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ABRIL 2.004
APRIL 2.004
THE MORPHEA (localized
scleroderma) !!!
New therapeutic alternatives!!!
HOT LINK
THE MORPHEA
1.) Use of Imiquimod Cream 5% in the
Treatment of Localized Morphea.
)
2.) Suggested mechanisms of action of
UVA phototherapy in morphea: a molecular study.
3.) PUVA-cream
photochemotherapy for the treatment of localized scleroderma.
4.) Topical calcipotriol
ointment in the treatment of morphea.
5.) Combined treatment with
calcipotriol ointment and low-dose ultraviolet A1 phototherapy in childhood
morphea.
6.) Treatment of scleroderma.
7.) Classification of morphea (localized
scleroderma).
8.) Novel autoantibody to Cu/Zn
superoxide dismutase in patients with localized scleroderma.
9.) Morphea and Toxoplasma Gondii [In
Process Citation].
10.) Anti-DNA topoisomerase IIalpha
autoantibodies in localized scleroderma.
11.) Topical tacrolimus in the
treatment of localized scleroderma.
12.) Does solitary morphoea profunda
progress?.
13.) Oral calcitriol as a new
therapeutic modality for generalized morphea.
14.) Morphea-like reaction to D-penicillamine
therapy.
15.) Treatment of generalized morphea
with oral 1,25-dihydroxyvitamin D3.
1.) Use of Imiquimod Cream 5% in the Treatment of
Localized Morphea.
J Cutan Med Surg. 2004 May 3 [Epub ahead of print]
Man J, Dytoc MT.
Division of Dermatology, University of Alberta, T6G 2G3, Edmonton, Alberta,
Canada.
Fibrosis is characterized by the increased deposition of collagen and other
matrix components by fibroblasts. This process occurs as a reaction to
inflammation and is mediated by numerous cytokines including transforming growth
factor beta (TGF-beta). Localized cutaneous scleroderma or morphea is
characterized by fibrosis. Current treatment for morphea includes topical,
intralesional, or systemic corticosteroids, vitamin D analog (calcitriol and
calcipotriol), photochemotherapy, laser therapy, antimalarials, phenytoin, D-penicillamine,
and colchicine, all with varying degrees of success. In this case report,
imiquimod cream 5% (Aldara(R)), which induces interferon and in turn inhibits
TGF-beta, was employed to treat morphea.
2.) Suggested mechanisms of action
of UVA phototherapy in morphea: a molecular study.
Photodermatol Photoimmunol Photomed. 2004 Apr;20(2):93-100.
El-Mofty M, Mostafa W, Esmat S, Youssef R, Bousseila M, Nagi N, Shaker O,
Abouzeid A.
Department of Dermatology, Phototherapy Unit, Faculty of Medicine, Cairo
University, Egypt.
BACKGROUND: Ultraviolet A (UVA) phototherapy proved to be an efficient line of
treatment of scleroderma. The mechanism through which it acts is still not
clear.
OBJECTIVES: To detect the mechanism of action of UVA phototherapy in
morphea through measuring its effect on the levels of different parameters
related to collagen metabolism.
METHODS: Twenty-one cases of morphea were
treated with low-dose broad-band UVA for 20 sessions.
Twelve cases received 20
J/cm(2)/session with a cumulative dose of 400 J/cm(2) and nine cases received 10
J/cm(2)/session with a cumulative dose of 200 J/cm(2). The response was assessed
clinically every week. Two skin biopsies were taken from the lesional skin of
each patient before starting and after the end of therapy. Paraffin sections
were examined for quantitative polymerase chain reaction measurement of collagen
I, collagen III, collagenase, transforming growth factor-beta (TGF-beta) and
interferon gamma (IFNgamma).
RESULTS: Eighteen patients reported remarkable
softening of the skin lesions, with variable degrees ranging from moderate in
57.1% of them good in 19% to very good response in 9.5%. After treatment, all
the studied parameters revealed statistically significant changes. There was a
significant decrease in collagen I, collagen III and TGF-beta and a significant
increase in collagenase (MMP-1) and IFNgamma. The relative change was found to
be greatest in collagenase, followed by IFNgamma then TGF-beta and finally
collagen I.
The changes in collagen I, collagenase, IFNgamma and TGF-beta were
found to increase gradually with the degree of clinical response. In all the
parameters studied the relative change was significantly higher in cases treated
with 20 J/cm(2)/session in contrast to those treated with 10 J/cm(2)/session
although no statistically significant difference could be detected in the
clinical response to those doses.
