Morphea and Related Disorders E-Book
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- Herausgeber: Bentham Science Publishers
- Kategorie: Fachliteratur
- Sprache: Englisch
- Veröffentlichungsjahr: 2024
Morphea and Related Disorders is a comprehensive reference on morphea. The book covers the subject in 20 chapters. The book starts with a detailed introduction and history of the morphea and its various classifications systems. Next, the book progresses into epidemiology, predisposing factors and pathogenic mechanisms, followed by histopathology for morphea diagnosis and a detailed review of clinical presentations.
Subsequent chapters cover associated diseases and extracutaneous manifestations, medical investigations, treatment guidelines and special topics (Idiopathic atrophoderma of Pasini and Pierini, Linear atrophoderma of Moulin, Parry-Romberg syndrome, Lichen sclerosus, pediatric morphea and eosinophilic fasciitis).
Key features
The most detailed reference book on morphea
Easy and simple language for readers
Chapter synopsis at the beginning of each chapter
Learning points at the end of the chapter
More than 100 high resolution colored photographs
Information boxes and tables to enhance readability.
Covers basic knowledge on morphea, including pathogenesis, clinical presentations, and classification
Includes guidelines for professionals
Includes chapters on special topics for advanced readers
Morphea and Related Disorders is the definitive reference book for medical students, residents, instructors, and physicians.
Readership
Medical students, instructors, and physicians (dermatologists, rheumatologists, and general physicians)
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FOREWORD
I feel privileged to write this foreword for the book titled “Morphea and Related Disorders”, edited by Dr. Tasleem Arif unquestionably one of my most exceptionally brilliant students. Dr. Tasleem did his postgraduation in dermatology under my supervision as the head of the Postgraduate Department of Dermatology, Venereology, and Leprosy at Government Medical College Srinagar, Jammu and Kashmir, India. Throughout his post-graduation, Dr. Tasleem manifested a profound interest in Morphea and related disorders, leading him to select these disorders as the focal point of his thesis.
This remarkably comprehensive book efficaciously addresses the missing gaps in our understanding of the range of these disorders.
Focus on the classification of Morphea, a comprehensive account of topics like linear atrophoderma of Moulin, Idiopathic Atrophoderma of Pasini and Pierini, Parry-Romberg syndrome, and Extragenital Lichen sclerosus makes it interesting for the readers thereby transforming it into an invaluable resource book for dermatologists as well as rheumatologists
I congratulate Dr. Tasleem for coming forth with a book on a spectrum of disorders that are still an enigma for the practicing dermatologist.
PREFACE
The aim of this book titled “Morphea and related disorders” is to give a comprehensive and detailed description of morphea and some of the disorders related to it. Morphea as a subject, has not been addressed adequately as other topics in dermatology like pigmentary dermatoses, bullous disorders, psoriasis, atopic dermatitis, etc. Patients of morphea are mainly managed by dermatologists and rheumatologists though other specialties like pediatrics, internal medicine, gynecology and obstetrics, and orthopedics are also involved in managing such patients. There have been several debates regarding various aspects of morphea especially its terminology, classification, etc. Unfortunately, I couldn’t come across a single book, which has exclusively addressed morphea in total. Moreover, there has been plenty of confusion regarding certain conditions like Linear atrophoderma of Moulin, Parry Romberg syndrome, Idiopathic atrophoderma of Pasini and Pierini, Eosinophilic fasciitis and Lichen sclerosus; whether they constitute subtypes of morphea or they are separate disease entities. Thus, there existed an unmet need for a book giving an in-depth understanding of morphea and to give a compendious account of such bewildering conditions. Through this book, I have tried to address such issues.
The inspiration for writing the book on this subject came in 2012 during my dermatology residency programme when I was assigned thesis related to scleroderma. My research was based on both localized (morphea) as well as systemic (systemic sclerosis) forms of scleroderma. Since, the enrollment of my first patient for thesis research, I have been collecting data, figures, etc. as a preparation for this unique book project. So in other words, the drafting for book has been for the last 2-3 years but the actual preparation has been there for a decade. One of the major boosts to my confidence to write on this subject came from New England Journal of medicine (NEJM). Every physician is well aware of the impact and reputation which NEJM has in medical science. My basic research on morphea and systemic sclerosis was published in 2015 in BMC Gastroenterology Journal. That research was reviewed by NEJM in their journal watch and they concluded their journal watch based on findings of our research. That gave me an impetus to write on scleroderma. Since then, I have consistently made research on scleroderma and published around 25 research articles related to it. With such numbers and expertise in scleroderma, I felt probably I can attempt to edit and author a book on morphea. The everlasting prayers of my parents for my success have been a pillar in shaping my career.
