Asymptomatic Plaques
A 55-year Caucasian female has had a lesion on her back, under her bra line, for the past 3 years. The patient states the lesion began as a dark reddish-brown patch of skin and has evolved over time (Figure). The lesion is not painful and does not itch.
Past medical history is positive for degenerative disc disease, hypothyroidism, and hyperlipidemia.
Physical examination revealed a well-circumscribed lesion with a hyperpigmented border. The center of the lesion was firm, hairless, and thickened. There was no loss of sensation throughout the lesion.
Discussion. Morphea is an inflammatory condition marked by sclerosis of the skin and subcutaneous tissue at the affected sites. Localized scleroderma is another term for morphea. Plaque or circumscribed morphea is the most common subtype.1 Although lesions are localized, extracutaneous symptoms may be present.
Morphea is differentiated from systemic scleroderma by lack of internal organ involvement, sclerodactyly, and Raynaud’s phenomenon.1,2 Morphea begins as an erythematous to purplish patch or plaque, usually painless. These lesions are frequently found in areas of friction or pressure, such as the bra line.
As the plaque evolves, the central area thickens, hardens, and becomes a pearly-white color surrounded by a hyperpigmented border. Morphea affects both adults and children with an incidence of 0.4 to 2.7 per 100,000 people, has a predilection for females, and affects Caucasians more frequently.1-3 The cause of morphea is unknown, however, there have been studies suggesting an autoimmune association.4
Interestingly, this patient had been diagnosed with Hashimoto’s thyroiditis years prior. Diagnosis is made with a clear clinical picture. To support the diagnosis or determine the depth of disease, a biopsy may be performed, but is not necessary.
Treatment is often not warranted for cases of uncomplicated morphea.5 However, for more complicated cases, methotrexate, systemic steroids, and ultraviolet A1 light phototherapy have proven useful as has topical tacrolimus.2,6 The lesions may take months to years to resolve.2 In order to assess disease progression and reduce morbidity, close follow-up is warranted.
References:
1.Fett N, Werth VP. Update on morphea: part I. Epidemiology, clinical presentation, and pathogenesis. J Am Acad Dermatol. 2011;64(2):217-228; quiz 229-230.
2.Christen-Zaech S, Hakim MD, Afsar FS, Paller AS. Pediatric morphea (localized scleroderma): review of 136 patients. J Am Acad Dermatol. 2008;59(3):
385-396.
3.El Fékih N, Réjaibi I, Kamoun H, et al. Localized scleroderma: a retrospective study about 92 cases. Tunis Med. 2009;87(9):573-578.
4.Leitenberger JJ, Cayce RL, Haley RW, et al. Distinct autoimmune syndromes in morphea: a review of 245 adult and pediatric cases. Arch Dermatol. 2009;
145(5):545-550.
5.Habif TP. Clinical dermatology: A color guide to diagnosis and therapy. 5th ed. Philadelphia, PA: Elsevier/Mosby; 2009:707-708.
6.Fett N, Werth VP. Update on morphea: part II. Outcome measures and treatment. J Am Acad Dermatol. 2011;64(2):231-242; quiz 243-244.