CONCLUSIONS: The efficacy of low-dose UVA
phototherapy in the treatment of localized scleroderma is mainly obtained by the
increased production of MMP-1 and IFNgamma, and to a lesser extent by decreasing
TGF-beta and collagen production. Concerning the use of 10 or 20 J/cm(2)/session
those effects are dose dependent, but the clinical response does not
significantly differ.
3.) PUVA-cream photochemotherapy for the
treatment of localized scleroderma.
J Am Acad Dermatol. 2000
Oct;43(4):675-8
Grundmann-Kollmann M, Ochsendorf F, Zollner TM, Spieth K, Sachsenberg-Studer E,
Kaufmann R, Podda M.
Department of Dermatology, Johann Wolfgang Goethe University, Frankfurt,
Germany.
BACKGROUND: The efforts to treat localized scleroderma, including therapies with
potentially hazardous side effects, are often unsatisfactory. Recently,
PUVA-bath photochemotherapy has been proven highly effective in the treatment of
localized scleroderma. Another form of topical PUVA therapy, 8-methoxypsoralen
(8-MOP) containing cream or gel preparations, has been proven to be as effective
as PUVA-bath therapy for palmoplantar dermatoses.
OBJECTIVE: We sought to assess
the efficacy of PUVA-cream photochemotherapy in patients with localized
scleroderma.
METHODS: Four patients with localized scleroderma were included in
the study. Diagnosis was confirmed by 20 MHz ultrasound assessment as well as
pretreatment skin biopsy specimens from lesional skin. PUVA-cream therapy was
performed 4 times a week; all patients received 30 treatments.
RESULTS:
PUVA-cream photochemotherapy induced significant clinical improvement or
clearance of localized scleroderma in all patients. Clearance was documented by
clinical features as well as by 20 MHz ultrasound and histopathologic analysis.
CONCLUSION: PUVA-cream phototherapy can be highly effective in patients with
localized scleroderma even if previous therapy was unsuccessful.
4.) Topical
calcipotriol ointment in the treatment of morphea.
J Dermatolog Treat. 2003 Dec;14(4):219-21.
Tay YK.
National Skin Centre, and Changi General Hospital, 2 Simei Street 3, Singapore
529889. [email protected]
A 5-year-old girl presented with a 2-month history of an indurated
hypopigmented, atrophic plaque of biopsy-documented morphea over the right hip
area. Previous treatment with 0,1% betamethasone valerate cream twice a day for
3 months failed to improve the lesion. She was treated with calcipotriol
ointment twice daily, with nightly occlusion to the plaque for 9 months, and
this resulted in resolution. No side effects were noted.
5.) Combined treatment with calcipotriol ointment and low-dose ultraviolet A1
phototherapy in childhood morphea.
Pediatr Dermatol. 2001 May-Jun;18(3):241-5.
Kreuter A, Gambichler T, Avermaete A, Jansen T, Hoffmann M, Hoffmann K, Altmeyer
P, von Kobyletzki G, Bacharach-Buhles M.
Department of Dermatology, Ruhr-University Bochum, Bochum, Germany.
[email protected]
Various therapies for morphea have been used with limited success, including
ones with potentially hazardous side effects. When morphea occurs in childhood
it may lead to progressive and long-lasting induration of the skin and
subcutaneous tissue, growth retardation, and muscle atrophy.
We report an open
prospective study in which the efficacy of a combined treatment with
calcipotriol ointment and low-dose ultraviolet A1 (UVA1) phototherapy in
childhood morphea was investigated. Nineteen children (mean age 8.5 years, range
3-13 years) with morphea were exposed to UVA1 (340-400 nm) phototherapy at a
dose of 20 J/cm(2) four times a week for 10 weeks. Forty phototherapy sessions
resulted in a cumulative dose of 800 J/cm(2) UVA1.
In addition, calcipotriol
ointment (0.005%) was applied twice a day. After 10 weeks, palpation and
inspection showed a remarkable softening and repigmentation of formerly affected
skin resulting in a highly significant (p < 0.001) decrease of the mean clinical
score from 7.3 +/- 0.9 at the beginning to 2.4 +/- 0.9 (relative reduction
67.1%) at the end of combined therapy. Our results indicate that a combined
therapy with calcipotriol ointment and low-dose UVA1 phototherapy is highly
effective in childhood morphea.
Further controlled studies are necessary to
investigate whether this combined therapy is superior to UVA1 phototherapy
alone.
6.) Treatment of scleroderma.
Arch Dermatol. 2002 Jan;138(1):99-105.