Being the solo editor as well as author/co-author of 12 chapters (out of 20 chapters) of this book, the journey of this book for the past 2-3 years has seen lots of ups and downs. One of the major reasons was Covid-19. Apart from that, this era has been full of trials to me and my family. We have faced practically some calamities. At one stage, the circumstances became so difficult that I felt I will not be able to edit or author this book. But massive credit goes to my wife, Dr Marwa Sami, who knew what this book means to me. Despite our strenuous and back-breaking conditions, she kept me motivating and giving me timely reminders to complete this book. I don’t feel this book could have been accomplished without her continuous motivation.
There are several features which add uniqueness to this book. Probably, the first book which has been written exclusively on morphea describing it’s all parameters ranging from etiology to treatment. There are individual chapters’ on topics like linear atrophoderma of Moulin, Parry Romberg syndrome, Idiopathic atrophoderma of Pasini and Pierini, Eosinophilic fasciitis, Lichen sclerosus and Pediatric morphea. Even in the most advanced textbooks of dermatology, we can hardly find any substantial account on such topics. Every chapter begins with a table having the main substance summarized in the form of chapter synopsis. Learning points in the form of a table are provided at the end of each chapter so that readers can conclude what they have learnt from the chapter. The text of each chapter is enriched with ample number of boxes and tables to enhance the readability. Boxes are provided to summarize the content of a particular section for quick revision. This book will serve as reference book to dermatologists, rheumatologists and physicians ranging from resident to professor as well as practicing physicians. Ultimately, I am hopeful that readers will unveil several horizons related to morphea and its related disorders while reading this book.
DEDICATION
This book is dedicated to:
…………If anyone killed an innocent human, it would be as if he killed all mankind; And if anyone saved a life, it would be as if he saved the life of entire mankind………
(The Glorious Quran; Chapter 5: Verse 32.)
As an editor and author/co-author (of 12 chapters out of 20) of this book, if only one human gets correctly diagnosed and treated as a result of this book, I will feel that I have done my job.
List of Contributors
Introduction and History
Tasleem Arif1,2,*Abstract
INTRODUCTION
Morphea is a group of chronic inflammatory diseases which is characterized by sclerosis of the skin as a result of excessive collagen deposition in the dermis and subcutaneous tissue [1]. The word scleroderma has been widely used to account for any condition where there are skin lesions associated with sclerosis of the skin. However, to be precise, the term scleroderma is used to connote a spectrum of disorders, which are characterized by sclerotic skin lesions as their primary disease process and presentation. These include a localized and a systemic form. The localized type which has been inappropriately termed as ‘localized scleroderma’, denotes a group of related disorders characterized by varying degrees of sclerosis, fibrosis and atrophy in the skin and subcutaneous tissues, that can occasionally extend deep into the fascia, muscle, bone and brain. However, the term localized scleroderma is not appropriate and a more apt term “Morphea” has been introduced in the literature to account for the confusion created by the term localized scleroderma’. Firstly, under the umbrella term of localized scleroderma, other disorders can be incorporated into it whose primary manifestation is not scleroderma; scleroderma is one of their secondary manifestations. There is a long list of such diseases which can have lesions similar to localized scleroderma, notable among them are chronic graft-versus-host disease, lipodermatosclerosis, porphyria cutanea tarda, etc. Secondly, among the types of morphea, there is an entity called generalized morphea which can be read as ‘generalized localized scleroderma’ if we use the term localized scleroderma instead of morphea. The term “generalized localized scleroderma” will be a source of confusion to the authors as well as to the readers. Hence, this term localized scleroderma is discouraged and that is the reason throughout this book the term morphea will be preferred instead of localized scleroderma. On the other hand, the systemic form of scleroderma is systemic sclerosis (SSC), which, in addition to sclerotic skin lesions, is characterized by the presence of sclerodactyly, vascular symptoms in the form of Raynaud phenomenon, abnormalities of the nail fold capillaries, and specific internal organ system involvement like gastrointestinal tract, lung, kidneys, etc. Though the process of development of sclerosis in the skin may follow similar mechanisms in the two diseases (morphea and systemic sclerosis); these are considered as two distinct entities with different antibody profiles, prognosis and treatment.
SSC has been further classified into two subtypes: limited cutaneous systemic sclerosis (LcSSC) and diffuse cutaneous systemic sclerosis (DcSSC). The former affects the distal extremities leading to sclerodactyly. It is associated with a long preceding history of Raynaud phenomenon, telangiectasias, and gastrointestinal involvement, and conveys a risk of isolated pulmonary artery hypertension. On the contrary, DcSSC is differentiated from LcSSC by proximal (above the knee and elbow and trunk) involvement of the skin. Though patients with DcSSC also suffer from sclerodactyly, they have a shorter history of onset of the Raynaud phenomenon, telangiectasias, and gastrointestinal involvement. These patients are at increased risk of interstitial lung fibrosis and renal crisis. These two subsets also have contrasting specific antibody profiles [2-5].
