aline Tamires Lapa
- Postgraduate Program in Child and Adolescent Health, Faculty of Medical Science, State University of Campinas, 13083-970 Campinas (UNICAMP), Brazil
| | - Fernando Augusto Peres
- Rheumatology Lab, Faculty of Medical Science, State University of Campinas, 13083-970 Campinas, SP, Brazil
| | - Caio Rodrigues Guirau
- Rheumatology Lab, Faculty of Medical Science, State University of Campinas, 13083-970 Campinas, SP, Brazil
| | - Simone Appenzeller
- Rheumatology Division, Faculty of Medical Science, State University of Campinas, 13083-970 Campinas, SP, Brazil
- Rheumatology Lab, Faculty of Medical Science, State University of Campinas, 13083-970 Campinas, SP, Brazil
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Karaca NE, Aksu G, Karaca E, Tuzun F, Gunes AT, Ozkinay F, Kutukculer N. Progressive morphea of early childhood tracing Blaschko’s lines on the face: involvement of X chromosome monosomy in pathogenesis and clinical prognosis. Int J Dermatol 2011; 50:1406-1410. [DOI: 10.1111/j.1365-4632.2011.04900.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Noh TW, Park SH, Kang YS, Lee UH, Park HS, Jang SJ. Morphea developing at the site of healed herpes zoster. Ann Dermatol 2011; 23:242-5. [PMID: 21747631 DOI: 10.5021/ad.2011.23.2.242] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 05/28/2010] [Accepted: 06/23/2010] [Indexed: 11/08/2022] Open
Abstract
Wolf's isotopic response describes the occurrence of a new, unrelated disease that appears at the same location as a previously healed skin disease, and the most common primary skin disease of this phenomenon is herpes zoster. Several cutaneous lesions have been described to occur at the site of healed herpes zoster, and granulomatous dermatitis and granuloma annulare have been reported to be the most common second diseases. The pathogenesis of the isotopic response is still unclear. Morphea can develop at the site of regressed herpes zoster and a few such cases have been reported. We present here an additional case of morphea that developed at the site of previously healed herpes zoster, and we review the relevant literature.
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Affiliation(s)
- Tae Woo Noh
- Department of Dermatology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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22
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Maletic J, Tsirka V, Ioannides P, Karacostas D, Taskos N. Parry-Romberg Syndrome Associated with Localized Scleroderma. Case Rep Neurol 2010; 2:57-62. [PMID: 20671858 PMCID: PMC2905582 DOI: 10.1159/000314927] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Parry-Romberg syndrome is a rare neurocutaneous disorder of unknown origin. It is characterized by progressive facial hemiatrophy and frequently overlaps with a condition known as linear scleroderma ‘en coup de sabre’. Neurological involvement is frequently described in these patients, including migraine, facial pain and epilepsy, which represent the commonest neurological conditions, sometimes associated with brain abnormalities ipsilaterally to the skin lesions. We present a case of Parry-Romberg syndrome with neurological involvement in a patient with diagnosed localized scleroderma (morphea).
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Affiliation(s)
- Jelena Maletic
- B Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece
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23
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Chiang KL, Chang KP, Wong TT, Hsu TR. Linear scleroderma "en coup de sabre": initial presentation as intractable partial seizures in a child. Pediatr Neonatol 2009; 50:294-8. [PMID: 20025145 DOI: 10.1016/s1875-9572(09)60081-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Linear scleroderma is a form of localized scleroderma characterized by sclerotic lesions distributed in a linear, band-like pattern. The "en coup de sabre" subtype of linear scleroderma is more often associated with systemic morbidity, including ocular, oral, and neurological abnormalities. Here, we report one patient with typical linear scleroderma "en coup de sabre" (LSCS). Initially, he presented with refractory partial seizures before the characteristic skins lesion on his head developed. This was a rare case with obvious brain parenchyma involvement. We did not prescribe medication but performed serial brain magnetic resonance imaging follow-up for the intraparenchymal lesion. The atrophic changes of the skin, face and brain remained the same, and his seizures had not worsened at the most recent follow-up. Parry-Romberg syndrome, a very similar condition, should be differentiated from LSCS.
