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Kreuter A, Moinzadeh P, Kinberger M, Horneff G, Worm M, Werner RN, Hammacher A, Krieg T, Wenzel J, Oeschger M, Weibel L, Müllegger R, Hunzelmann N. S2k guideline: Diagnosis and therapy of localized scleroderma. J Dtsch Dermatol Ges 2024; 22:605-620. [PMID: 38426689 DOI: 10.1111/ddg.15328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 03/02/2024]
Abstract
The updated S2k guideline deals with the diagnosis and therapy of localized scleroderma (LoS). LoS represents a spectrum of sclerotic skin diseases in which, depending on the subtype and localisation, structures such as adipose tissue, muscles, joints, and bones may also be affected. Involvement of internal organs or progression to systemic sclerosis does not occur. LoS can be classified into four main forms: limited, generalized, linear, and mixed forms, with some additional subtypes. For cases of limited skin involvement, the guideline primarily recommends therapy with topical corticosteroids. UV therapy can also be recommended. In subtypes with severe skin or musculoskeletal involvement, systemic therapy with methotrexate is recommended. During the active phase of the disease, systemic glucocorticosteroids can be used additionally. In cases of methotrexate and steroid refractory courses, contraindications, or intolerance, mycophenolate mofetil, mycophenolic acid, or abatacept can be considered as second-line systemic therapies. In the case of linear LoS, autologous adipose-derived stem cell transplantation can also be performed for correcting soft tissue defects.
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Affiliation(s)
- Alexander Kreuter
- Department of Dermatology, Venereology and Allergology, Helios St. Elisabeth Hospital Oberhausen, Oberhausen, Germany
- Department of Dermatology, Venereology and Allergology, Helios St. Johannes Hospital Duisburg, Duisburg, Germany
| | - Pia Moinzadeh
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Maria Kinberger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Division of Evidence-Based Medicine (dEBM), Berlin, Germany
| | - Gerd Horneff
- Department of General Pediatrics, Asklepios Hospital, St. Augustin, Germany
| | - Margitta Worm
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Berlin, Germany
| | - Ricardo N Werner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Division of Evidence-Based Medicine (dEBM), Berlin, Germany
| | | | - Thomas Krieg
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Jörg Wenzel
- Department of Dermatology and Allergology, University Bonn, Bonn, Germany
| | | | - Lisa Weibel
- University Children's Hospital Zurich, Zurich, Switzerland
| | - Robert Müllegger
- Department of Dermatology and Venereology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Nicolas Hunzelmann
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
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Kreuter A, Moinzadeh P, Kinberger M, Horneff G, Worm M, Werner RN, Hammacher A, Krieg T, Wenzel J, Oeschger M, Weibel L, Müllegger R, Hunzelmann N. S2k‐Leitlinie: Diagnostik und Therapie der zirkumskripten Sklerodermie. J Dtsch Dermatol Ges 2024; 22:605-621. [PMID: 38574014 DOI: 10.1111/ddg.15328_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 04/06/2024]
Abstract
ZusammenfassungDie vorliegende aktualisierte S2k‐Leitlinie befasst sich mit der Diagnostik und der Therapie der zirkumskripten Sklerodermie (ZS). Diese umfasst ein Spektrum sklerotischer Erkrankungen der Haut mit, je nach Subtyp und Lokalisation, möglicher Beteiligung von hautnahen Strukturen wie Fettgewebe, Muskulatur, Gelenke und Knochen. Ein Befall innerer Organe oder ein Übergang in eine systemische Sklerodermie treten nicht auf. Eingeteilt werden kann die ZS in die vier Hauptformen der limitierten, generalisierten, linearen und gemischten Form. Teilweise existieren weitere Unterformen. Bei limitiertem Hautbefall empfiehlt die Leitlinie primär eine Therapie mit topischen Kortikosteroiden. Eine UV‐Therapie kann ebenfalls sinnvoll sein. Bei Subtypen mit schwerem Hautbefall oder muskuloskelettalem Befall wird eine systemische Therapie mit Methotrexat empfohlen. In der aktiven Phase der Erkrankung können ergänzend systemische Glukokortikosteroide eingesetzt werden. Bei MTX‐ und Steroid‐refraktären Verläufen, Kontraindikation oder Unverträglichkeit sollten Mycophenolat‐Mofetil, Mycophenolsäure oder Abatacept als Systemtherapie der zweiten Wahl eingesetzt werden. Bei einer linearen ZS kann zudem eine autologe Fettstammzelltransplantation zur Korrektur von Weichteildefekten erfolgen.