Morphea is an uncommon, autoimmune disease though relatively benign, characterized by round or oval, irregular or linear plaques that are initially dull red or violaceous or brownish (Fig. 1.1), smooth and indurated/sclerosed but later turn atrophic. They are histologically characterized by sclerosis of the dermis and/or subcutaneous tissue (Fig. 1.2) [1]. They are commonly confined to the skin and subcutaneous tissues; less commonly they can extend deeper and involve fat, fascia, muscle, bone and joints and rarely involve the eyes and brain. Like most of the other autoimmune diseases, morphea has been reported as more common in females. Though autoantibodies such as antinuclear antibody (ANA), antihistone, and anti-ssDNA can be found in the patients of morphea; however the SSC-specific autoantibodies such as anticentromere, anti-topoisomerase, and anti-RNA polymerase antibodies are rarely found in these patients. In addition, the organ system involvement that is typical of SSC, viz., gastrointestinal tract involvement, lung involvement and scleroderma renal disease does not occur in morphea. Though, nearly one-fifth to one-quarter of patients with morphea have been reported to experience extracutaneous manifestations but the SSC-specific organ system involvement doesn’t occur in morphea. Previously, morphea was considered a self-limiting disease. However in the last decade, many reviews have been published on morphea and there is ample evidence to suggest that a protracted, relapsing–remitting course may be common in morphea. Certain types of morphea if left untreated, can cause significant cosmetic and functional morbidity. Though the disease itself doesn’t seem to increase the chance of mortality; however, the disease can lead to significant morbidity as a result of flexion contractures, limb and facial asymmetry, extracutaneous manifestations, eye and CNS involvement; and psychological disability [6-9].
The treatment of morphea has been updated. Currently, there are several treatment options available for morphea which include topicals, phototherapy, systemic drugs, and recently biologicals. The choice of agent for treatment will depend upon several factors like the type of the morphea, the extent of the disease, the activity of the disease, the presence of deformities, etc. In the treatment of severe morphea, methotrexate in combination with systemic steroids and ultraviolet A1 light phototherapy has been the most effective treatment option [7].
Fig. (1.1)) Morphea: Ill-defined brownish hyperpigmented indurated plaque over lower back. [Copyright: Arif T, Hassan I, Nisa N. Morphea and vitiligo-A very uncommon association. Our Dermatol Online. 2015;6(2):232-234]. Fig. (1.2)) Histopathology of morphea showing dense homogenized bundles of collagen in the dermis (H and E, 100x).There are several other dermatoses which have been described in close relation with morphea. They can cause great diagnostic confusion as they may be seen occurring in association with morphea. They can possess similar clinical and histopathological findings. These include idiopathic atrophoderma of Pasini and Pierini (IAPP), linear atrophoderma of Moulin (LAM), Parry Romberg syndrome (PRS), Eosinophilic fasciitis (EF) and lichen sclerosus (LS). These have been discussed separately and in appropriate chapters in the book.
HISTORY
The history of morphea dates back to some 400 BC (Table 1.1) when Hippocrates mentioned a condition of thickened skin. Literally, the word “scleroderma” has been derived from the Greek words ‘skleros’ meaning ‘hard or indurated’ and ‘derma’ referring to skin. Curzio of Naples described the first case of generalized “hardness” of the skin in a young woman in 1752.
The term “sclérodermie” was coined by the French physician Gintrac in 1847. The first detailed description of morphea was given by Thomas Addison. He described a few cases with keloidal lesions and referred to them as “Keloid of Alibert” in 1854. He tried to differentiate it from the true keloid. He used the term “Keloid of Alibert” as he believed that Alibert was the first to discriminate and accurately describe this condition [10]. The typical histopathologic changes of scleroderma, including the increase in collagen and thickening of vessel walls in the involved skin were described by Matsui in 1924. The differentiating features of morphea and systemic sclerosis were described by O’Leary and Nomland in 1930 [11].