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Affiliation(s)
- Kuo-Liang Chiang
- Department of Pediatrics, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
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24
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WOZNIAK JACEK, DABROWSKI RAFAL, LUCZAK DARIUSZ, KWIATKOWSKA MALGORZATA, MUSIEJ-NOWAKOWSKA ELZBIETA, KOWALIK ILONA, SZWED HANNA. Evaluation of Heart Rhythm Variability and Arrhythmia in Children with Systemic and Localized Scleroderma. J Rheumatol 2009; 36:191-6. [DOI: 10.3899/jrheum.080021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To evaluate possible disturbances in autonomic regulation and cardiac arrhythmias in children with localized and systemic scleroderma.Methods.There were 40 children included in the study: 20 with systemic and 20 with localized scleroderma. The control group comprised 20 healthy children.Results.In 24-hour Holter recording, the average rate of sinus rhythm was significantly higher in the groups with systemic and localized scleroderma than in the control group, but there was no significant difference between them. The variability of heart rhythm in both groups was significantly decreased. In the group with systemic scleroderma, single supraventricular ectopic beats were observed in 20% and runs were seen in 40% of patients. In the group with localized scleroderma, supraventricular single ectopic beats occurred in 35% of patients and runs in 45% of those studied. Ventricular arrhythmia occurred in 2 children with systemic scleroderma, but in 1 child, it was complex.Conclusion.The most frequent cardiac arrhythmias in both types of scleroderma in children were of supraventricular origin, whereas ventricular arrhythmias did not occur very often. There were no significant differences in autonomic disturbances manifesting as a higher heart rate and decreased heart rate variability between localized and systemic scleroderma.
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25
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Denton CP, Derrett-Smith EC. Juvenile-onset systemic sclerosis: children are not small adults. Rheumatology (Oxford) 2008; 48:96-7. [DOI: 10.1093/rheumatology/ken418] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
PURPOSE OF REVIEW Localized scleroderma, also known as morphea, is the most frequent form of scleroderma in childhood. Early diagnosis, appropriate assessment and effective treatment may improve the long-term outcome. RECENT FINDINGS Recent studies, regarding the microchimerism theory or the mechanism of action of phototherapy, have yielded important information on the disease etiopathogenesis. Others have added interesting contributions on new outcome measures for the disease assessment and for the development of future therapeutic trials. Previous results, using methotrexate and phototherapy, have been confirmed. A successful use of bosentan, an endothelin receptor antagonist with vasodilatative and antifibrotic properties for refractory cutaneous ulcerations in pansclerotic morphea, opens new horizons of treatment. SUMMARY Studies over the past year highlight the role of some outcome measures in the disease assessment and monitoring, with important implications both for the clinical practice and future clinical trials.
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Russo RAG, Katsicas MM. Clinical characteristics of children with Juvenile Systemic Sclerosis: follow-up of 23 patients in a single tertiary center. Pediatr Rheumatol Online J 2007; 5:6. [PMID: 17550632 PMCID: PMC1869029 DOI: 10.1186/1546-0096-5-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 05/01/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Juvenile systemic sclerosis (JSS) is a multisystem connective tissue disease characterized by skin fibrosis and internal organ involvement. It has a low prevalence, even in a tertiary facility setting. The purpose of the present study is to describe and analyze the clinical and laboratory characteristics of a group of children with JSS followed in a single center. METHODS Clinical charts of children with a diagnosis of JSS who were seen at a tertiary referral center between 1995 and 2005 were reviewed. Clinical features were recorded and analysed. RESULTS Twenty-three patients who met preliminary classification criteria for JSS were included. Age at first symptom attributable to JSS was 6 (1-14) years, The first symptom attributable to JSS was Raynaud's phenomenon in 14 cases. Proximal sclerosis (23 patients, 100%), sclerodactyly (21, 91%), Raynaud's phenomenon (19, 83%), and periungual capillaropathy (17, 74%) were the most consistent clinical findings during follow-up. Respiratory involvement occurred in two thirds of our patients, and it manifested as dyspnea as well as abnormal imaging and/or pulmonary function tests; pulmonary hypertension was an infrequent finding. Dysphagia was the commonest gastrointestinal symptom (9 patients, 39%). The most frequent musculoskeletal symptom was arthralgia (14 children, 6%); symmetrical arthritis was found in 8 (35%) patients. Periungual capillary abnormalities were evident during physical examination in 17 children; capillaroscopy revealed abnormalities in all 19 examined patients. ANA were present in 17 (74%) children: homogeneous pattern was the most frequent (8 patients), nucleolar (5) and speckled (4) were less common. CONCLUSION Raynaud's phenomenon heralds the beginning of the disease. Capilaroscopy is a major adjuvant in the diagnosis, since autoantibody determination may not offer sensitive and specific markers. Skin and vascular manifestations are the most common clinical features, while internal organ involvement is more rare. Cardiopulmonary disease is the most frequent visceral involvement, leading to significant morbidity.