Sapadin AN, Fleischmajer R.
Department of Dermatology, Mount Sinai School of Medicine, 1425 Madison Ave, PO
Box 1047, New York, NY 10029, USA.
The treatment of systemic sclerosis (scleroderma) is difficult and remains a
great challenge to the clinician. Because the cause is unknown, therapies are
directed to improve peripheral blood circulation with vasodilators and
antiplatelet aggregation drugs, to prevent the synthesis and release of harmful
cytokines with immunosuppressant drugs, and to inhibit or reduce fibrosis with
agents that reduce collagen synthesis or enhance collagenase production.
The
purpose of this review is to critically analyze conventional and new treatments
of systemic sclerosis and localized scleroderma. The therapeutic options
discussed for the treatment of systemic sclerosis include the use of (1)
vasodilators (calcium channel blockers [nifedipine], angiotensin-converting
enzyme inhibitors [captopril, losartan potassium], and prostaglandins [iloprost,
epoprostenol]), (2) immunosuppressant drugs (methotrexate, cyclosporine,
cyclophosphamide, and extracorporeal photopheresis), and (3) antifibrotic agents
(D-penicillamine, colchicine, interferon gamma, and relaxin).
The treatment
options reviewed for localized scleroderma include the use of corticosteroids,
vitamin D analogues (calcitriol, calcipotriene), UV-A, and methotrexate.
Preliminary reports on new therapies for systemic sclerosis are also considered.
These include the use of minocycline, psoralen-UV-A, lung transplantation,
autologous stem cell transplantation, etanercept, and thalidomide.
7.) Classification of morphea (localized scleroderma).
Mayo Clin Proc. 1995
Nov;70(11):1068-76.
Comment in:
Mayo Clin Proc. 1996 Mar;71(3):318.
Peterson LS, Nelson AM, Su WP.
Division of Rheumatology and Internal Medicine, Mayo Clinic Rochester, MN 55905,
USA.
OBJECTIVE: To classify and describe morphea (localized scleroderma). DESIGN: A
review of morphea and its subtypes is presented.
RESULTS: The current
classification of morphea is incomplete and confusing. As knowledge of the
spectrum of disease continues to evolve, the controversy and confusing nature of
its multiple subtypes present a challenge for the physician who encounters a
patient with this condition. Thus, we propose that morphea be classified into
the following five groups: plaque, generalized, bullous, linear, and deep. This
classification, based on clinical morphologic findings, will simplify the
diagnostic and therapeutic approach.
CONCLUSION: Morphea represents a wide
variety of clinical entities that seen to be on the opposite end of the
scleroderma spectrum from systemic sclerosis. The cutaneous lesions eventually
evolve from a sclerotic stage to a nonindurated stage, and residual
hypopigmentation or hyperpigmentation follows.
The histologic pattern in
patients with morphea is similar to that in patients with progressive systemic
sclerosis. Although treatment is nonstandardized, hydroxychloroquine sulfate may
be beneficial.
8.) Novel autoantibody to Cu/Zn superoxide dismutase in patients
with localized scleroderma.
J Invest Dermatol. 2004 Mar;122(3):594-601.
Nagai M, Hasegawa M, Takehara K, Sato S.
Department of Dermatology, Kanazawa University Graduate School of Medical
Science, Kanazawa, Japan.
Abnormal production of reactive oxygen species (ROS) induces tissue damage and
superoxide dismutase (SOD) that converts superoxide radicals to hydrogen
peroxide functions as defense against ROS. Cu/Zn SOD administration has been
shown to be effective for various fibrotic conditions by inhibiting the
fibrogenic effects of ROS.
We hypothesized that autoimmune background in
localized scleroderma induced anti-Cu/Zn SOD autoantibodies that inhibited SOD
activity and thereby contributed to fibrosis by increasing ROS.
ELISA using
human purified Cu/Zn SOD revealed that IgG or IgM anti-Cu/Zn SOD Ab was detected
in the serum of 89% of localized scleroderma patients, especially 100% of
patients with generalized morphea, the severest form of localized scleroderma,
but was positive only in the serum of less than 15% of patients with other
autoimmune disorders, including systemic sclerosis, systemic lupus
erythematosus, dermatomyositis, and autoimmune bullous disorders. The
immunoblotting analysis confirmed the presence of IgG anti-Cu/Zn SOD Ab in sera
from localized scleroderma patients.