REFERENCES
[1]Arif T, Adil M, Amin SS, et al. Clinico-epidemiological Study of Morphea from a Tertiary Care Hospital. Curr Rheumatol Rev 2018; 14: 201-204.[PMID: 29637865][2]Arif T, Adil M, Sodhi JS. Upper gastrointestinal endoscopy in systemic sclerosis: A cross sectional study. J Pak Assoc Dermatol 2019;29 (4):374-383.[3]Arif T, Hassan I. Raynauds phenomenon in systemic sclerosis: Its prevalence and its relationship with the disease onset and subset-An experience from the Kashmir valley, India. West Indian Med journal 2018; 67 (1): 52-56.[4]Arif T, Adil M, Singh Sodhi J, Hassan I. Assessment of modified Rodnan skin score and esophageal manometry in systemic sclerosis: a study correlating severity of skin and esophageal involvement by objective measures. Acta Dermatovenerol Alp Pannonica Adriat. 2018; 27: 169-173.[PMID: 30564828][5]Arif T, Adil M, Hassan I. Antibody profile in systemic sclerosis patients: A cross sectional study from Kashmir Valley of India. J Pak Assoc Derm 2018; 28(1): 45-50.[6]Fett N, Werth VP. Update on morphea: part I. Epidemiology, clinical presentation, and pathogenesis. J Am Acad Dermatol 2011; 64(2): 217–28.[http://dx.doi.org/10.1016/j.jaad.2010.05.045] [PMID: 21238823][7]Fett N, Werth VP. Update on morphea: part II. Outcome measures and treatment. J Am Acad Dermatol 2011; 64(2): 231–42.[http://dx.doi.org/10.1016/j.jaad.2010.05.046] [PMID: 21238824][8]Fett N. Scleroderma: nomenclature, etiology, pathogenesis, prognosis, and treatments: facts and controversies. Clin Dermatol 2013; 31(4): 432–7.[http://dx.doi.org/10.1016/j.clindermatol.2013.01.010] [PMID: 23806160][9]Arif T, Majid I, Haji MLI. Late onset ‘en coup de sabre’ following trauma: Rare presentation of a rare disease. Our Dermatol Online 2015; 6(1): 49-51.[http://dx.doi.org/10.7241/ourd.20151.12][10]Addison T. On the keloid of Alibert, and on true keloid. Med Chirurg Trans. 1854; 37: 27.[http://dx.doi.org/10.1177/095952875403700106] [PMID: 20896031][11]O’Leary PA, Nomland R. A clinical study of one hundred and three cases of scleroderma. Am J Med Sci. 1930; 180: 95.[http://dx.doi.org/10.1097/00000441-193007000-00013]Classification
Tasleem Arif1,2,*,Marwa Sami3Abstract
INTRODUCTION
Morphea, inappropriately also called as, localized scleroderma, comprises a group of distinct conditions that primarily involve the skin and subcutaneous tissues.
Lesions clinically range from very small plaques limited to the skin only, to diseases that have the potential to cause significant physiological and aesthetic deformities, with a wide range of extracutaneous manifestations. Based on the specific subtype and localization, structures near the skin that include fascia, muscles, fat, bones and joints can also get affected. Involvement of internal organ systems like the lungs, gastrointestinal tract, kidneys and the heart is usually absent in morphea. Morphea should be viewed as a distinct entity from systemic sclerosis because of its almost exclusive cutaneous involvement and absence of visceral organ involvement except in rare instances. The differences between morphea and systemic sclerosis have already been discussed in chapter 1.
There are several types of morphea. Each type has a different clinical presentation and level of tissue involvement. However, the common denominator among the types of morphea is the presence of skin thickening (Induration) with an increased amount of collagen in the indurated lesion at any stage of disease evolution [1, 2]. Due to its broad clinical spectrum, several different attempts have been made to classify morphea. However, to date, no universally accepted classification system has been proposed which can account for all the heterogeneity seen in the clinical spectrum of morphea. Despite several classification systems which have categorized the disease, there are still controversies among authors as to which conditions should be included within the spectrum of morphea. This is particularly relevant with the three related atrophic variants viz., linear atrophoderma of Moulin (LAM), Idiopathic Atrophoderma of Pasini and Pierini (IAPP) and Parry-Romberg syndrome (PRS). A similar fate is faced by Eosinophilic fasciitis and Lichen sclerosus (LS). There has been controversy regarding bullous morphea and deep morphea. Whether the two should be kept as separate subtypes or not. Another headache to the system of classification is what constitutes generalized morphea as it has been defined in different ways by different authors. In this chapter, the authors will describe the various classification systems that have been suggested for morphea. However, in view of the lack of a single universally accepted classification system of morphea, the author has suggested a simple classification which can avoid most of the controversies by taking some suggestions from the already published classification systems. That classification system will be followed throughout this book.
CLASSIFICATION BY O’ LEARY ET AL.
The earliest attempt to classify scleroderma was made by O’Leary and Nomland. They published their clinical study of 103 cases of scleroderma in 1930. They broadly classified scleroderma into two types: 1) Generalized forms of scleroderma (associated with a varying degree of systemic involvement), 2) Localized forms of scleroderma, usually without systemic manifestations. Localized scleroderma is further divided into two types Table (2.1). A) Morphea and B) Other types [3, 4]. The classification of localized scleroderma is described as follows:
Morphea
Localized
According to them, a localized variant of morphea comprised of cutaneous patches having a variable size of 2 to 20 cm. These patches were having varied clinical presentations ranging from the classically sclerosed, carnauba wax- colored plaque to hyperpigmented atrophic areas present over the trunk and extremities. These lesions have signs of inflammation and later involute of their own.
