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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Morphea&#44; also known as localized scleroderma&#44; encompasses a set of cutaneous sclerotic disorders of unknown etiology&#44; with a wide range of manifestations and symptoms that range from mild local discomfort to severe complications&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are many classifications of morphea&#44; although one of the most widely used is that of Laxer and Zulian&#44; which differentiates between 5 subtypes&#58; circumscribed &#40;the most common of the 5&#41;&#44; linear&#44; generalized&#44; pan-sclerotic&#44; and mixed&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Other classification systems include less frequent subtypes such as guttate and bullous morphea&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Generalized morphea is characterized by &#8805;&#8239;4 plaques measuring at least&#8239;3&#8239;cm that coalesce and affect 2 or more anatomical regions&#46; This subtype must be distinguished from systemic sclerosis&#44; mainly through clinical characteristics&#46; The absence of Raynaud phenomenon&#44; sclerodactyly&#44; facial involvement&#44; abnormal nailfold capillaroscopy findings&#44; visceral involvement&#44; and specific autoantibodies all point toward a diagnosis of generalized morphea&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Teske et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> recently mapped lesions in patients with generalized morphea in order to attempt to define the different patterns of presentation&#46; The authors reported 2 clinically relevant subtypes&#58; the isomorphic subtype&#44; with lesions at areas affected by friction&#59; and the symmetric subtype&#44; where involvement was similar on the trunk and extremities at both sides of the midline&#46; The latter pattern was predominant in males and more frequently affected the deep planes of the dermis&#44; the subcutaneous cellular tissue&#44; and the fascia&#46; The authors excluded unilateral generalized morphea from the classification&#46; In this condition&#44; the lesions affect only 1 side of the body and are considered linear morphea in most publications&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The literature contains several cases of patients with generalized morphea and various types of malignancy&#44; such as lung cancer and breast cancer&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> although while systemic sclerosis has been reported to be a paraneoplastic phenomenon&#44; the association between morphea and cancer is not so consolidated&#46; Nevertheless&#44; given the potential association&#44; it seems advisable to take a targeted clinical history and appropriate work-up to rule out malignancy&#44; especially in older patients with acute onset morphea and extensive involvement&#46; Morphea has also been reported to be induced by various medications&#44; with the most commonly reported in the literature being tumor necrosis factor &#945; drugs<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#40;although&#44; paradoxically&#44; infliximab has led to a good response in some cases of morphea<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41;&#46; Given the recent report of a case of morphea induced by nivolumab&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> this possibility should be taken into account when there is a temporal relationship with the introduction of a new drug&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As for treatment of morphea&#44; topical drugs are the approach of choice in localized and superficial forms&#46; Cream formulations of corticosteroids&#44; tacrolimus&#44; calcipotriol&#44; and even imiquimod 5&#37; have been shown to improve symptoms in several series&#46; In the case of generalized or deep forms&#44; immunosuppressants and phototherapy are more useful&#46; The most widely reported and successful immunosuppressant is methotrexate&#44; with mycophenolate mofetil being a good alternative&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As new molecular pathways involved in the pathogenesis are discovered&#44; new therapeutic targets appear&#46; In this sense&#44; favorable responses have been reported with abatacept&#44; imatinib&#44; tocilizumab&#44; and apremilast &#40;although data for apremilast are based on animal models&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In the future&#44; other drugs aimed at specific interleukins could prove very useful&#46;</p></span>"
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Resident’s Forum
RF - Generalized Morphea: Definition and Associations
FR - Morfea generalizada: definición y asociaciones
A. García-Vázquez
Autor para correspondencia
alejandrogv92@gmail.com

Corresponding author.
, S. Guillen-Climent, M.D. Ramón Quiles
Servicio de Dermatología, Hospital Clínico Universitario de Valencia, Valencia, Spain
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This subtype must be distinguished from systemic sclerosis&#44; mainly through clinical characteristics&#46; The absence of Raynaud phenomenon&#44; sclerodactyly&#44; facial involvement&#44; abnormal nailfold capillaroscopy findings&#44; visceral involvement&#44; and specific autoantibodies all point toward a diagnosis of generalized morphea&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Teske et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> recently mapped lesions in patients with generalized morphea in order to attempt to define the different patterns of presentation&#46; The authors reported 2 clinically relevant subtypes&#58; the isomorphic subtype&#44; with lesions at areas affected by friction&#59; and the symmetric subtype&#44; where involvement was similar on the trunk and extremities at both sides of the midline&#46; The latter pattern was predominant in males and more frequently affected the deep planes of the dermis&#44; the subcutaneous cellular tissue&#44; and the fascia&#46; The authors excluded unilateral generalized morphea from the classification&#46; In this condition&#44; the lesions affect only 1 side of the body and are considered linear morphea in most publications&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The literature contains several cases of patients with generalized morphea and various types of malignancy&#44; such as lung cancer and breast cancer&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> although while systemic sclerosis has been reported to be a paraneoplastic phenomenon&#44; the association between morphea and cancer is not so consolidated&#46; Nevertheless&#44; given the potential association&#44; it seems advisable to take a targeted clinical history and appropriate work-up to rule out malignancy&#44; especially in older patients with acute onset morphea and extensive involvement&#46; Morphea has also been reported to be induced by various medications&#44; with the most commonly reported in the literature being tumor necrosis factor &#945; drugs<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#40;although&#44; paradoxically&#44; infliximab has led to a good response in some cases of morphea<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41;&#46; Given the recent report of a case of morphea induced by nivolumab&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> this possibility should be taken into account when there is a temporal relationship with the introduction of a new drug&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As for treatment of morphea&#44; topical drugs are the approach of choice in localized and superficial forms&#46; Cream formulations of corticosteroids&#44; tacrolimus&#44; calcipotriol&#44; and even imiquimod 5&#37; have been shown to improve symptoms in several series&#46; In the case of generalized or deep forms&#44; immunosuppressants and phototherapy are more useful&#46; The most widely reported and successful immunosuppressant is methotrexate&#44; with mycophenolate mofetil being a good alternative&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As new molecular pathways involved in the pathogenesis are discovered&#44; new therapeutic targets appear&#46; In this sense&#44; favorable responses have been reported with abatacept&#44; imatinib&#44; tocilizumab&#44; and apremilast &#40;although data for apremilast are based on animal models&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In the future&#44; other drugs aimed at specific interleukins could prove very useful&#46;</p></span>"
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