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Affiliation(s)
- Alexander Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Hospital Oberhausen, Oberhausen, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Helios St. Johannes Hospital Duisburg, Duisburg, Deutschland
| | - Pia Moinzadeh
- Klinik und Poliklinik für Dermatologie und Venerologie, Uniklinik Köln, Köln, Deutschland
| | - Maria Kinberger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Berlin, Deutschland
| | - Gerd Horneff
- Allgemeine Kinder- und Jugendmedizin, Asklepios Klinik St. Augustin, St. Augustin, Deutschland
| | - Margitta Worm
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Dermatologie, Venerologie und Allergologie, Berlin, Deutschland
| | - Ricardo N Werner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Berlin, Deutschland
| | | | - Thomas Krieg
- Klinik und Poliklinik für Dermatologie und Venerologie, Uniklinik Köln, Köln, Deutschland
| | - Jörg Wenzel
- Klinik und Poliklinik für Dermatologie und Allergologie, Universität Bonn, Bonn, Deutschland
| | | | - Lisa Weibel
- Universitäts-Kinderspital Zürich, Zürich, Schweiz
| | - Robert Müllegger
- Abteilung für Dermatologie und Venerologie am Landesklinikum Wiener Neustadt, Wiener Neustadt, Österreich
| | - Nicolas Hunzelmann
- Klinik und Poliklinik für Dermatologie und Venerologie, Uniklinik Köln, Köln, Deutschland
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3
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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. [PMID: 38456584 DOI: 10.1111/jdv.19912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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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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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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Badshah II, Brown S, Weibel L, Rose A, Way B, Sebire N, Inman G, Harper J, O'Shaughnessy RFL. Differential expression of secreted factors SOSTDC1 and ADAMTS8 cause profibrotic changes in linear morphoea fibroblasts. Br J Dermatol 2019; 180:1135-1149. [PMID: 30367460 DOI: 10.1111/bjd.17352] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Linear morphoea (LM) is a rare connective tissue disorder characterized by a line of thickened skin and subcutaneous tissue and can also affect the underlying muscle and bone. Little is known about the disease aetiology, with treatment currently limited to immune suppression, and disease recurrence post-treatment is common. OBJECTIVES In order to uncover new therapeutic avenues, the cell-intrinsic changes in LM fibroblasts compared with site-matched controls were characterized. METHODS We grew fibroblasts from site-matched affected and unaffected regions from five patients with LM, we subjected them to gene expression analysis and investigation of SMAD signalling. RESULTS Fibroblasts from LM lesions showed increased migration, proliferation, altered collagen processing, and abnormally high basal levels of phosphorylated SMAD2, thereby rendering them less responsive to transforming growth factor (TGF)-β1 and reducing the degree of myofibroblast differentiation, which is a key component of the wound-healing and scarring process in normal skin. Conditioned media from normal fibroblasts could reverse LM-affected fibroblast migration and proliferation, suggesting that the LM phenotype is driven by an altered secretome. Gene array analysis and RNA-Seq indicated upregulation of ADAMTS8 and downregulation of FRAS1 and SOSTDC1. SOSTDC1 knock-down recapitulated the reduced TGF-β1 responsiveness and LM fibroblast migration, while overexpression of ADAMTS8 induced myofibroblast markers. CONCLUSIONS We demonstrate that cell-intrinsic changes in the LM fibroblast secretome lead to changes observed in the disease, and that secretome modulation could be a viable therapeutic approach in the treatment of LM.
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Affiliation(s)
- I I Badshah
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
| | - S Brown
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
- Restoration of Appearance and Function Trust, Leopold Muller Building, Mount Vernon Hospital, Northwood, Middlesex, U.K
| | - L Weibel
- Department of Dermatology, University Hospital, Zurich, Switzerland
| | - A Rose
- Division of Cancer Research, University of Dundee, School of Medicine, Dundee, U.K
| | - B Way
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
| | - N Sebire
- Histopathology, Great Ormond Street Hospital, London, U.K
| | - G Inman
- Division of Cancer Research, University of Dundee, School of Medicine, Dundee, U.K
| | - J Harper
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
| | - R F L O'Shaughnessy
- Immunobiology and Dermatology, UCL Institute of Child Health, London, U.K
- Livingstone Skin Research Centre, UCL Institute of Child Health, London, U.K
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Queen Mary University of London, London, U.K
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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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Clinical Usefulness of Magnetic Resonance Imaging in Four Children With Scleroderma. Arch Rheumatol 2017; 33:230-235. [PMID: 30207558 DOI: 10.5606/archrheumatol.2018.6498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/31/2017] [Indexed: 11/21/2022] Open
Abstract
Children with localized scleroderma may have more serious sequelae than adults with the disease. In this case report, we analyzed four girls with localized scleroderma (generalized morphea) to evaluate the clinical usefulness of magnetic resonance imaging in facilitating disease control and investigating patient responsiveness to various treatments. Two of the children had flexion contracture, and two displayed a clear high-intensity area in the bone marrow under the sclerotic skin on magnetic resonance imaging. Two girls had different bilateral circumferences of the legs or forearms. These abnormalities were detected without any obvious changes in blood chemistry. Our results demonstrated that magnetic resonance imaging is useful for the evaluation of treatment effects for localized scleroderma in children.