Generalized
In generalized morphea, numerous plaques are present which at times may involve the entire trunk, though they didn’t give the definite criteria to diagnose generalized morphea. These plaques have pigmentation, atrophy and sclerosis depending upon the stage of evolution of the disease. The prognosis of this type was considered good.
Other Types
Linear
In this type, there are linear bands or streaks of waxy/sclerosed skin involving a limb. It may or may not be associated with plaque morphea.
Localized Forms Associated with Hemiatrophy
This subtype may present with a small indurated plaque on the forehead or scalp and can include linear morphea en coup de sabre. There can be atrophy of bone or muscle of the face in collaboration with the involvement of upper or lower limbs or both. Though there is hardly any risk of mortality, there is variable morbidity depending upon the magnitude of hemiatrophy and any associated congenital defects.
This classification though kick-started the process of classifying morphea, however, there were many limitations in the classification system. Some of them are mentioned as follows. Firstly, there was no clear-cut definition of generalized morphea with regard to the number of lesions or the size of lesions or the number of anatomic areas affected by the disease. Secondly, the most severe form of morphea, the pansclerotic type was not mentioned in the classification. Thirdly, the classification broadly divided scleroderma into localized and systemic forms, however, the intermediate forms like linear atrophoderma of Moulin (LAM), Idiopathic Atrophoderma of Pasini and Pierini (IAPP), Lichen sclerosus (LS), etc. were left out. Finally, a mixed type of morphea where different types can be present in the same patient was lacking in the system.
CLASSIFICATION OF LOCALIZED SCLERODERMA BY RODNAN ET AL (1979)
Rodnan, Jablonska and Medsger in 1979 divided localized scleroderma into two broad types: 1) Morphea and 2) Linear scleroderma [5, 6]. Their classification is mentioned in Table 2.2.
Morphea
Morphea was further divided into plaque type, generalized, guttate, subcutaneous type, keloidal, bullous type and superficial primary atrophic morphea (atrophoderma of Pasini and Pierini)
Linear Scleroderma
Scleroderma en coup de sabre with or without associated facial hemiatrophy. This classification system was a refined one over the previous classification. Some new terms were introduced in the classification like guttate morphea, bullous type, keloidal form, etc. However, it had similar limitations as the previous one. Generalized morphea was not defined with respect to the number or size of plaques. Similarly, intermediate scleroderma entities like LAM, LS, etc. were not mentioned in the classification, though they tried to accommodate the atrophoderma of Pasini and Pierini in the morphea classification system [6].
MODIFIED AMERICAN RHEUMATISM ASSOCIATION (ARA) CLASSIFICATION FOR LOCALIZED SCLERODERMA
The classification of localized scleroderma by ARA has been mentioned in Table 2.3. They broadly divided localized scleroderma into two types: morphea and linear scleroderma both having subtypes.
According to them, plaque-type morphea can occur at any part of the body rarely involving the face and extremities. The size of the plaque may vary from 1cm to the palm of the hand. As a rule of thumb, skin is moveable over the underlying tissues. The plaque may start as an erythematous and edematous area or as an ivory white plaque with the lilac ring. The disease is usually self-limiting in 3-5 years but rarely may persist for as long as 25 years.
Guttate morphea usually presents with multiple superficial white papules of varying sizes (2-10 mm). The sites of predilection include the shoulders and chest. The lesions lack follicular plugging, a feature differentiating them from LS. The lesions are arranged in a linear band.
Generalized morphea presents with lesions similar to plaque-type morphea but in widespread distribution and the lesions show a tendency to coalesce with one another and extend peripherally. Generalized morphea is usually bilateral and lesions may show secondary changes like pigmentation, development of bullae, calcinosis and purpura. Such patients may develop complications like ulcers, contracture and disability. Long-standing ulcers may develop malignant change. These patients usually suffer from morbidity and disability for years.
Linear scleroderma usually involves the pediatric population although it can persist till adulthood. It usually involves the upper and lower limbs. Atrophy, sclerosis, contractures and limitations of limb movement can occur. When linear scleroderma involves the forehead and scalp causing atrophy, and sclerosis and can extend to the underlying bone, it is termed as en coup de sabre [7].