Remarkably, anti-Cu/Zn SOD autoantibody
could inhibit Cu/Zn SOD enzymatic activity. Collectively, these results indicate
that anti-Cu/Zn SOD Ab is a novel, major autoantibody in localized scleroderma,
and also suggest that the autoantibody may play a role in the development of
fibrosis by directly inhibiting SOD activity.
9.) Morphea and Toxoplasma Gondii [In Process Citation]
Rev Med Chir Soc Med Nat Iasi. 2003 Jul-Sep;107(3):646-9.
[Article in Romanian]
Solovastru L, Amalinei C.
Disciplina de Dermatologie, Facultatea de Medicina, Universitatea de Medicina si
Farmacie Gr.T. Popa Iasi.
Circumscribed scleroderma or morphea is a rare disease that involves limited
areas of skin and usually is not associated with visceral lesions. Its etiology
is still debated, but its appearance signifies a particular immunological
status. We present a case of a male patient, which developed morphea lesions
during the infection with Toxoplasma gondii.
Clinical manifestation was
characteristic for the classic plaque-type of morphea. Diagnosis was confirmed
by the histopathologic examine of the cutaneous lesions. The evolution of
lesions was correlated with antibodies titre for Toxoplasma gondii, and local
administration of corticosteroids accelerated the evolution to cutaneous lesions
stabilization.
10.) Anti-DNA topoisomerase IIalpha
autoantibodies in localized scleroderma.
.
Arthritis Rheum. 2004 Jan;50(1):227-32.
Hayakawa I, Hasegawa M, Takehara K, Sato S.
Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.
OBJECTIVE: To determine the prevalence and clinical correlation of anti-DNA
topoisomerase IIalpha (anti-topo IIalpha) antibody in patients with localized
scleroderma.
METHODS: Anti-topo IIalpha antibodies or anti-DNA topoisomerase I
(topo I) antibodies were determined by enzyme-linked immunosorbent assay (ELISA)
and immunoblotting. Inhibition of topo IIalpha enzymatic activity by the
antibodies was evaluated by decatenation assays using kinetoplast DNA as a
substrate.
RESULTS: IgG or IgM anti-topo IIalpha antibody was detected in 76%
(35 of 46) of patients with localized scleroderma, and in 85% (11 of 13) of
patients with generalized morphea, the severest form of localized scleroderma.
This prevalence of the antibody in patients with localized scleroderma was much
higher than that found in patients with systemic sclerosis (SSc) (5 of 37
[14%]), systemic lupus erythematosus (2 of 26 [8%]), dermatomyositis (2 of 20
[10%]), and in healthy controls (3 of 42 [7%]). Immunoblotting confirmed the
presence of IgG anti-topo IIalpha antibody in sera from patients with localized
scleroderma and showed no cross-reactivity of anti-topo IIalpha antibody with
topo I. Anti-topo I antibody was not detected by ELISA in any sera from patients
with localized scleroderma.
In addition, anti-topo I antibody from SSc patients
did not cross-react with topo IIalpha.
The presence of anti-topo IIalpha
antibody was associated with a greater total number of sclerotic lesions and
number of plaque lesions in patients with localized scleroderma. Furthermore,
anti-topo IIalpha antibody was able to inhibit topo IIalpha enzymatic activity.
CONCLUSION: The results of the present study indicate that anti-topo IIalpha is
a major autoantibody in localized scleroderma, and is distinct from anti-topo I
antibody in SSc.
11.) Topical tacrolimus in the treatment of localized
scleroderma.
Eur J Dermatol. 2003 Nov-Dec;13(6):590-2.
Mancuso G, Berdondini RM.
Department of Dermatology, Municipal Hospital of Lugo, via Pescantini 33, 48022
Lugo (RA), Italy.
Although the cause of localized scleroderma is unknown, an autoimmune mechanism
is suspected. We describe two patients with localized scleroderma treated with
topical tacrolimus, an immunosuppressive macrolide antibiotic. Topical
tacrolimus 0.1% ointment applied twice daily under occlusion led to a
significant clinical improvement of late sclerotic lesions and complete
clearance of early inflammatory skin lesions in 3 months.
These were the first
cases of successful topical tacrolimus therapy in localized scleroderma and
should be regarded as a promising treatment option for LS, especially on account
of its high tolerability that permits prolonged use without side-effects.
12.) Does solitary morphoea profunda progress?.
Clin Exp Dermatol. 2004 Jan;29(1):25-7.
Azad J, Dawn G, Shaffrali FC, Holmes SC, Barnetson RJ, Forsyth A.
