SCLERODERMA ================ From: GenadijS@aol.com I have an 8 y.o. WF pt. with a 1 year history of linear scleroderma of the right parietal scalp and right temple and forehead regions. The scalp plaques are yellowish, indurated, and devoid of hair follicles. The forehead and temple areas are beginning to get involved, with pallor mixed with slight erythema, and slight atrophy but no induration yet. There is no bony involvement and no soft tissue depression suggestive of Parry-Romberg Syndrome, and her eye is ok. She is otherwise well, with a normal sed rate and neg. ANA. I had her on Plaquenil for 4 months but during this time lesions progressed. She saw a Rheumatology consultant recently upon referral through the Scleroderma Foundation. He placed her on methotrexate instead. I had not found any reference to using methotrexate in this condition in my searches of the literature on Medline, or in any texts. I have used MTX in this age group before in one desperate case of severe psoriasis, but only for a few months. Please send your comments and/or suggestions. ================ From: "MARK NAYLOR" On 2/6/96 GenadijS@aol.com asked for treatment recommendations for en coup de sabre type linear scleroderma. Pardon the anecdotal nature of this response, but I recently had an excellent result in the treatment of linear scleroderma of the forehead in a 16 y/o female with a 6-8 month history of a progressively enlarging lesion on the forehead who was almost certain to have a poor cosmetic outcome without therapy. I found a case series that used PUVA, (systemic psoralens) and after 15 treatments (the reference patients had around 20 or so treatments as I recall) her huge (3 cm) divot has not only stopped growing, it has actually shrunk to about 2 cm and is filling in enough that it is getting difficult to see (depth and diameter are both definitely and noticably reducing). This treatment has some rationale if you presume that scleroderma is essentially an autoimmune response and PUVA is wiping out immunocompetent cells in the dermis. Anyway it appears to have exceeded my fondest expectations in my series of one and might be worth a try in your patient, particularly if cosmetic outcome is important. Here is the original reference, by the way: 1. Kerscher M, Volkenandt M, Meurer M, et al.: Treatment of localised scleroderma with PUVA bath photochemotherapy. Lancet 343(8907):1233, 1994. Mark Naylor, M.D. =================== From: alson@hk.super.net (WONG) It is very interesting.I wonder if a topical psoralens would produce similar effect since it affects a localised area ,very few dermatologist in hong kong get hold of PUVA facilities. Alson Wong ============== From: Steve Feldman At the Photomedicine Society meeting, the same group also reported success with long wave UVA light without the psoralen for localized scleroderma. Steve Feldman ========================= From: KSmithDerm@aol.com Linear scleroderma has been reported with a Lyme-like organism - might be good to get a Bosma stain on a biopsy specimen. I've had several patients with morphea respond well to antibiotics - Minocin and Doryx were the best until Zithromax came along. Zithromax gives very high and persistent tissue levels, but you still need to Rx for about 6 months because the spirochetes divide rarely, and are only susceptible to Rx when they are dividing. Take photos - this will make it much easier to objectively assess response to Rx, and to encourage patient to persist with Rx. KC Smith MD FRCPC ======================= From: Gfweb@aol.com As far as I know there have been no North American cases of morphea that had demonstrable Borrelia. It seems that European morphea is different in this respect. Guy Webster, MD, PhD From: Steve Feldman At the AAD poster session, another European morphea study and review of the literature said that only one of many PCR/morphea/Borrelia studies in Europe detected Borrelia in localized scleroderma. The author suggested that the one positive European report was an aberration and that their (European) morphea probably also has nothing to do with Borrelia. Steve Feldman, MD, PhD ======================= From: GenadijS@aol.com Thank you for the helpful input. Borrelia titers were negative, but a biopsy was not performed. Would you suggest biopsy of the areas of established sclerosis in the scalp, or the evolving areas of pallor and faint erythema on the lateral forehead and temple? I would assume that the latter would be more likely to reveal organisms, although the overall histopathology might be less specific overall. ======================= From: drpuritz@li.net (Dr. Elliott Puritz) Is a biopsy needed? An interesting point that you suggest is that organisms might be present with a negative Borrelia titer. If you strongly suspect Borreliosis, why not simply treat with adequate doses of Doxycycline or an alternative drug and observe the response? Elliot Puritz ================= From: KSmithDerm@aol.com I would biopsy the erythematous or violaceous border, and have it stained using the Bosma modification of the Steiner silver stain. Borrelia titres are pretty useless, and I think that the Borrelia in these cases will turn out to be someting other than Borrelia burgdorferi. Kevin C. Smith, MD, FRCPC ==================