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9
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Knobler R, Moinzadeh P, Hunzelmann N, Kreuter A, Cozzio A, Mouthon L, Cutolo M, Rongioletti F, Denton CP, Rudnicka L, Frasin LA, Smith V, Gabrielli A, Aberer E, Bagot M, Bali G, Bouaziz J, Braae Olesen A, Foeldvari I, Frances C, Jalili A, Just U, Kähäri V, Kárpáti S, Kofoed K, Krasowska D, Olszewska M, Orteu C, Panelius J, Parodi A, Petit A, Quaglino P, Ranki A, Sanchez Schmidt JM, Seneschal J, Skrok A, Sticherling M, Sunderkötter C, Taieb A, Tanew A, Wolf P, Worm M, Wutte NJ, Krieg T. European Dermatology Forum S1-guideline 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 2017; 31:1401-1424. [PMID: 28792092 DOI: 10.1111/jdv.14458] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 06/26/2017] [Indexed: 12/13/2022]
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 guideline focuses on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, current strategies in the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this guideline provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes of systemic sclerosis with diseases of the rheumatological spectrum.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Moinzadeh
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - A Cozzio
- Department of Dermatology, Venereology and Allergology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - L Mouthon
- Service de Médecine Interne, Centre de référence maladies rares: vascularites et sclérodermie systémique, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - M Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - F Rongioletti
- Dermatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - C P Denton
- Division of Medicine, Centre for Rheumatology, University College London, London, UK
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L A Frasin
- Dermatology Unit, Hospital of Lecco, Lecco, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - A Gabrielli
- Department of Clinical and Molecular Science, Università Politecnica delle Marche, Ancona, Italy
| | - E Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - G Bali
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - J Bouaziz
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - A Braae 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
| | - C Frances
- Department of Dermatology and Allergology, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - A Jalili
- Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - U Just
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - V Kähäri
- Department of Dermatology and Venereology, Turku University Hospital and University of Turku, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- Department of Dermato-Allergology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - D Krasowska
- Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Lublin, Poland
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - C Orteu
- Department of Dermatology, Connective Tissue Diseases Service, Royal Free Hospital, London, UK
| | - J Panelius
- Department of Dermatology, Allergology and Venereology, University of Helsinki, and Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - A Parodi
- Department of Dermatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - A Petit
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - P Quaglino
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - A Ranki
- Department of Dermatology, Allergology and Venereology, Inflammation Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J M Sanchez Schmidt
- Department of Dermatology, Hospital del Mar-Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - M Sticherling
- Department of Dermatology, University Hospital of Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Taieb
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Tanew
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Wolf
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Worm
- Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - N J Wutte
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - T Krieg
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
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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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11
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Garcia-Romero MT, Randhawa HK, Laxer R, Pope E. The role of local temperature and other clinical characteristics of localized scleroderma as markers of disease activity. Int J Dermatol 2016; 56:63-67. [DOI: 10.1111/ijd.13452] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/07/2016] [Accepted: 07/28/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Maria T. Garcia-Romero
- Department of Pediatric Medicine; Dermatology Section; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Harkamal K. Randhawa
- Department of Pediatric Medicine; Dermatology Section; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Ronald Laxer
- Departments of Pediatrics and Medicine; Division of Rheumatology; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Elena Pope
- Department of Pediatric Medicine; Dermatology Section; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
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12
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Kreuter A, Krieg T, Worm M, Wenzel J, Moinzadeh P, Kuhn A, Aberer E, Scharffetter-Kochanek K, Horneff G, Reil E, Weberschock T, Hunzelmann N. German guidelines for the diagnosis and therapy of localized scleroderma. J Dtsch Dermatol Ges 2016; 14:199-216. [PMID: 26819124 DOI: 10.1111/ddg.12724] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Localized scleroderma designates a heterogeneous group of sclerotic skin disorders. Depending on the subtype, severity, and site affected, adjacent structures such as adipose tissue, muscles, joints, and bones may be involved. This is an update of the existing German AWMF (Association of the Scientific Medical Societies in Germany) guidelines (classification: S2k). These guidelines provide an overview of the definition, epidemiology, classification, pathogenesis, laboratory workup, histopathology, clinical scoring systems, as well as imaging and device-based workup of localized scleroderma. Moreover, consensus-based recommendations are given on the management of localized scleroderma depending on its clinical subtype. Treatment recommendations are presented in a therapeutic algorithm. No financial support was given by any pharmaceutical company. The guidelines are valid until July 2019.
