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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 20 | 10 | 30 |
| 2024 Octubre | 84 | 42 | 126 |
| 2024 Septiembre | 83 | 34 | 117 |
| 2024 Agosto | 117 | 64 | 181 |
| 2024 Julio | 95 | 30 | 125 |
| 2024 Junio | 81 | 41 | 122 |
| 2024 Mayo | 81 | 26 | 107 |
| 2024 Abril | 75 | 27 | 102 |
| 2024 Marzo | 78 | 26 | 104 |
| 2024 Febrero | 67 | 37 | 104 |
| 2024 Enero | 57 | 33 | 90 |
| 2023 Diciembre | 70 | 18 | 88 |
| 2023 Noviembre | 66 | 26 | 92 |
| 2023 Octubre | 54 | 29 | 83 |
| 2023 Septiembre | 47 | 24 | 71 |
| 2023 Agosto | 44 | 21 | 65 |
| 2023 Julio | 64 | 33 | 97 |
| 2023 Junio | 56 | 19 | 75 |
| 2023 Mayo | 71 | 27 | 98 |
| 2023 Abril | 51 | 29 | 80 |
| 2023 Marzo | 91 | 20 | 111 |
| 2023 Febrero | 109 | 25 | 134 |
| 2023 Enero | 55 | 19 | 74 |
| 2022 Diciembre | 69 | 37 | 106 |
| 2022 Noviembre | 49 | 45 | 94 |
| 2022 Octubre | 44 | 23 | 67 |
| 2022 Septiembre | 58 | 37 | 95 |
| 2022 Agosto | 32 | 46 | 78 |
| 2022 Julio | 44 | 39 | 83 |
| 2022 Junio | 32 | 43 | 75 |
| 2022 Mayo | 72 | 37 | 109 |
| 2022 Abril | 95 | 36 | 131 |
| 2022 Marzo | 98 | 41 | 139 |
| 2022 Febrero | 88 | 19 | 107 |
| 2022 Enero | 90 | 34 | 124 |
| 2021 Diciembre | 55 | 31 | 86 |
| 2021 Noviembre | 57 | 40 | 97 |
| 2021 Octubre | 67 | 57 | 124 |
| 2021 Septiembre | 58 | 37 | 95 |
| 2021 Agosto | 87 | 33 | 120 |
| 2021 Julio | 66 | 19 | 85 |
| 2021 Junio | 58 | 30 | 88 |
| 2021 Mayo | 37 | 40 | 77 |
| 2021 Abril | 80 | 73 | 153 |
| 2021 Marzo | 65 | 21 | 86 |
| 2021 Febrero | 51 | 22 | 73 |
| 2021 Enero | 44 | 15 | 59 |
| 2020 Diciembre | 25 | 11 | 36 |
| 2020 Noviembre | 21 | 14 | 35 |
| 2020 Octubre | 20 | 16 | 36 |
| 2020 Septiembre | 23 | 12 | 35 |
| 2020 Agosto | 19 | 18 | 37 |
| 2020 Julio | 18 | 17 | 35 |
| 2020 Junio | 20 | 18 | 38 |
| 2020 Mayo | 14 | 8 | 22 |
| 2020 Abril | 12 | 10 | 22 |
| 2020 Marzo | 12 | 8 | 20 |
| 2020 Febrero | 3 | 2 | 5 |
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