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Affiliation(s)
- Ricardo AG Russo
- Service of Immunology and Rheumatology, Hospital de Pediatría Prof. Dr. Juan P. Garrahan. Combate de los Pozos 1881, (1245) Buenos Aires, Argentina
| | - María M Katsicas
- Service of Immunology and Rheumatology, Hospital de Pediatría Prof. Dr. Juan P. Garrahan. Combate de los Pozos 1881, (1245) Buenos Aires, Argentina
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Abstract
PURPOSE OF REVIEW Localized scleroderma, also known as morphoea, has a variety of clinical manifestations that can include systemic involvement. Early recognition, diagnosis and treatment may improve the long-term outcome. RECENT FINDINGS A large multicentre study coordinated by the Pediatric Rheumatology European Society has yielded important information on the epidemiology and clinical manifestations of juvenile localized scleroderma, especially as it pertains to systemic manifestations. Previous results using methotrexate and corticosteroids have been confirmed. Studies on phototherapy have also demonstrated efficacy. A new immunomodulator, imiquimod, has shown promise in an initial case series. SUMMARY Studies over the past year highlight the wide range of extracutaneous manifestations and different forms of localized scleroderma and suggest that treatment may be beneficial.
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Affiliation(s)
- Ronald M Laxer
- Department of Paediatrics and Medicine, University of Toronto, Vice President, Education and Quality, The Hospital for Sick Children, Toronto, Canada.
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Misra R, Singh G, Aggarwal P, Aggarwal A. Juvenile onset systemic sclerosis: a single center experience of 23 cases from Asia. Clin Rheumatol 2006; 26:1259-62. [PMID: 17180299 DOI: 10.1007/s10067-006-0483-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 11/03/2006] [Accepted: 11/06/2006] [Indexed: 11/29/2022]
Abstract
The aim of this paper was to study the spectrum of juvenile scleroderma (JSSc) seen at a tertiary care referral center in Asia. Retrospective analysis of case records of patients with systemic sclerosis, having age of onset less than 16 years and seen at our hospital from 1988 to 2004, was done. Patients with linear scleroderma and morphea were excluded. There were 23 patients (19 girls, 4 boys) with median age of onset of 12 years (range 5-16 years). The median age at presentation was 17 years (range 10-34 years). The median time from first symptoms to presentation was 4 years (range 0.2-26 years). Among these, 14 had diffuse systemic sclerosis (DSSc), while 9 had limited scleroderma (LSSc). The clinical features seen at presentation in patients were: Raynaud's phenomenon in 19, digital ulcers in 14, loss of finger tip pulp in 12, reflux in 8, dysphagia in 7, arthritis in 8, digital gangrene in 2, and pulmonary artery hypertension in 1. Antinuclear antibody was positive in 15 out of 18 patients tested. Interstitial lung disease was seen in 15 patients, 6 of whom had diffuse disease. The median skin score was 22 (range 7-48) . One patient died of primary pulmonary hypertension within 1 year of onset of symptoms. At a mean follow-up of 34 months, 14 patients were stable or had improvement in skin score or dyspnea on exertion. DSSc and LSSc in childhood have a clinical presentation similar to adult patients, with cardiopulmonary involvement being the major predictor of outcome. The short-term prognosis of JSSc is good.