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Affiliation(s)
- Alexander Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, Oberhausen, Germany
| | - Thomas Krieg
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology, and Allergology, Charité - University Medical Center Berlin, Berlin, Germany
| | - Jörg Wenzel
- Department of Dermatology and Allergology, University Hospital Bonn, Bonn, Germany
| | - Pia Moinzadeh
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Annegret Kuhn
- Interdisciplinary Center for Clinical Studies (IZKS), University Medical Center Mainz, Mainz, Germany
| | - Elisabeth Aberer
- Department of Dermatology and Venereology, University Hospital Graz, Graz, Austria
| | | | - Gerd Horneff
- Department of General Pediatrics, Asklepios Hospital, St. Augustin, Germany
| | - Emma Reil
- Emma Reil, Scleroderma Support Group, Heilbronn, Germany
| | - Tobias Weberschock
- Department of Dermatology, Venereology, und Allergology, University Hospital Frankfurt and Work Group EbM Frankfurt, Institute for General Medicine, Johann Wolfgang Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Nicolas Hunzelmann
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
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13
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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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14
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Kreuter A, Krieg T, Worm M, Wenzel J, Moinzadeh P, Kuhn A, Aberer E, Scharffetter-Kochanek K, Horneff G, Reil E, Weberschock T, Hunzelmann N. Deutsche Leitlinie zur Diagnostik und Therapie der zirkumskripten Sklerodermie. J Dtsch Dermatol Ges 2016. [DOI: 10.1111/ddg.130_12724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alexander Kreuter
- Klinik für Dermatologie; Venerologie und Allergologie; HELIOS St. Elisabeth Hospital Oberhausen
| | - Thomas Krieg
- Klinik und Poliklinik für Dermatologie und Venerologie; Uniklinik Köln
| | - Margitta Worm
- Klinik für Dermatologie; Venerologie und Allergologie; Charité - Universitätsmedizin; Berlin
| | - Jörg Wenzel
- Klinik und Poliklinik für Dermatologie und Allergologie; Universität Bonn
| | - Pia Moinzadeh
- Klinik und Poliklinik für Dermatologie und Venerologie; Uniklinik Köln
| | - Annegret Kuhn
- Interdisziplinäres Zentrum Klinische Studien (IZKS); Universitätsmedizin Mainz
| | - Elisabeth Aberer
- Universitätsklinik für Dermatologie und Venerologie; Medizinische Universität Graz
| | | | - Gerd Horneff
- Allgemeine Kinder- und Jugendmedizin; Asklepios Klinik; St. Augustin
| | - Emma Reil
- Emma Reil; Sklerodermie Selbsthilfe e.V.; Heilbronn
| | - Tobias Weberschock
- Klinik für Dermatologie; Venerologie und Allergologie; Universitätsklinikum Frankfurt und Arbeitsgruppe EbM Frankfurt; Institut für Allgemeinmedizin; Johann Wolfgang Goethe-Universität; Frankfurt am Main
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15
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Garcia-Romero M, Laxer R, Pope E. Correlation of clinical tools to determine activity of localized scleroderma in paediatric patients. Br J Dermatol 2015; 174:408-10. [DOI: 10.1111/bjd.14001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M.T. Garcia-Romero
- Department of Paediatric Medicine; Dermatology Section; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - R. Laxer
- Departments of Paediatrics and Medicine; Division of Rheumatology; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - E. Pope
- Department of Paediatric Medicine; Dermatology Section; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
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16
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Wang P, Guo W, Liu S. A rare case of juvenile localised scleroderma with intra-oral and dental involvement. Exp Ther Med 2015; 10:2213-2215. [PMID: 26668618 DOI: 10.3892/etm.2015.2791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 09/01/2015] [Indexed: 11/06/2022] Open
Abstract
Juvenile localised scleroderma is a rare childhood disorder of the immune system and connective tissue with unknown etiology. There are different types of localised scleroderma, including linear scleroderma (where the lesion appears as a line or streak) and plaque or circumscribed morphea (where the lesion appears as a roundish lesion). The present report describes the case of a 10-year-old girl, who presented with a history of linear scleroderma with nose, oral and dental involvement, and outlines the diagnosis of the case based on the clinical presentation, pathology, X-ray and cone beam computed tomography images. The treatment strategy that was selected for the patient is additionally discussed.
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Affiliation(s)
- Peng Wang
- Department of Periodontology, Yantai Stomatological Hospital, Yantai, Shandong 264008, P.R. China
| | - Wei Guo
- Department of Periodontology, Yantai Stomatological Hospital, Yantai, Shandong 264008, P.R. China
| | - Shutai Liu
- Department of Periodontology, Yantai Stomatological Hospital, Yantai, Shandong 264008, P.R. China
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17
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Das S, Bernstein I, Jacobe H. Correlates of self-reported quality of life in adults and children with morphea. J Am Acad Dermatol 2014; 70:904-10. [PMID: 24534655 PMCID: PMC3992170 DOI: 10.1016/j.jaad.2013.11.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 11/21/2013] [Accepted: 11/25/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Determining a disease's impact on life quality is important in clinical decision making, research, and resource allocation. Determinants of quality of life (QOL) in morphea are poorly understood. OBJECTIVE We sought to ascertain demographic and clinical variables correlated with negative impact on self-reported QOL in morphea. METHODS We conducted a cross-sectional survey of the Morphea in Adults and Children cohort. RESULTS Symptoms (pruritus and pain) and functional impairment were correlated with decreased QOL in children and adults. This was true in both sexes and was independent of subtype and age. Patient-reported QOL correlated with physician-based measures of disease severity in adults, but not in children. Patients with linear and generalized morphea had the greatest impact on QOL. LIMITATIONS Small sample size is a limitation. CONCLUSION Symptoms and functional impairment were determinants of impaired life quality in both children and adults independent of morphea subtype. These results suggest that clinicians should consider suppressing the accumulation of new lesions (when rapidly accumulating) and symptoms (pain and pruritus) in the treatment of patients with morphea.
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Affiliation(s)
- Shinjita Das
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Ira Bernstein
- Department of Biostatistics and Clinical Science, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heidi Jacobe
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas.
