1
|
Desai R, Chawla H, Larin K, Assassi S. Methods for objective assessment of skin involvement in systemic sclerosis. Curr Opin Rheumatol 2023; 35:301-308. [PMID: 37605869 PMCID: PMC11015902 DOI: 10.1097/bor.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
PURPOSE OF REVIEW Skin fibrosis is the most prominent disease manifestation of systemic sclerosis (SSc). Although the treatment for other SSc manifestations has expanded over the years, there is limited progress in identifying effective treatment options for SSc skin involvement. This is in part due to limitations in the utilized outcome measures for assessment of skin fibrosis. This review focuses on different emerging assessment tools for SSc skin involvement and their potential use for clinical care and multicenter trials. RECENT FINDINGS Durometer and other device-based methodologies requiring application of direct pressure to the affected skin have been studied in SSc. However, there are concerns that the required application of pressure might be a source of variability. Ultrasound-based methods have been compared with modified Rodnan Skin Score in several studies, indicating acceptable construct validity. However, few studies have examined their criterion validity by providing comparisons to skin histology. Optical coherence-based methods show promising preliminary results for simultaneous assessment of skin fibrosis and vasculopathy. Further standardization and validation (including comparison to skin histology) of these promising novel assessment tools in large, longitudinal SSc cohort studies are needed to establish them as clinically useful outcome measures with acceptable sensitivity to change. SUMMARY Recent advances in imaging techniques provide a promising opportunity for development of a valid and reliable assessment tool for quantification of SSc skin fibrosis, which can pave the way for approval of effective treatment options for this high burden disease manifestation.
Collapse
Affiliation(s)
- Ruhani Desai
- Division of Rheumatology, The University of Texas Health Science Center at Houston, TX, USA
| | - Harshdeep Chawla
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Kirill Larin
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Shervin Assassi
- Division of Rheumatology, The University of Texas Health Science Center at Houston, TX, USA
| |
Collapse
|
2
|
Ghosh S, Baker L, Chen F, Khera Z, Vain A, Zhang K, Hood A, Smith H, Chen H, Jagasia M, Tkaczyk E. Interrater reproducibility of the Myoton and durometer devices to quantify sclerotic chronic graft-versus-host disease. Arch Dermatol Res 2023; 315:2545-2554. [PMID: 37227518 DOI: 10.1007/s00403-023-02626-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/30/2023] [Accepted: 04/10/2023] [Indexed: 05/26/2023]
Abstract
Chronic graft-versus-host disease (cGVHD) is a severe complication in long-term survivors of allogeneic hematopoietic stem cell transplantation. This disease is challenging to manage clinically due to a lack of validated tools to quantitatively measure skin sclerosis. The current gold standard for measuring skin sclerosis is the NIH Skin Score which has only moderate agreement among clinicians and experts. To more accurately assess skin sclerosis in cGVHD, the Myoton and durometer devices can be used to directly measure biomechanical parameters of the skin. However, the reproducibility of these devices is not known in patients with cGVHD. To determine this reproducibility, three observers independently measured 10 anatomic sites in each of seven patients with sclerotic cGVHD using the Myoton and durometer. Clinical reproducibility was measured by mean pairwise differences (U-statistic) and intraclass correlation coefficients (ICCs) with 95% confidence intervals (CIs). Mean pairwise differences, expressed in true physical units, were used to report typical errors for each anatomic site and device. Mean pairwise differences were less than 11% of the average overall values for all five Myoton parameters and durometer hardness. These were lower for Myoton creep (4.1%), relaxation time (4.7%), and frequency (5.1%) than decrement (9.0%), stiffness (10.4%), and durometer hardness (9.0%). Myoton parameters creep, relaxation time, and frequency showed promise for capturing skin biomechanics more accurately than Myoton stiffness, decrement, or durometer hardness. Mean pairwise differences trended highest in the shin and volar forearm and lowest in the dorsal forearm. The interobserver ICC for overall (averaged across all measured body sites of a patient) creep (0.94; 95% CI 0.87-1.00), relaxation time (0.96; 95% CI 0.90-1.00), and frequency (0.95; 95% CI 0.88-1.00), trended higher than that for decrement (0.43; 95% CI 0.00-0.88), stiffness (0.92; 95% CI 0.81-1.00), and durometer hardness (0.82; 95% CI 0.61-1.00). Similar trends were observed in healthy participants. These findings can help clinicians design better studies to assess therapeutic response to new cGVHD treatments and support the interpretation of future measurements.