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Affiliation(s)
- Ramnath Misra
- Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
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30
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Rosenkranz ME, Agle LMA, Efthimiou P, Lehman TJA. Systemic and localized scleroderma in children: current and future treatment options. Paediatr Drugs 2006; 8:85-97. [PMID: 16608370 DOI: 10.2165/00148581-200608020-00002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Scleroderma is a group of rare and complex diseases with varied clinical manifestations. The most obvious manifestation of the diseases is skin hardening and sclerosis. Scleroderma can be divided into two main subgroups: systemic and localized. The systemic form, also known as systemic sclerosis, involves diffuse skin involvement and potentially severe visceral involvement. Localized scleroderma on the other hand is more common in children and usually confined to a specific region of the body with no internal organ involvement. The juvenile forms of systemic sclerosis and localized scleroderma are important conditions in children because of the clinical severity and substantial mortality of systemic scleroderma and the major growth defects associated with childhood-onset localized disease even if the active disease itself is self-limited. The pathogenic pathways of the various forms of scleroderma are only partially defined, but the main defect in scleroderma is abnormal collagen deposition leading to eventual fibrosis in the skin as well as multiple organ systems such as the heart and lungs in juvenile systemic sclerosis. Therapeutics are divided into three main subgroups for systemic sclerosis: antifibrotics, anti-inflammatories, and vasodilators. For localized disease, anti-inflammatories, vitamin D analogs, and UV irradiation have been investigated. However, the infrequency of scleroderma in the pediatric population plus the fact that this disease is very often self-limiting makes randomized controlled trials very difficult. It is for this reason that most data on treatment modalities for this disease have been extrapolated from studies in adult patients. There is no one therapy for systemic sclerosis or localized scleroderma that has proven to be very effective or significantly disease modifying. However, current therapeutic strategies must be initiated early in the disease course for maximum beneficial clinical effects. New interventions such as autologous stem cell transplant and cytokine-directed therapies are under investigation as potential treatments for this complex disease.
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Affiliation(s)
- Margalit E Rosenkranz
- Hospital for Special Surgery, Division of Pediatric Rheumatology, New York, New York, USA
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31
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Zulian F, Vallongo C, de Oliveira SKF, Punaro MG, Ros J, Mazur-Zielinska H, Galea P, Da Dalt L, Eichenfield LF. Congenital localized scleroderma. J Pediatr 2006; 149:248-51. [PMID: 16887444 DOI: 10.1016/j.jpeds.2006.04.052] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Revised: 02/14/2006] [Accepted: 04/13/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Juvenile localized scleroderma (JLS) usually has its onset during later childhood. This report describes the clinical and serologic features of six children with congenital localized scleroderma (CLS). STUDY DESIGN A large, multinational study was conducted among pediatric rheumatology and dermatology centers by collecting information on demographics, family history, triggering environmental factors, clinical features, laboratory reports, and treatment of patients with JLS. Patients with onset at birth were carefully examined. RESULTS Among 750 patients with JLS, 6 patients (0.8%) had scleroderma-related lesions at birth. Female-to-male ratio was 2:1. All patients had linear scleroderma, in four involving the face with en coup de sabre appearance. Two patients were misdiagnosed as having skin infection, one nevus, one salmon patch, and two undefined skin lesions. The mean diagnostic delay was 3.9 years. In comparison with the group of 733 patients with late-onset JLS, CLS presented a significantly more prolonged disease duration at diagnosis and a higher frequency of en coup de sabre subtypes. CONCLUSIONS Congenital localized scleroderma is a rare and probably underestimated condition in neonates. The linear subtype was the exclusive manifestation of the disease. CLS should be included in the differential diagnosis of infants with cutaneous erythematous fibrotic lesions to avoid functional and aesthetic sequelae and to allow prompt therapy.
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Holland KE, Steffes B, Nocton JJ, Schwabe MJ, Jacobson RD, Drolet BA. Linear scleroderma en coup de sabre with associated neurologic abnormalities. Pediatrics 2006; 117:e132-6. [PMID: 16326691 DOI: 10.1542/peds.2005-0470] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Linear scleroderma represents a unique form of localized scleroderma that primarily affects the pediatric population, with 67% of patients diagnosed before 18 years of age. When linear scleroderma occurs on the head, it is referred to as linear scleroderma en coup de sabre, given the resemblance of the skin lesions to the stroke of a sabre. Here we describe 3 pediatric patients with linear scleroderma en coup de sabre who presented with neurologic abnormalities before or concurrent with the diagnosis of their skin disease. Our patients' cases highlight the underrecognized relationship between neurologic complications and linear scleroderma en coup de sabre and illustrate the importance of a thorough skin examination in patients with unexplained neurologic disease.