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18
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Abstract
Morphea (localized scleroderma) is a rare fibrosing disorder of the skin and underlying tissues characterized by skin thickening and hardening due to increased collagen deposition. The significance of the disease depends on the extent of the lesions, potential for functional disability or cosmetic disfigurement, and presence or absence of extracutaneous manifestations. Treatment is tailored; circumscribed forms may require only topical treatment, while forms causing functional impairment or severe cosmetic change may require systemic treatment. Although localized scleroderma has a good prognosis, some clinical subtypes can be deforming and irreversibly disabling, especially when affecting the extremities or the face.
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Affiliation(s)
- Elena Pope
- Section of Dermatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Ronald M Laxer
- Departments of Paediatrics and Medicine, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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19
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Sugiura K, Muro Y, Tomita Y. A case of a childhood linear scleroderma with limb asymmetry. Mod Rheumatol 2014. [DOI: 10.3109/s10165-004-0302-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Inflammatory Arthritis, Sacroiliitis, and Morphea: Evidence of a Systemic Inflammatory Disease. Case Rep Rheumatol 2013; 2013:347694. [PMID: 23997976 PMCID: PMC3749611 DOI: 10.1155/2013/347694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 07/08/2013] [Indexed: 11/18/2022] Open
Abstract
Morphea is a skin disease characterized by local skin inflammation and fibrosis. Extracutaneous manifestations have been described with this disease including inflammatory arthritis. We describe a case of morphea who developed inflammatory polyarthritis and sacroiliitis coincident with new skin lesions.
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21
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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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22
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Li SC, Liebling MS, Haines KA, Weiss JE, Prann A. Initial evaluation of an ultrasound measure for assessing the activity of skin lesions in juvenile localized scleroderma. Arthritis Care Res (Hoboken) 2011; 63:735-42. [DOI: 10.1002/acr.20407] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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23
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JUE MS, KIM MH, KO JY, LEE CW. Digital image processing for the acquisition of graphic similarity of the distributional patterns between cutaneous lesions of linear scleroderma and Blaschko’s lines. J Dermatol 2011; 38:778-83. [DOI: 10.1111/j.1346-8138.2010.01162.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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24
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A surgical approach for stable lesions of linear scleroderma. Kaohsiung J Med Sci 2010; 26:621-3. [PMID: 21126716 DOI: 10.1016/s1607-551x(10)70095-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 04/26/2010] [Indexed: 10/18/2022] Open
Abstract
A 29-year-old Japanese woman presented with alopecia lesions in her occipital region and was diagnosed as linear scleroderma. Topical steroids along with psoralen and UVA light therapy were applied, but the lesion persisted. A surgical approach was therefore selected to treat the lesion. The resection was successful without any recurrence for 1 year. Sclerotic lesions on the exposed areas can cause cosmetic disfigurement, and surgery may be a useful modality for treating stable linear scleroderma.
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25
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Frequency of antinuclear antibodies in mestizo Mexican children with morphea. Clin Rheumatol 2010; 29:1055-9. [DOI: 10.1007/s10067-010-1515-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 05/20/2010] [Accepted: 06/02/2010] [Indexed: 10/19/2022]
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26
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LI SUZANNEC, FELDMAN BRIANM, HIGGINS GLORIAC, HAINES KATHLEENA, PUNARO MARILYNNG, O’NEIL KATHLEENM. Treatment of Pediatric Localized Scleroderma: Results of a Survey of North American Pediatric Rheumatologists. J Rheumatol 2009; 37:175-81. [DOI: 10.3899/jrheum.090708] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.We surveyed pediatric rheumatologists (PR) in North America to learn how they treat pediatric localized scleroderma (LS), a disease associated with significant morbidity for the growing child.Methods.A Web-based survey was sent to the 195 PR members of the pediatric rheumatology research alliance CARRA (Childhood Arthritis and Rheumatology Research Alliance). Members were asked which medications they use to treat LS and which factors modify their treatment strategies. Clinical vignettes were provided to learn the specific treatment regimens used.Results.A total of 158 PR from over 70 clinical centers in the United States and Canada participated in the survey, representing 81% of the CARRA membership. These PR saw over 650 patients with LS in the prior year. Nearly all respondents treated LS with methotrexate (MTX) and corticosteroids; most of them intensify treatment for lesions located on the face or near a joint, and about half intensify treatment for recent disease onset (< 6 months). Most PR reserve topical medications for limited treatment situations. Clinical vignettes showed that PR use a broad range of treatment doses and durations for MTX and corticosteroids.Conclusion.Most PR in North America treat localized scleroderma with a combination of MTX and corticosteroids. However, there is no consensus on specific treatment regimens. There is a need for controlled treatment trials to better determine optimal therapy for this potentially disabling disease.