This classification considered three subtypes for the deep morphea viz., nodular, subcutaneous and profunda. This classification too had several drawbacks like what constitutes the generalized morphea. Objective criteria to define generalized morphea was lacking. They did not include the Idiopathic Atrophoderma of Pasini and Pierini (IAPP) in the classification system owing to the controversial relationship between morphea and IAPP. A good percentage of patients have two or more than two types of morphea called mixed morphea. That was also missing in the classification. Similar was the case with LAM, PRS and Pansclerotic morphea.
CLASSIFICATION OF MORPHEA BY PETERSON ET AL.
In view of the limitations of ARA classification of localized scleroderma, Peterson et al. in 1995 came up with a better classification scheme [8]. They classified morphea into five general types: plaque morphea, generalized morphea, bullous morphea, linear morphea, and deep morphea Table 2.4. This classification has been widely used by dermatologists throughout the globe though it was also having some limitations. This classification tried to give a holistic approach to classifying morphea. An account of this classification is as follows:
Plaque Morphea
This type represents the superficial type of morphea which is usually restricted to the dermis and rarely involves the subcutaneous tissue. It has been further divided into several subtypes:
Morphea en Plaque
This is the most common variant of plaque-type morphea. It usually involves only one or two anatomic sites. The trunk is the most common site affected followed by extremities. The face is rarely involved. Plaques have well-defined borders which separate them from the surrounding normal skin. It usually starts with one or more round or oval indurated plaques which are larger than 1 cm in size. An erythematous halo or a violaceous ring (lilac ring) if present is characteristic of the plaque. As the disease progresses, the skin overlying the lesion becomes sclerotic while the inflammation subsides. After a variable disease course which may span from months to years, the disease burns out, there is softening of the plaque and atrophy ensues. There can be areas of hyperpigmentation or hypopigmentation in the plaque.
Guttate Morphea
This type of morphea presents with multiple oval lesions of varying size (2 to 10 mm) in diameter. The upper part of the trunk is the most common affected site. There is mild erythema surrounding these lesions. As the disease progresses, lesions develop mild induration with dyspigmentation (hyperpigmentation or hypopigmentation).
Atrophoderma of Pasini and Pierini
Peterson et al. grouped IAPP as a subtype of plaque morphea which later faced criticism. It is characterized by hyperpigmented atrophic plaques with characteristic “cliff-drop borders”. The plaques are asymptomatic and usually involve the trunk. Such plaques usually fail to develop induration. Hence, due to the absence of overt inflammation and sclerosis in the lesions, it was considered as a “burnt-out morphea.” It can present alone or occur with other morphea subtypes.
Keloid Morphea
It is characterized by nodular lesions that look similar to keloids in the presence of typical lesions of morphea. These nodules can be solitary or confluent.
Lichen Sclerosus (LS)
LS is characterized by shiny atrophic white plaques. Such plaques are usually preceded by violaceous skin lesions. The ano-genital area is the most commonly affected site, however, extragenital LS affecting the trunk and extremities also occur. Peterson et al. classified LS as a subtype of plaque morphea which was a controversial aspect of the classification.
Generalized Morphea
The onset of this type of morphea is usually insidious. Generalized morphea is considered when individual plaques enlarge to become confluent or plaques disseminate and involve more than two anatomic sites.
Bullous Morphea
In this type of morphea, there are tense sub-epidermal bullae in the presence of typical lesions of morphea. The lesions usually involve the limbs, trunk, face, or neck. Lesions can be superficial or extend deep into the dermis. A plausible expla-
nation for Bulla formation was attributed to the lymphatic obstruction caused by the sclerodermatous process or due to the localized trauma.
Linear Morphea
This type is characterized by one or more linear indurated streaks that can involve extremities and face or scalp or all three areas in the pediatric population. In this morphea, the disease can extend to the dermis, subcutaneous tissue, fascia, muscle, and even the underlying bone.
Linear Morphea (Linear Scleroderma)
This type of morphea usually manifests as a discrete linear induration mainly involving the limbs. It may or may occur in a zosteriform distribution. In 95% of the cases, the disease is unilateral. It may lead to several complications like limb atrophy, joint contractures and consequent deformities. The disease can extend beyond the subcutaneous tissue of the limbs to affect the growth and development of bony structures. In a study of patients having linear morphea, 20% of the patients had atrophy of underlying muscle and bone affecting lower limbs, having a leg length discrepancy of 1.5- to 7-cm. Contractures usually develop when linear morphea involves a joint. This type of morphea can result in severe flexural deformity which may need amputation [9].
En Coup de Sabre
When linear morphea involves the face or scalp, the lesions often resemble a stroke from a sword (sabre), hence the name ‘en coup de sabre’. The usual site of affection is the paramedian forehead. The disease is mostly unilateral, however, bilateral cases rarely occur. It can lead to several complications like ptosis, loss of eyelashes or eyebrows, uveitis, pseudo-oculomotor palsy, lingual atrophy and dental problems [10-13].