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Affiliation(s)
- Kristen E Holland
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Zulian F, Athreya BH, Laxer R, Nelson AM, Feitosa de Oliveira SK, Punaro MG, Cuttica R, Higgins GC, Van Suijlekom-Smit LWA, Moore TL, Lindsley C, Garcia-Consuegra J, Esteves Hilário MO, Lepore L, Silva CA, Machado C, Garay SM, Uziel Y, Martini G, Foeldvari I, Peserico A, Woo P, Harper J. Juvenile localized scleroderma: clinical and epidemiological features in 750 children. An international study. Rheumatology (Oxford) 2005; 45:614-20. [PMID: 16368732 DOI: 10.1093/rheumatology/kei251] [Citation(s) in RCA: 258] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Juvenile localized scleroderma (JLS) includes a number of conditions often grouped together. With the long-term goal of developing uniform classification criteria, we studied the epidemiological, clinical and immunological features of children with JLS followed by paediatric rheumatology and dermatology centres. METHODS A large, multicentre, multinational study was conducted by collecting information on the demographics, family history, triggering environmental factors, clinical and laboratory features, and treatment of patients with JLS. RESULTS Seven hundred and fifty patients with JLS from 70 centres were enrolled into the study. The disease duration at diagnosis was 18 months. Linear scleroderma (LS) was the most frequent subtype (65%), followed by plaque morphea (PM) (26%), generalized morphea (GM) (7%) and deep morphea (DM) (2%). As many as 15% of patients had a mixed subtype. Ninety-one patients (12%) had a positive family history for rheumatic or autoimmune diseases; 100 (13.3%) reported environmental events as possible trigger. ANA was positive in 42.3% of the patients, with a higher prevalence in the LS-DM subtype than in the PM-GM subtype. Scl70 was detected in the sera of 3% of the patients, anticentromere antibody in 2%, anti-double-stranded DNA in 4%, anti-cardiolipin antibody in 13% and rheumatoid factor in 16%. Methotrexate was the drug most frequently used, especially during the last 5 yr. CONCLUSION This study represents the largest collection of patients with JLS ever reported. The insidious onset of the disease, the delay in diagnosis, the recognition of mixed subtype and the better definition of the other subtypes should influence our efforts in educating trainees and practitioners and help in developing a comprehensive classification system for this syndrome.
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Affiliation(s)
- F Zulian
- Dipartimento di Pediatria, Università di Padova, Via Giustiniani 3, 35128 Padova, Italy.
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Abstract
This article discusses the various clinical, laboratory, and therapeutic aspects of systemic sclerosis and localized scleroderma in children. The close collaboration among pediatricians, rheumatologists, and dermatologists represents an important advance in the management of these disabling conditions.
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Affiliation(s)
- Francesco Zulian
- Pediatric Rheumatology Unit, Department of Pediatrics, University of Padova, Via Giustiniani 3 35128, Padua, Italy.
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36
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Zulian F, Vallongo C, Woo P, Russo R, Ruperto N, Harper J, Espada G, Corona F, Mukamel M, Vesely R, Musiej-Nowakowska E, Chaitow J, Ros J, Apaz MT, Gerloni V, Mazur-Zielinska H, Nielsen S, Ullman S, Horneff G, Wouters C, Martini G, Cimaz R, Laxer R, Athreya BH. Localized scleroderma in childhood is not just a skin disease. ACTA ACUST UNITED AC 2005; 52:2873-81. [PMID: 16142730 DOI: 10.1002/art.21264] [Citation(s) in RCA: 210] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Juvenile localized scleroderma is usually considered a disease that is confined to the skin and subcutaneous tissue. We studied the prevalence and clinical features of extracutaneous manifestations in a large cohort of children with juvenile localized scleroderma. METHODS Data from a multinational study on juvenile scleroderma was used for this in-depth study. Clinical features of patients with extracutaneous manifestations were compared with those of patients who had exclusively skin involvement. RESULTS Seven hundred fifty patients entered the study. One hundred sixty-eight patients (22.4%) presented with a total of 193 extracutaneous manifestations, as follows: articular (47.2%), neurologic (17.1%), vascular (9.3%), ocular (8.3%), gastrointestinal (6.2%), respiratory (2.6%), cardiac (1%), and renal (1%). Other autoimmune conditions were present in 7.3% of patients. Neurologic involvement consisted of epilepsy, central nervous system vasculitis, peripheral neuropathy, vascular malformations, headache, and neuroimaging abnormalities. Ocular manifestations were episcleritis, uveitis, xerophthalmia, glaucoma, and papilledema. In more than one-fourth of these children, articular, neurologic, and ocular involvements were unrelated to the site of skin lesions. Raynaud's phenomenon was reported in 16 patients. Respiratory involvement consisted essentially of restrictive lung disease. Gastrointestinal involvement was reported in 12 patients and consisted exclusively of gastroesophageal reflux. Thirty patients (4%) had multiple extracutaneous features, but systemic sclerosis (SSc) developed in only 1 patient. In patients with extracutaneous involvement, the prevalence of antinuclear antibodies and rheumatoid factor was significantly higher than that among patients with only skin involvement. However, Scl-70 and anticentromere, markers of SSc, were not significantly increased. CONCLUSION Extracutaneous manifestations of juvenile localized scleroderma developed in almost one-fourth of the children in this study. These extracutaneous manifestations often were unrelated to the site of the skin lesions and sometimes were associated with multiple organ involvement. The risk of developing SSc was very low. This subgroup of patients with juvenile localized scleroderma should be evaluated extensively, treated more aggressively, and monitored carefully.