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27
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Kreuter A, Krieg T, Worm M, Wenzel J, Gambichler T, Kuhn A, Aberer E, Scharffetter-Kochanek K, Hunzelmann N. [AWMF Guideline no. 013/066. Diagnosis and therapy of circumscribed scleroderma]. J Dtsch Dermatol Ges 2009; 7 Suppl 6:S1-14. [PMID: 19660073 DOI: 10.1111/j.1610-0387.2009.07178.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Localized scleroderma is a rare autoimmune disease with primary affection of the skin, and occasional involvement of the fat tissue, muscle, fascia, and bone. Depending on the clinical subtype, the spectrum of skin lesions ranges from singular plaque lesions to severe generalized or linear subtypes which may lead to movement restrictions and permanent disability. This German S1-guideline proposes a classification of localized scleroderma that, considering the extent and depth of fibrosis, distinguishes limited, generalized, linear, and deep forms of localized scleroderma, together with its associated subtypes. The guideline includes a description of the pathogenesis, of differential diagnoses, and particular aspects of juvenile localized scleroderma, as well as recommendations for histopathologic, serologic, and biometric diagnostic procedures. Based on studies of topical and systemic treatments as well as phototherapy for localized scleroderma published in international literature, a treatment algorithm was developed which takes account of the different subtypes and the extent of disease.
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28
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Toledano C, Rabhi S, Kettaneh A, Fabre B, Fardet L, Tiev KP, Cabane J. Localized scleroderma: a series of 52 patients. Eur J Intern Med 2009; 20:331-6. [PMID: 19393504 DOI: 10.1016/j.ejim.2008.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 05/02/2008] [Accepted: 07/07/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Localized scleroderma also called morphea is a skin disorder of undetermined cause. The widely recognized Mayo Clinic Classification identifies 5 main morphea types: plaque, generalized, bullous, linear and deep. Whether each of these distinct types has a particular clinical course or is associated with some patient-related features is still unclear. METHODS We report here a retrospective series of patients with localized scleroderma with an attempt to identify features related to the type of lesion involved. The medical records of all patients with a diagnosis of localized scleroderma were reviewed by skilled practitioners. Lesions were classified according to the Mayo Clinic Classification. The relationship between each lesion type and various clinical features was tested by non-parametrical methods. RESULTS The sample of 52 patients included 43 females and 9 males. Median age at onset was 30 y (range 1-76). Frequencies of patients according to morphea types were: plaque morphea 41 (78.8%) (including morphea en plaque 30 (57.7%) and atrophoderma of Pasini-Pierini 11 (21.1%)), linear scleroderma 14 (26.9%). Nine patients (17.3%) had both types of localized scleroderma. Median age at onset was lower in patients with linear scleroderma (8 y (range 3-44)) than in others (36 y (range 1-77)) (p=0.0003). Head involvement was more common in patients with linear scleroderma (37.5%) than in other subtypes (11.1%) (p=0.05). Atrophoderma of Pasini-Pierini was never located at the head. Systemic symptoms, antinuclear antibodies and the rheumatic factor were not associated with localized scleroderma types or subtypes. CONCLUSION These results suggest that morphea types, in adults are not associated with distinct patient features except for age at disease onset (lower) and the localization on the head (more frequent), in patients with lesions of the linear type.
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Affiliation(s)
- C Toledano
- Department of Internal Medicine Centre Hospitalo-Universitaire Saint-Antoine, 75012 Paris, Assistance Publique/Hôpitaux de Paris, France.
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Zancanaro PCQ, Isaac AR, Garcia LT, Costa IMC. Esclerodermia localizada na criança: aspectos clínicos, diagnósticos e terapêuticos. An Bras Dermatol 2009; 84:161-72. [DOI: 10.1590/s0365-05962009000200009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A esclerodermia localizada, ou morféia, acomete crianças em idade escolar e, em geral, é autolimitada, apesar de localmente desfiguradora. A literatura descreve inúmeros fatores etiopatogênicos, bem como modalidades de investigação e tratamento. Este artigo reúne os estudos mais recentes e discute sua aplicação clínica.
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Christen-Zaech S, Hakim MD, Afsar FS, Paller AS. Pediatric morphea (localized scleroderma): review of 136 patients. J Am Acad Dermatol 2008; 59:385-96. [PMID: 18571769 DOI: 10.1016/j.jaad.2008.05.005] [Citation(s) in RCA: 168] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2007] [Revised: 04/20/2008] [Accepted: 05/07/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND Morphea is an autoimmune inflammatory sclerosing disorder that may cause permanent functional disability and disfigurement. OBJECTIVES We sought to determine the clinical features of morphea in a large pediatric cohort. METHODS We conducted a retrospective chart review of 136 pediatric patients with morphea from one center, 1989 to 2006. RESULTS Most children showed linear morphea, with a disproportionately high number of Caucasian and female patients. Two patients with rapidly progressing generalized or extensive linear morphea and arthralgias developed restrictive pulmonary disease. Initial oral corticosteroid treatment and long-term methotrexate administration stabilized and/or led to disease improvement in most patients with aggressive disease. LIMITATIONS Retrospective analysis, relatively small sample size, and risk of a selected referral population to the single site are limitations. CONCLUSIONS These data suggest an increased prevalence of morphea in Caucasian girls, and support methotrexate as treatment for problematic forms. Visceral manifestations rarely occur; the presence of progressive problematic cutaneous disease and arthralgias should trigger closer patient monitoring.