Progressive Hemifacial Atrophy
Progressive hemifacial atrophy (Parry-Romberg syndrome) causes hemifacial atrophy. The primary disease site is the subcutaneous tissue, muscle or bone. Most often skin remains mobile lacking sclerosis as the affliction of the dermis is a secondary change. However, in linear morphea, the dermis and subcutaneous tissues are the primary affected sites, and later the deep tissues are involved [14]. The relationship between Parry-Romberg syndrome and morphea en coup de sabre is a topic of debate and has been discussed in detail in chapter 17.
Deep Morphea
Deep morphea involves the deeper dermis, subcutaneous tissue, fascia, or superficial muscle. The lesions of deep morphea are usually more diffuse and are not present in a linear pattern, a feature that differentiates it from linear morphea. Though the level of depth of involvement may vary, the histopathological changes of different types of deep morphea are similar. They divided deep morphea into 4 types
Subcutaneous Morphea
As the name suggests, subcutaneous tissue is the primary site of involvement of subcutaneous morphea. Contrary to the lesions of ‘morphea en plaque’, the plaques of subcutaneous morphea are deeper and bound down. It was termed subcutaneous morphea by Jablonska [6]. A clinical study of 16 patients with subcutaneous morphea was described by Person and Su. According to them, the plaques were ill-defined, hyperpigmented and symmetrically distributed. The inflammation was more pronounced than that associated with other types of morphea. The rapid onset of sclerosis and pronounced inflammation were the characteristic features of this type [15].
Eosinophilic Fasciitis
It is a deep fibrotic condition involving fascia affecting the extremities proximal to the hands and feet. The fascia is the primary site of disease. There have been two schools of thought regarding the placement of this disease. Several authors have described it as a separate entity and kept it distinct from the typical morphea. However, histopathology may share features with deep morphea subtypes. In addition, eosinophilic fasciitis has been reported in patients having morphea and systemic sclerosis [16, 17]. Based on such features, Peterson et al classified eosinophilic fasciitis as a subtype of morphea and placed it in the deep morphea group. Eosinophilic fasciitis has been described in detail in chapter 20.
Morphea Profunda
This entity was introduced by Su and Person in 1981 based on a histopathological study of 23 cases. In this type of morphea, the entire skin feels taut, thickened and bound down. For diagnosing morphea profunda, they suggested a triad of criteria based on clinical, histopathological and therapeutic aspects of the disease: (1) Diffuse, bound-down, taut and deep cutaneous sclerosis; (2) Significant thickening and hyalinization of collagen bundles of both the subcutaneous tissue and the fascia along with a dense inflammatory cell infiltrate; and (3) Response to systemic corticosteroids, antimalarial agents, or other anti-inflammatory drugs [18]. Whittaker et al. in 1989 described patients with solitary indurated plaques having features of morphea profunda [19].
Disabling Pansclerotic Morphea of Children
This type of morphea was first reported by Diaz-Perez et al. in 1980 [20]. It is a mutilating variant of morphea with an aggressive disease course having significant disease morbidity. Clinically, patients present with generalized disease involving the trunk, extremities, scalp and face. The toes and fingertips are spared. The disease usually affects patients before the age of 14 years. The sclerotic plaques that develop in this disease extend deep into the subcutaneous tissue, fascia, muscle, and even bone, hence the name “Pansclerotic”. This type of morphea is considered to have the worst prognosis [8].
The classification system proposed by Peterson et al. was widely used by authors throughout the world. However, this classification had several drawbacks. Firstly, they classified the Atrophoderma of Pasini and Pierini and Lichen sclerosus as sub-types of morphea. Though both of them bear some relationship with morphea. However, there is still controversy about it and to date it has not been solved. Hence keeping them with morphea was not justified. Similarly, Eosinophilic fasciitis which primarily involves fascia and skin involvement is a secondary phenomenon in it; has been kept under morphea. Though morphea and EF have been reported to be present in the same patient but that doesn’t justify it being a subtype of morphea. Secondly, generalized morphea has not been defined completely. Thirdly, a good percentage of patients have more than one type of morphea, described as mixed type, and was missing in the classification. Additionally, regarding deep morphea, any type of morphea can extend beneath the dermis and involve subjacent tissues. Finally, terms like subcutaneous morphea and morphea profunda are similar. It looked very difficult to differentiate them. Some of these deficiencies were later discussed by Laxer/Zulian and Kreuter et al. in their classifications coming ahead.