Collapse
Affiliation(s)
- Shramana Ghosh
- Dermatology and Research Services, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, TN, Nashville, USA
| | - Laura Baker
- Dermatology and Research Services, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, TN, Nashville, USA
| | - Fuyao Chen
- Dermatology and Research Services, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, TN, Nashville, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
- Medical Scientist Training Program, Yale School of Medicine, New Haven, CT, USA
| | - Zain Khera
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, TN, Nashville, USA
| | - Arved Vain
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, TN, Nashville, USA
- University of Tartu Institute of Physics, Tartu, Estonia
| | - Kathy Zhang
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, TN, Nashville, USA
| | - Alexis Hood
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, TN, Nashville, USA
| | - Hayden Smith
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, TN, Nashville, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | | | - Eric Tkaczyk
- Dermatology and Research Services, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA.
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, TN, Nashville, USA.
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA.
| |
Collapse
|
3
|
Ivanova Z, Aleksiev T, Dobrev H, Atanasov N. Use of a novel indentometer to evaluate skin stiffness in healthy and diseased human skin. Skin Res Technol 2023; 29:e13384. [PMID: 37522487 PMCID: PMC10339004 DOI: 10.1111/srt.13384] [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: 01/02/2023] [Accepted: 05/25/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Mechanical behavior of the skin can be evaluated by different non-invasive methods. In this study, we applied a new measurement device based on indentometry to determine the skin mechanical properties in healthy individuals and in patients with systemic sclerosis (SSc). MATERIAL AND METHODS Three studies were performed. Study 1 included 100 healthy individuals (46 male and 54 female) divided into four age groups with mean ages of 21.5, 28.9, 51.2, and 69.3 years, respectively. Test sites were located on the center of the forehead and the middle of both volar forearms. Study 2 included 16 healthy individuals (two males and 14 females). Test sites were on both volar forearms. Measurements were made before and after the application of Vaseline and emulsion with 12% urea. Study 3 included 20 patients (one male and 19 females) with SSc and 60 age-matched healthy individuals (23 males and 37 females). Test sites were on the center of the forehead and the middle of both volar forearms. Skin stiffness was measured with skin Indentometer IDM 800 (Courage + Khazaka, Cologne, Germany) equipped with two probes with pin diameters of 3 and 5 mm, respectively. The stiffer the skin, the less deep the displacement by the indenter. The smaller the diameter, the deeper the pin will go into the skin when using the same force. In addition, the Corneometer CM 820 (Courage + Khazaka) was used to determine epidermal water content in study 2. RESULTS Indentometric (IDM) values of healthy subjects measured with both probes were lower on the forehead compared to volar forearms. There was no significant difference between both forearms. In all age groups, the IDM values on the male forearms were lower than on the female forearms whereas there was no significant difference on the forehead. In both sex and on all test locations a significant positive correlation between age and IDM values measured with both probes was observed. There was a significant positive correlation between IDM values measured with both probes. The application of moisturizers induced significant changes in epidermal water content whereas the IDM values remained unchanged. At both the forehead and volar forearms, the IDM values in patients with SSc were significantly lower compared to the healthy control skin. CONCLUSION The non-invasive indentometric method used can successfully distinguish the changes in normal skin mechanical properties related to age, sex, and anatomical location, as well as in patients with SSc. The method is not appropriate to study the changes related to epidermal hydration.
Collapse
Affiliation(s)
- Zlatina Ivanova
- Department of Dermatology and Venereology, Medical FacultyMedical UniversityPlovdivBulgaria
| | - Teodor Aleksiev
- Department of Dermatology and Venereology, Medical FacultyMedical UniversityPlovdivBulgaria
| | - Hristo Dobrev
- Department of Dermatology and Venereology, Medical FacultyMedical UniversityPlovdivBulgaria
| | - Nikolay Atanasov
- Department of Health Management and Health Economics, Faculty of Public HealthMedical UniversityPlovdivBulgaria
| |
Collapse
|
4
|
Abstract
Systemic sclerosis, also known as scleroderma, is a rare and complex autoimmune connective-tissue disease. Once considered an untreatable and unpredictable condition, research advancements have improved our understanding of its disease pathogenesis and clinical phenotypes and expanded our treatment armamentarium. Early and accurate diagnosis is essential, while ongoing efforts to risk stratify patients have a central role in predicting both organ involvement and disease progression. A holistic approach is required when choosing the optimal therapeutic strategy, balancing the side-effect profile with efficacy and tailoring the treatment according to the goals of care of the patient. This Seminar reviews the multiple clinical dimensions of systemic sclerosis, beginning at a precursor very early stage of disease, with a focus on timely early detection of organ involvement. This Seminar also summarises management considerations according to the pathological hallmarks of systemic sclerosis (eg, inflammation, fibrosis, and vasculopathy) and highlights unmet needs and opportunities for future research and discovery.