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Affiliation(s)
- Stéphanie Christen-Zaech
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611-2997, USA
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31
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Uziel Y, Feldman BM, Krafchik BR, Laxer RM, Yeung RSM. Increased serum levels of TGFbeta1 in children with localized scleroderma. Pediatr Rheumatol Online J 2007; 5:22. [PMID: 18053185 PMCID: PMC2233624 DOI: 10.1186/1546-0096-5-22] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Accepted: 12/03/2007] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There are neither sensitive nor specific laboratory tests for measuring disease activity in localized scleroderma (LS). Monitoring is done almost exclusively by clinical assessment. Our aim was to determine whether serum concentrations of TGFbeta1 are a good biomarker of disease activity in children with LS. METHODS 55 pediatric patients with LS were divided into sub-types according to their main lesion; morphea, generalized morphea, linear scleoderma affecting a limb or the face. The lesions were further categorized by overall clinical assessment into active, inactive, and indeterminate groups according to disease activity. Serum TGFbeta1 concentration levels were measured by enzyme linked immunosorbent assay (ELISA), analyzed and correlated with disease subtypes and disease activity. RESULTS The mean TGFbeta1 concentration were significantly higher in the patient group (51393 +/- 33953 pg/ml) than in the control group (9825 +/- 5287 pg/ml) (P < 0.001). The mean concentration were elevated in all the disease subtypes, and did not correlate with disease duration or activity. CONCLUSION Serum concentration of TGFbeta1 were elevated in patients with all subtypes of LS irrespective of clinical disease activity. Although TGFbeta1 may play an important role in the pathogenesis of local skin fibrosis, circulating blood levels of molecules known to act locally may not be useful biomarkers of disease activity.
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Affiliation(s)
- Yosef Uziel
- Divisions of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada.
| | - Brian M Feldman
- Divisions of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada,Departments of HPME and PHS, University of Toronto, Toronto, Canada
| | - Bernice R Krafchik
- Divisions Dermatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Ronald M Laxer
- Divisions of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Rae SM Yeung
- Divisions of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada,Departments of Immunology and Medical Sciences, University of Toronto, Toronto, Canada
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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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33
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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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34
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Manuel Pardal-Fernández J, Rodríguez-Vázquez M, Medrano-González F, Iñiguez-De Onzoño Martín L. [Not Available]. REUMATOLOGIA CLINICA 2006; 2:278-279. [PMID: 21794342 DOI: 10.1016/s1699-258x(06)73060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- José Manuel Pardal-Fernández
- Unidad de Electromiografía Clínica. Servicio de Neurofisiología. Complejo Hospitalario Universitario de Albacete. Albacete. España
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35
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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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Kawashima H, Watanabe C, Kashiwagi Y, Sato S, Ioi H, Sasamoto M, Takekuma K, Ookubo Y, Ooi T, Hoshika A. Therapy of childhood generalized morphea: case reports and reviews of the literature of Japanese cases. Pediatr Int 2006; 48:342-5. [PMID: 16732809 DOI: 10.1111/j.1442-200x.2006.02218.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hisashi Kawashima
- Department of Paediatrics, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan.
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37
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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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39
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Abstract
As our understanding of connective tissue disease expands, so too does our therapeutic armamentarium. We have learned that autoimmunity triggers inflammation through unchecked, proliferative cell-mediated inflammation. By targeting this arm of the cytokine cascade, it may be possible to arrest further progression. Several biologic agents, such as etanercept, alefacept, infliximab, efaluzimab, and, recently, adalimumab, have come to market for adult psoriasis and are now undergoing trials for juvenile SLE, psoriasis, and psoriatic arthritis. Of note, etanercept has been used successfully in juvenile rheumatoid arthritis for more than 10 years. These agents target cell-mediated inflammation through various mechanisms and hold great promise for the treatment of many of the disease states discussed above. Moreover, the biologics carry an improved side-effect profile not seen with traditional agents such as corticosteroids and will be central in the evolution of targeted therapeutics for these complex immunologic diseases.
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Affiliation(s)
- Robert L Buka
- Children's Hospital and Health Center San Diego, University of California San Diego, 8010 Frost Street, Suite 602, San Diego, CA 92123, USA.
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40
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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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41
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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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42
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Abstract
Scleroderma is a relatively rare disorder in children. Among its subsets, localized scleroderma is more common in children than the systemic variety. No exciting new finding was reported in 2001 specifically applicable to childhood scleroderma. However, many new advances in our understanding of the growth factors, cytokines, and chemokines were reported. These studies should help us to understand the pathogenesis of early lesions of scleroderma, vascular changes, and fibrosis and perhaps lead us toward more rational therapy.
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Affiliation(s)
- Balu H Athreya
- Department of Pediatrics, Thomas Jefferson University/Jefferson Medical College Philadelphia, Pennsylvania, USA.
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43
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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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44
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Abstract
We report a 6-year-old boy with unilateral generalized morphea distributing on the right side of his lower leg, trunk, and upper arm. A skin biopsy from the right thigh showed accumulation of thick collagen bundles extending from the middle dermis to the subcutaneous fat tissue. The levels of antinuclear antibodies, rheumatoid factor, and anti single-stranded DNA antibody were elevated. No severe deformity or functional disabilities were noted. With topical corticosteroid therapy, the sclerotic skin became gradually softer, and no progression of sclerosis has been noted for one year.