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37
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Abstract
In this paper, the various systemic manifestations reported in localized scleroderma, their incidence, their relationship with systemic sclerosis, and their relationship with other autoimmune or connective tissue diseases will be analyzed.
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Affiliation(s)
- Francesco Zulian
- Pediatric Rheumatology Unit, Department of Pediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy.
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Cefle A, Cefle K. A case of mandibuloacral dysplasia presenting with features of scleroderma. Int J Clin Pract 2004; 58:635-8. [PMID: 15311567 DOI: 10.1111/j.1368-5031.2004.00139.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Juvenile scleroderma, a relatively rare condition, may be confused with a number of progeroid syndromes like Hutchinson-Gilford syndrome, Werner syndrome and Rothmund-Thomson syndrome. In this case report, we describe a 9-year-old boy who presented with sclerodactyly, acroosteolysis and scleroderma-like involvement of the skin over hands and feet, which suggested a diagnosis of juvenile scleroderma initially. However, absence of Raynaud's phenomenon, sparing of the skin other than hands and feet and negative serological studies did not support this diagnosis. On the basis of additional findings (micrognathia, dental malformation, a 'beaked nose', open cranial sutures and sparse hair), the patient was diagnosed as mandibuloacral dysplasia, a rare autosomal recessive disease. This case demonstrates that mandibuloacral dysplasia should be considered in the differential diagnosis of juvenile scleroderma in the presence of atypical features such as negative serological studies, absence of Raynaud's phenomenon, sparse hair and micrognathia.
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Affiliation(s)
- A Cefle
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Kocaeli University.
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Abstract
The scleroderma disorders remain challenging conditions in pediatric rheumatology to understand pathologically and indeed for which to provide care. It is clear that much progress is being made in the clinical approach to understanding this group of group of disorders. It seems likely that the different lesions of LS may represent unique immunopathogenic mechanisms or perhaps reflect unique genetic or other characteristics of the patients themselves. To take advantage of the revolution in therapies now occurring in rheumatology it is critical that controlled clinical trials are developed with appropriate agreed upon outcome measures for both localized and systemic disease.
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MESH Headings
- Adolescent
- Antibodies, Antinuclear/analysis
- Child
- Diagnosis, Differential
- Esophageal Diseases/complications
- Humans
- Lung Diseases/complications
- Outcome Assessment, Health Care
- Prognosis
- Raynaud Disease/complications
- Scleroderma, Localized/classification
- Scleroderma, Localized/diagnosis
- Scleroderma, Localized/epidemiology
- Scleroderma, Localized/immunology
- Scleroderma, Localized/therapy
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/diagnosis
- Scleroderma, Systemic/immunology
- Scleroderma, Systemic/therapy
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Affiliation(s)
- Kevin J Murray
- Department of Rheumatology, Princess Margaret Hospital for Children, GPO Box D184, Perth, WA 6008, Australia.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Centre, Sehgal Nursing Home, Panchwati, Azadpur, Delhi, India.