Collapse
Affiliation(s)
- Elizabeth R Volkmann
- Department of Medicine, Division of Rheumatology, University of California, Los Angeles, CA, USA; David Geffen School of Medicine, Los Angeles, CA, USA.
| | | | - Vanessa Smith
- Department of Internal Medicine and Department of Rheumatology, Ghent University (Hospital), Ghent, Belgium; Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Centre, Ghent, Belgium
| |
Collapse
|
5
|
Ivanova Z, Aleksiev T, Dobrev H, Atanasov N. Use of a novel Indentometer to evaluate skin induration in localized scleroderma and psoriasis vulgaris. Skin Res Technol 2022; 28:317-321. [PMID: 35020956 PMCID: PMC9907702 DOI: 10.1111/srt.13134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/18/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Diseased skin in localized scleroderma (LS) and plaque psoriasis (PPs) is characterized by induration that can be evaluated by non-invasive bioengineering methods. In this study, we applied a new measurement device based on indentometry to determine the changes of skin mechanical properties in patients with LS and PPs. MATERIAL AND METHODS A total of 30 sclerodermatous plaques in 12 patients with LS and 46 psoriatic plaques in 19 patients with PPs were measured with Indentometer IDM 800 (Courage + Khazaka, Cologne, Germany). The device measures the penetration depth of the probe indenter (pin) into the skin in mm. We used two probes with pin diameters 3 and 5 mm, respectively. The stiffer the skin, the less deep is the displacement by the indenter. The smaller the diameter, the deeper the pin will go into the skin when using the same force. The measurements were made on diseased skin and in adjacent normal skin served as control. In addition, the psoriatic plaques were measured before and after treatment. RESULTS The sclerodermatous skin and the psoriatic skin showed lower Indentometer values compared to adjacent normal skin as measured with both probes. This suggests that diseased skin is stiffer than healthy skin. The values of psoriatic plaques increased after treatment applied that correlates with the clinical improvement. The Indentometric readings significantly negatively correlated with clinical scores of skin induration. There was a significant correlation between the measurements with probe 3 mm and probe 5 mm. CONCLUSION The non-invasive method used is appropriate for objective and quantitative determination of the degree of skin induration in LS and PPs as well as for assessment of the disease evaluation and treatment efficacy.
Collapse
Affiliation(s)
- Zlatina Ivanova
- Department of Dermatology and Venereology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Teodor Aleksiev
- Department of Dermatology and Venereology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Hristo Dobrev
- Department of Dermatology and Venereology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Nikolay Atanasov
- Department of Health Management and Health Economics, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
| |
Collapse
|
6
|
Vanhaecke A, Cutolo M, Heeman L, Vilela V, Deschepper E, Melsens K, Smith V. HIGH FREQUENCY ULTRASONOGRAPHY: RELIABLE TOOL TO MEASURE SKIN FIBROSIS IN SSC? A systematic literature review and additional pilot study. Rheumatology (Oxford) 2021; 61:42-52. [PMID: 34037710 DOI: 10.1093/rheumatology/keab462] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To investigate the reliability of high frequency ultrasound (HFUS) in measuring skin fibrosis in systemic sclerosis (SSc). METHODS First, a systematic review (according to PRISMA) was conducted to identify studies that documented HFUS' reliability in SSc as a primary outcome. Then, in an additional pilot study, the inter- and intra-rater reliability of two investigators performing HFUS for dermal thickness (DT) measurements in a standardised manner across all 17 areas of the modified Rodnan Skin Score was evaluated in a group of 59 SSc patients and descriptively in 44 healthy controls (HC). As an external validation, DT measurements by HFUS were performed in a separate group of 30 SSc patients by the same first and another third investigator. RESULTS The systematic review retained few (4/1719 unique records) small-scale studies, with mixed study populations (combining SSc and HC). The reported data herein are suggestive of the inter-/intra-rater reliability of HFUS (ICCs ranging 0.65-0.94/0.55-0.96, respectively). Additionally, in our pilot study, inter-/intra-rater reliability was good-to-excellent in both SSc groups and HC (ICCs ranging 0.70-0.97/0.70-0.98 and 0.65-0.95/0.63-0.96, respectively). CONCLUSION The identified small-scale studies were not only combining data from SSc and HC, they were also heterogeneous in terms of technical aspects (probes and frequency), image acquisition methods ([number of] areas assessed) and definitions used for skin thickness, which prevents drawing unequivocal conclusions. Despite these limitations, our standardized pilot study corroborated the findings in literature, paving the way for the applicability of HFUS as a reliable (complementary) tool to quantify skin fibrosis in SSc.
Collapse
Affiliation(s)
- Amber Vanhaecke
- Department of Internal Medicine, Ghent University, Ghent, Belgium.,Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Lise Heeman
- Department of Internal Medicine, Ghent University, Ghent, Belgium.,Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Veronica Vilela
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - Ellen Deschepper
- Biostatistics Unit, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Karin Melsens
- Department of Internal Medicine, Ghent University, Ghent, Belgium.,Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Vanessa 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 Centre (IRC), Ghent, Belgium
| |
Collapse
|