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Affiliation(s)
- Yayoi Nagai
- Division of Dermatology, Tone Central Hospital, Numata, Gunma, Japan
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45
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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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46
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Abstract
Linear scleroderma is an unusual disorder characterized by linear streaks of fibrotic skin involvement, which can lead to severe limb deformities and contractures. The authors present a case of severe wrist contracture in a child with linear scleroderma treated by release of the contracture with coverage of the exposed carpus with an abductor digiti minimi flap and skin graft. Reports of successful treatment of extremity deformities are rare. At 1 year this correction appears to have been successful.
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Affiliation(s)
- W G Lyle
- Section of Plastic Surgery, Medical College of Georgia, Augusta, USA
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47
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Abstract
We evaluated the self-esteem and quality of life of 47 children with morphea with the use of the Harter self-perception profile for children and Visual Analog Scale. Most children with morphea have normal self-worth and a high quality of life. Morphea, like some other childhood chronic illnesses, does not impair self-esteem.
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Affiliation(s)
- Y Uziel
- Department of Pediatrics, the Divisions of Rheumatology and Dermatology, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
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48
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Uziel Y, Feldman BM, Krafchik BR, Yeung RS, Laxer RM. Methotrexate and corticosteroid therapy for pediatric localized scleroderma. J Pediatr 2000; 136:91-5. [PMID: 10636981 DOI: 10.1016/s0022-3476(00)90056-8] [Citation(s) in RCA: 164] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Localized scleroderma (LS) can cause permanent disability, and there is no universally accepted effective treatment. Methotrexate (MTX) has been shown to be effective in the treatment of systemic sclerosis. OBJECTIVES To determine the efficacy and tolerability of MTX and corticosteroid therapy in patients with LS. METHODS MTX, 0.3 to 0.6 mg/kg per week, was given to 10 patients (6 girls, 4 boys; mean age, 6.8 years; mean disease duration before starting treatment, 4 years) with active LS. In addition, pulse intravenous methylprednisolone, 30 mg/kg for 3 days monthly for 3 months, was given to 9 patients at the initiation of therapy. RESULTS One patient discontinued taking MTX after a month; the remaining 9 patients responded. The median time to response was 3 months (95% CI, 1.15-4.85). One responder discontinued taking MTX after a year because of leukopenia; the LS worsened within 2 months. In another patient LS flared up after 10 months and responded to an increased dose of MTX and intravenous methylprednisolone. At the last follow-up visit, all patients who continued to receive MTX therapy had inactive skin lesions. CONCLUSION Treatment with MTX and corticosteroids appears to be effective in the treatment of LS and is generally well tolerated. A placebo-controlled study is necessary to confirm the efficacy of MTX therapy in LS.
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Affiliation(s)
- Y Uziel
- Division of Rheumatology and Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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49
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Abstract
Cutaneous disease is frequent in many of the rheumatic disorders. Some of these disorders such as lupus erythematosus, dermatomyositic, scleroderma, and vasculitis are defined by their cutaneous manifestations. As investigation increases our understanding of these disorders, available therapy becomes more logical and less empiric. This article deals with some of the newer therapies for these disorders.
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Affiliation(s)
- J P Callen
- Division of Dermatology, University of Louisville School of Medicine, Kentucky, USA.
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50
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Arnett FC, Tan FK, Uziel Y, Laxer RM, Krafchik BR, Antohi S, Bona C. Autoantibodies to the extracellular matrix microfibrillar protein, fibrillin 1, in patients with localized scleroderma. ARTHRITIS AND RHEUMATISM 1999; 42:2656-9. [PMID: 10616014 DOI: 10.1002/1529-0131(199912)42:12<2656::aid-anr22>3.0.co;2-n] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Serum autoantibodies to fibrillin 1, the major component of microfibrils in the extracellular matrix, recently have been reported to occur in the tight skin mouse and in patients with systemic sclerosis, but not in patients with other connective tissue diseases. This study was undertaken to determine whether antifibrillin 1 antibodies could be detected in patients with localized forms of scleroderma. METHODS Sera from 50 patients with localized scleroderma (27 with linear scleroderma and 23 with morphea) and 51 normal controls were tested for IgG and IgM antifibrillin 1 autoantibodies, using a radioimmunoassay (RIA) and a human recombinant fibrillin 1 protein (rFbn-1). RESULTS Both in patients with linear scleroderma and in those with morphea, mean levels of IgM and IgG binding to rFbn-1 were significantly higher than in controls. Eight patients with linear scleroderma (30%) and 6 patients with morphea (26%) had IgG autoantibodies to fibrillin 1 (rFbn-1) by RIA, compared with 3 controls (6%) (P = 0.006 and P = 0.022, respectively). No correlations between antifibrillin 1 antibodies and active skin disease or antinuclear antibody positivity were found. CONCLUSION Autoantibodies to fibrillin 1 occur in patients with both forms of localized scleroderma (linear scleroderma and morphea). The clinical and pathogenetic significance of this autoimmune response remains to be determined.
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Affiliation(s)
- F C Arnett
- Division of Rheumatology and Immunogenetics, University of Texas Medical School, Houston 77030, USA
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