Department of Dermatology, Royal Infirmary, 84 Castle Street, Glasgow G4 0SF,
Scotland, UK. [email protected]
Solitary morphoea profunda (SMP) is an unusual form of scleroderma and is rarely
mentioned in the literature. The back of the trunk is described as the commonest
site of involvement by SMP.
This disease has been recognized as a nonprogressive
condition. We report three cases of SMP seen at our department within a 1-year
period. Interestingly, all three patients were females and the lesions were
situated on the right upper buttock. In one patient the lesion extended despite
using topical tacrolimus but subsequently the lesion was kept under control with
topical clobetasol propionate.
Eur J Dermatol. 2003 Nov-Dec;13(6):590-2.
13.) Oral calcitriol as a new therapeutic modality for
generalized morphea.
Arch Dermatol. 1994 Oct;130(10):1290-3.
Comment in:
Arch Dermatol. 1995 Jul;131(7):850-1.
Hulshof MM, Pavel S, Breedveld FC, Dijkmans BA, Vermeer BJ.
Department of Dermatology, University Hospital Leiden, The Netherlands.
BACKGROUND: None of the commonly used drugs for the treatment of scleroderma
appears to significantly influence the fibrotic stage of this disorder.
Recently, a beneficial effect of the treatment with oral calcitriol (1,25
dihydroxyvitamin D3) in 10 patients with systemic sclerosis and four patients
with morphea was described. This fact could be ascribed to the immunoregulatory
effects of calcitriol observed in vitro and to inhibition of fibroblast growth.
We treated three patients with extensive morphea with remarkable results.
OBSERVATION: Three patients with generalized morphea were treated with
calcitriol in an oral daily dose of 0.50 to 0.75 microgram. After 3 to 7 months
of treatment, the mobility of the joints improved and the skin extensibility
increased. No adverse effects were observed. The improvement persisted after
discontinuation of therapy during a follow-up period of 1 to 2 years.
CONCLUSION: Calcitriol showed a beneficial effect in generalized morphea during
an open study. Double-blind, placebo-controlled trials are needed to assess its
therapeutic value.
14.) Morphea-like reaction to D-penicillamine therapy.
Morphea-like reaction to D-penicillamine therapy.
Ann Rheum Dis. 1981 Feb;40(1):42-4.
Bernstein RM, Hall MA, Gostelow BE.
We report the case of a 48-year-old woman who developed morphea-like plaques
after 1 year of treatment with D-penicillamine at 250 mg daily for a
seronegative erosive arthritis of rheumatoid type.
The rash began as several red
itchy patches on the trunk; these became thickened and shiny over about 3
months. The histological appearance was of increased dermal fibrosis with an
inflammatory infiltrate round dermal capillaries. However, epidermal changes
were not typical of morphea. New lesions ceased to appear within a few months of
stopping penicillamine, and by 1 year all the plaques were pale and symptomless.
15.) Treatment of generalized morphea with oral 1,25-dihydroxyvitamin
D3.
Adv Exp Med Biol. 1999;455:299-304.
Caca-Biljanovska NG, Vlckova-Laskoska MT, Dervendi DV, Pesic NP, Laskoski DS.
Department of Dermatology, University Hospital Skopje, Republic of Macedonia.
Scleroderma is a chronic connective tissue disease characterized by excessive
collagen synthesis and its deposition in the skin and various internal organs.
Immune system abnormalities and disturbances of connective tissue metabolism
have been suggested to play a central role in the pathogenesis of scleroderma.
1.25-Dihydroxyvitamin D3 (1.25(OH)2 D3 causes inhibition of fibroblast growth,
has a role in controlling collagen synthesis and deposition and has numerous
immunoregulatory activities.
We assessed the effects of oral 1.25 (OH)2 D3 in
the treatment of patients with generalized morphea. Three patients with
generalized morphea, entered an open prospective study. They were treated with
oral calcitriol (1.25 dyhidroxyvitamin D3) in an oral daily dose of 0.50-0.75
microgram. After the treatment period of 4-6 months, a significant clinical
improvement was observed.
The mobility of the joints improved, the skin
extensibility increased and a substantial improvement of the skin induration. No
serious side effects were observed. The improvement persisted after
discontinuation of therapy during a follow-up period of one year.
The evolution
of the patients' condition during the 6 months therapy with calcitriol, suggests
that it can be used as a beneficial agent in the treatment of generalized
morphea. Double-blind, placebo-controlled trials are needed to assess its
therapeutic value and a larger number of patients is desirable.
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DATA-MÉDICOS/DERMAGIC-JOURNAL / APRIL 2.004 / DR. JOSÉ LAPENTA
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