Case and Research Letters
Isomorphic Morphea in a Girl Motorcyclist
Morfea con distribución isomórfica en una niña motociclista
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"apellidos" => "de Lucas-Laguna" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario La Paz, Madrid, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Morfea con distribución isomórfica en una niña motociclista" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 788 "Ancho" => 750 "Tamanyo" => 61183 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Residual hyperpigmentation without sclerosis after treatment with oral corticosteroids and methotrexate.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Localized scleroderma, also known as morphea, is a fibrosing and inflammatory disease of the skin and underlying tissues. It is the most common type of scleroderma in childhood, with an incidence of 3.4 cases per 1<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>000 children per year.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Linear morphea is the most frequent presentation. The etiology and pathogenesis of this condition remain unknown, although the interaction between inflammatory, fibrotic, and vascular factors seems to play a fundamental role. It has also been suggested that local trauma can lead to the appearance of lesions.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 9-year-old girl with no medical history of interest reported asymptomatic skin lesions on both thighs that had gradually extended to the abdomen. The lesions had first appeared 1 year earlier. A closer examination of the patient's history revealed that she was a competitive motorcyclist who had been training for approximately 10<span class="elsevierStyleHsp" style=""></span>hours per week for the previous 2 years wearing a very tight motorcycle suit. Physical examination revealed hyperpigmented plaques with pearly areas on the anterior-medial aspect of both thighs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The lesions were distributed symmetrically and extended upward toward the trunk (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). There were no findings suggestive of systemic scleroderma. Given the suspicion of morphea, we performed a skin biopsy, which revealed thickening and compaction of collagen fibers at the level of the reticular dermis and a mild superficial and deep perivascular lymphoplasmacytic infiltrate. A blood analysis with biochemistry, complete blood count, and autoimmunity testing revealed no significant findings. Based on clinical, analytical, and histological findings, the diagnosis was morphea that could have been caused by local injury. The patient was treated with systemic corticosteroids at 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg/d (subsequently tapered) and methotrexate 10<span class="elsevierStyleHsp" style=""></span>mg weekly for 18 months. The induration resolved and only the hyperpigmentation persisted (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">While the etiology and pathogenesis of localized scleroderma are unknown, several case studies in the scientific literature report potential precipitating factors for both morphea and systemic sclerosis, such as friction caused by clothing, herpes zoster infection, vibration, and injury before onset of morphea.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–6</span></a> Vaccination is a key cause in children and has been well documented in the literature, with deep morphea and generalized morphea reported after vaccination against hepatitis B, bacille Calmette-Guérin, diptheria-tetanus-pertussis, and measles-mumps-rubella.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7–9</span></a> There have also been suggestions of an isotopic and isomorphic distribution depending on the appearance of the lesions in areas of skin injury in chronic sclerotic-type graft-vs-host disease,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> a process that is similar to morphea. The isotopic phenomenon is defined as the appearance of a new skin disease at the site of a previous, now healed, lesion or skin disease and with which there is no association. In contrast, the isomorphic phenomenon refers to the appearance of lesions of a previous skin disease on skin that had been subjected to injury. In this sense, in 2014, Grabell et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> published a study on the role of skin injury in the distribution of morphea lesions. The authors reported that 16% of patients with localized scleroderma associated onset and location with a previous injury, with chronic friction from clothing and surgery being the most common triggers of the isomorphic and isotopic phenomena, respectively. They also reported that isotopic lesions were more severe in clinical terms and in terms of their impact on quality of life.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present a case of morphea affecting the lower limbs and trunk of a girl who trained as a professional motorcyclist, thus suggesting that the condition was triggered by friction resulting from tight clothing and, possibly, vibration from the motorcycle, given the isomorphic distribution of the lesions. While the underlying mechanism has yet to be clarified, the injury itself seems to be associated with release of cytokines and growth factors in the damaged tissue,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> which may play a role in the development of morphea. This new case highlights the importance of the association between skin injury and localized scleroderma, not only in terms of pathogenesis, but also in terms of therapy, since these patients should avoid elective procedures or repeated skin injuries such as friction.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Abadías-Granado I, Feito-Rodríguez M, Nieto-Rodríguez D, de Lucas-Laguna R. Morfea con distribución isomórfica en una niña motociclista. Actas Dermosifiliogr. 2019;110:509–510.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 839 "Ancho" => 1200 "Tamanyo" => 132110 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hyperpigmented plaques with pearly areas that are indurated on palpation on the anterior-medial aspect of both thighs (A) and the right flank (B).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 788 "Ancho" => 750 "Tamanyo" => 61183 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Residual hyperpigmentation without sclerosis after treatment with oral corticosteroids and methotrexate.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence of childhood linear scleroderma and systemic sclerosis in the UK and Ireland" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 10 | 30 |
| 2024 October | 84 | 42 | 126 |
| 2024 September | 83 | 34 | 117 |
| 2024 August | 117 | 64 | 181 |
| 2024 July | 95 | 30 | 125 |
| 2024 June | 81 | 41 | 122 |
| 2024 May | 81 | 26 | 107 |
| 2024 April | 75 | 27 | 102 |
| 2024 March | 78 | 26 | 104 |
| 2024 February | 67 | 37 | 104 |
| 2024 January | 57 | 33 | 90 |
| 2023 December | 70 | 18 | 88 |
| 2023 November | 66 | 26 | 92 |
| 2023 October | 54 | 29 | 83 |
| 2023 September | 47 | 24 | 71 |
| 2023 August | 44 | 21 | 65 |
| 2023 July | 64 | 33 | 97 |
| 2023 June | 56 | 19 | 75 |
| 2023 May | 71 | 27 | 98 |
| 2023 April | 51 | 29 | 80 |
| 2023 March | 91 | 20 | 111 |
| 2023 February | 109 | 25 | 134 |
| 2023 January | 55 | 19 | 74 |
| 2022 December | 69 | 37 | 106 |
| 2022 November | 49 | 45 | 94 |
| 2022 October | 44 | 23 | 67 |
| 2022 September | 58 | 37 | 95 |
| 2022 August | 32 | 46 | 78 |
| 2022 July | 44 | 39 | 83 |
| 2022 June | 32 | 43 | 75 |
| 2022 May | 72 | 37 | 109 |
| 2022 April | 95 | 36 | 131 |
| 2022 March | 98 | 41 | 139 |
| 2022 February | 88 | 19 | 107 |
| 2022 January | 90 | 34 | 124 |
| 2021 December | 55 | 31 | 86 |
| 2021 November | 57 | 40 | 97 |
| 2021 October | 67 | 57 | 124 |
| 2021 September | 58 | 37 | 95 |
| 2021 August | 87 | 33 | 120 |
| 2021 July | 66 | 19 | 85 |
| 2021 June | 58 | 30 | 88 |
| 2021 May | 37 | 40 | 77 |
| 2021 April | 80 | 73 | 153 |
| 2021 March | 65 | 21 | 86 |
| 2021 February | 51 | 22 | 73 |
| 2021 January | 44 | 15 | 59 |
| 2020 December | 25 | 11 | 36 |
| 2020 November | 21 | 14 | 35 |
| 2020 October | 20 | 16 | 36 |
| 2020 September | 23 | 12 | 35 |
| 2020 August | 19 | 18 | 37 |
| 2020 July | 18 | 17 | 35 |
| 2020 June | 20 | 18 | 38 |
| 2020 May | 14 | 8 | 22 |
| 2020 April | 12 | 10 | 22 |
| 2020 March | 12 | 8 | 20 |
| 2020 February | 3 | 2 | 5 |
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