Morphea Treatment & Management
- Author: Jennifer V Nguyen, MD; Chief Editor: Dirk M Elston, MD more...
Although several regimens have shown benefit in case series, few controlled trials have been performed and data suggest wide variation in the approach to treatment. In general, therapy aimed at reducing inflammatory activity in early disease is more successful than attempts to decrease sclerosis in well-established lesions.
Superficial circumscribed morphea
Lesions of superficial circumscribed morphea often undergo gradual spontaneous resolution over a 3- to 5-year period. Limited disease can often be managed with topical therapy or lesion-limited phototherapy.
Treatment of active lesions with superpotent topical or intralesional corticosteroids may help reduce inflammation and prevent progression, although there is a lack of data supporting their efficacy.
Tacrolimus 0.1% ointment applied twice daily for 12 weeks may be a useful first-line agent for active, limited plaque morphea, as supported by a small double-blind, placebo-controlled study.
Topical calcipotriene may also be beneficial, especially when nightly occlusion (eg, with plastic wrap) is used to increase penetration of the medication. The combination of topical calcipotriol with betamethasone dipropionate has also been reported effective.
Imiquimod 5% cream 3-5 times per week has been shown to decrease lesional erythema and induration in small series.[48, 49, 50]
Generalized, linear, or deep morphea
Patients with potentially disabling generalized, linear, or deep morphea typically require more aggressive therapy.
Successful treatment of severe and/or rapidly progressive morphea with systemic corticosteroids (eg, high-dose intravenous methylprednisolone in monthly pulses or oral prednisone at various intervals) in combination with weekly low-dose methotrexate (MTX) has been reported in several case series. A randomized, double-blind, placebo-controlled trial demonstrated the efficacy of combination therapy with oral prednisone and methotrexate in children with active morphea. MTX alone can also be effective and has been used successfully as long-term therapy in both adults and children.[53, 54, 55, 56, 57]
Systemic corticosteroids can be helpful in the inflammatory phases of morphea, but they have little benefit for established sclerosis and are not recommended for long-term monotherapy given their risk of adverse effects and tendency for relapse with discontinuation.
Mycophenolate mofetil is a second-line agent that has been shown to be effective in patients with MTX-resistant disease. It is believed to function through antifibrotic mechanisms.[41, 58]
A few reports describe responses of severe morphea to cyclosporine.
The use of hydroxychloroquine to treat morphea has been advocated, but little documentation of success is present in the medical literature.
Despite promising results in case series involving both adults and children, oral calcitriol did not lead to significant improvement in a double-blinded placebo-controlled trial.[60, 61]
Phototherapy may be beneficial as a second-line therapy for refractory or severe disease, or as a first-line therapy for patients with generalized morphea given its low side effect profile compared to immunosuppressive agents. Phototherapy may be beneficial as a second-line therapy for refractory or severe disease or as a first-line therapy for patients with generalized morphea, given its low adverse effect profile compared with immunosuppressive agents. Broadband UVA (320-400 nm, low-dose), long-wavelength UVA (UVA1; 340-400 nm, low- or medium-dose), and psoralen plus UVA (oral or bath) photochemotherapy has produced marked clinical improvement of morphea lesions in multiple case series and a randomized controlled trial. Because UVA1 wavelengths penetrate deeper into the dermis, this modality is particularly effective in the treatment of morphea. Low-, medium-, and high-dose UVA are all effective. While some data suggest that medium-dose UVA1 provides for better long-term results than low-dose UVA1 in morphea as shown by ultrasound assessment, other data suggest similar outcomes.[39, 64] Unfortunately, the availability of UVA1 is currently limited. Narrowband UVB therapy, although less potent owing to its limited dermal penetration, can also be beneficial. Regimens combining UV therapy with topical corticosteroids or calcipotriene may be superior to either method alone.[66, 65]
A combination of acitretin and PUVA has also shown efficacy.
Few cases have shown benefit using extracorporeal photopheresis, particularly for generalized deep morphea.[68, 69]
In one case report, treatment of plaque-type morphea with the 585-nm pulsed dye laser led to substantial improvement.
Photodynamic therapy using topical 5-aminolevulinic acid was also effective in a small series, but a prospective, lesion-controlled study showed no significant difference with photodynamic therapy between treated and untreated lesions.
Bosentan has shown benefit for refractory cutaneous ulcerations in pansclerotic morphea. It is an endothelin receptor antagonist with vasodilatative and antifibrotic properties.
Other approaches aim to alter the cytokine milieu but await further study. These include topical halofuginone (transforming growth factor-beta synthesis inhibitor), TNF-alpha inhibitors, imatinib, and thalidomide (interleukin 12 and tumor necrosis factor-alpha inducer).[73, 74] A randomized, double-blinded, placebo-controlled trial demonstrated no benefit with intralesional interferon gamma.
Orthopedic surgery may be indicated if patients develop deformities of the joints and bones as sequelae of linear or deep morphea. Such surgical interventions include release of joint contractures and limb-lengthening procedures.
Plastic surgery can help to correct deformities due to atrophy of subcutaneous tissues. Reconstruction of the face and scalp may be beneficial to patients with en coup de sabre and Parry-Romberg syndrome, with possible use of tissue expansion and implants of autologous bone, fat, or synthetic materials (eg, polyethylene).
Referral to a dermatologist can help establish the diagnosis and initiate appropriate treatment of morphea.
Consultation with a physical and occupational therapist and a program of physical therapy are of utmost importance in maintaining range of motion and function of the extremities in patients with linear or deep morphea that crosses joint lines. Programs typically include passive stretching, muscle strengthening, and resting splints.
Ophthalmologic screening is indicated for children with head and neck lesions and/or concomitant central nervous system involvement.
Consultation with a neurologist is helpful for patients with craniofacial morphea who present with neurologic symptoms or have abnormalities detected via MRI of the brain.
Orthopedics and oral and maxillofacial surgery should be consulted as needed for bony and structural abnormalities.
Consultation with a dentist is required when craniofacial morphea leads to altered dentition or malocclusion.
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