CLASSIFICATION OF MORPHEA BY EUROPEAN PEDIATRIC RHEUMATOLOGY SOCIETY
To address certain deficiencies in the classification system proposed by Peterson et al., the Pediatric Rheumatology European Society in 2006 proposed a new classification system of juvenile localized scleroderma Table 2.5. Their classification, also known as Laxer and Zulian classification, included five subtypes: circumscribed morphea, generalized morphea, linear scleroderma, pansclerotic morphea and the new subtype “mixed” when two or more subtypes are present in the same patient [21]. This classification excluded Lichen sclerosus, atrophoderma of Pasini and Pierini, and eosinophilic fasciitis, however, they retained Parry Romberg syndrome. Certain modifications were introduced in the existing subtypes. Salient features of their classification are discussed below:
Circumscribed Morphea
It has been divided into two types-superficial and deep variants. In the superficial variant, there are round or oval circumscribed areas of induration that are limited to the epidermis and dermis. Such plaques can be single or multiple and most often have altered pigmentation and possess a violaceous, erythematous halo (lilac ring) which is more obvious in fair skin. In the deep variant, they have put the morphea profunda and subcutaneous morphea subtypes of Peterson et al. Oval or round circumscribed areas of deep skin induration extend to the subcutaneous tissue or fascia or underlying muscle (morphea profunda subtype of Peterson et al). The lesions can be single or multiple. Occasionally, the primary site of involvement is in the subcutaneous tissue without the involvement of the skin (subcutaneous type of Peterson et al).
Generalized Morphea
For generalized morphea, they proposed some discrete criteria which were missing in the previous classifications. Generalized morphea was considered when individual plaques are four or more in number and each plaque is larger than 3cm and becomes confluent involving at least two out of seven anatomic sites (right upper extremity, left upper extremity, right lower extremity, left lower extremity, head/neck, anterior trunk and posterior trunk). They also suggested that unilateral generalized morphea (usually having onset in childhood) should be regarded as an extreme variant.
Linear Morphea
Linear morphea can involve either the limbs/trunk or head/neck. It is considered as the most common subtype in pediatric population. It is characterized by one or more linear areas of induration that can involve the dermis, panniculus, muscle or even the underlying bone. It can lead to significant deformities. Not only upper and lower extremities can get involved but also the head and neck can get affected. Accordingly, linear morphea in the form of en coup de sabre variety (ECDS) (as the lesions resemble a stroke from the sword) and Parry Romberg syndrome characterize the linear morphea affecting the face/scalp. ECDS is considered a milder variant characterized by linear induration that affects the face and the scalp and sometimes involves muscle and underlying bone. On the other hand, PRS is considered a severe form of the disease that is characterized by hemifacial atrophy of the skin and tissue of the lower face (below the forehead) with only mild or absent involvement of the superficial skin [22, 23]. There is enough evidence to consider PRS as the severe end of the spectrum of ECDS. This could be the reason that they have classified it in the linear morphea affecting the head/neck. The presence of similar associated conditions like CNS, ocular and dental abnormalities has been reported in both conditions with similar prevalence [24-26]. In addition, the author and colleagues have carried out a recent review of literature in which they have shown enough evidence to suggest that PRS and ECDS lie on the same spectrum with ECDS being a milder variant while PRS lies on the severe end of the spectrum [23]. The relationship between ECDS and PRS has been discussed in detail also in chapter 17.
Pansclerotic Morphea
Pansclerotic morphea is the most severe type of morphea, fortunately very rarely encountered in the clinical set-up. There is generalized full-thickness involvement of the skin of the extremities, trunk, scalp and face. However, there is sparing of the toes and fingertips. Though the entire body can be affected by it but internal organ involvement is rarely seen. This feature differentiates it from systemic sclerosis. Chronic ulcers in pansclerotic morphea can evolve into squamous cell carcinoma which is a life-threatening complication [27-29]
Mixed Morphea
When two or more of the previous subtypes of morphea are present, the term mixed morphea is applied. This subtype has been missing in the previous classifications. According to a multicenter study comprising 750 children, it was found to constitute about 15% of the whole group [30].
Laxer and Zulian’s classification has been widely used by researchers. It was a refined classification in comparison to Peterson et al. The addition of mixed subtypes made it more comprehensive. However, certain questions remain to be answered. Generalized morphea has been defined as 4 or more plaques each more than 3 cm involving at least two anatomic regions. However, if there is a large plaque (or less than 4 plaques) covering the entire trunk or one complete limb, how it will be labelled. Is the area of involvement the only parameter needed or the deeper extension of disease is also important? In addition, disease entities like IAPP, EF, LS, and LAM which are somehow related to morphea have not been discussed in the classification.
CLASSIFICATION OF MORPHEA BY GERMAN DER-MATOLOGICAL SOCIETY
The German Dermatological Society in 2009 proposed S1 guidelines for the diagnosis and treatment of localized scleroderma that included a new classification which divided morphea broadly into 4 types: limited, linear, generalized, and deep types Table 2.6