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41
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Abstract
Juvenile scleroderma is a rare disease of childhood. The 2 main forms are localised and systemic scleroderma, although the pathogenesis of both forms is still unclear. The main clinical characteristic is the presence of skin sclerosis. Localised scleroderma can be divided into 3 different subtypes: morphoea, linear scleroderma and 'coup de sabre' lesions. The incidence is 0.2 to 0.4 per 100,000. 25 to 40% of patients are rheumatoid factor positive and 23 to 67% antinuclear antibody positive. An increased number of eosinophils occur in 31% of patients. Systemic sclerosis is an even rarer disease; approximately 10% of patients evolve the disease before the age of 18 years. The clinical presentation and disease course differ from the adult disease. This is reflected in the much better outcome. With regard to therapeutic options, there is still no gold standard for either form of the disease.
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Affiliation(s)
- I Foeldvari
- Paediatric Rheumatology Clinic, AK-Eilbek, Hamburg, Germany
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42
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Elst EF, Van Suijlekom-Smit LW, Oranje AP. Treatment of linear scleroderma with oral 1,25-dihydroxyvitamin D3 (calcitriol) in seven children. Pediatr Dermatol 1999; 16:53-8. [PMID: 10028002 DOI: 10.1046/j.1525-1470.1999.99016.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Linear scleroderma is a connective tissue disorder that characteristically involves the skin. Skin induration and pigmentary changes present in a linear distribution. Severe functional and cosmetic disability may occur, especially in growing children. No effective therapy for the fibrotic stage of scleroderma is available at present. Recently a beneficial effect of oral 1, 25-dihydroxyvitamin D3 (calcitriol) treatment was reported in adults. Calcitriol has a dose-dependent inhibition on fibroblast proliferation and collagen synthesis and has immunoregulatory activities. We assessed the efficacy of oral calcitriol treatment in seven pediatric patients with linear scleroderma. During the treatment dietary calcium intake was restricted. Calcium, inorganic phosphate, creatinine, and urea in the serum and urine was monitored. The urinary calcium:creatinine ratio was measured. The effects of the treatment were evaluated using a clinical scoring system. No side effects were observed. Five of the seven patients showed a good to excellent improvement of their lesions. One of them partly relapsed after 19 months, but showed an excellent response to a second therapy session with calcitriol. One patient with rapidly progressive disease failed to respond to therapy. Our results indicate that calcitriol can be an effective agent for treating localized scleroderma in children.
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Affiliation(s)
- E F Elst
- Department of Dermatology and Venereology, University Hospital Rotterdam, The Netherlands
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44
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Affiliation(s)
- C M Black
- Academic Unit of Rheumatology, Royal Free Hospital School of Medicine, London, United Kingdom
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45
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Abstract
Scleroderma is a diverse group of conditions which have in common fibrosis of skin and other tissues. Although less common in children than in adults, these conditions are an important cause of morbidity and occasional mortality when they occur in the pediatric population. Children are more likely than adults to develop localized forms of scleroderma, and because of the impact on growth, these can result in major facial or limb asymmetry, flexion contractures, and disability. Management approaches must take into consideration the effect of medications on the child (for example, growth failure and osteoporosis from corticosteroids) as well as the psychosocial impact of chronic illness and physical deformity on the child and family. This article describes the types of scleroderma identified in children, reviews epidemiologic and etiologic factors, and discusses management options. Because this is a rare group of diseases managed by both dermatologists and rheumatologists, large series of patients are rare, and controlled studies of management are not available.
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MESH Headings
- Adolescent
- Adult
- Age of Onset
- Child
- Child, Preschool
- Diagnosis, Differential
- Female
- Humans
- Incidence
- Male
- Prognosis
- Scleroderma, Localized/diagnosis
- Scleroderma, Localized/epidemiology
- Scleroderma, Localized/physiopathology
- Scleroderma, Localized/therapy
- Scleroderma, Systemic/diagnosis
- Scleroderma, Systemic/epidemiology
- Scleroderma, Systemic/physiopathology
- Scleroderma, Systemic/therapy
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Affiliation(s)
- H Emery
- Department of Pediatrics, University of California at San Francisco, 94143-0105, USA
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46
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Jablonska S, Blaszczyk M. Childhood-onset scleroderma from a dermatologist's perspective: comment on the article by Vancheeswaran et al. ARTHRITIS AND RHEUMATISM 1997; 40:1183-4. [PMID: 9182935 DOI: 10.1002/art.1780400629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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