Medication Summary
Glucocorticoids can be used systemically, topically in ointment form, or under occlusive dressings. Diluted triamcinolone acetonide suspension of 1:3 to 1:5 given by intralesional injection has been suggested. Repeated infiltrations are recommended every 3-4 weeks. Ointments containing heparin or heparinoids may also be helpful.
Linear scleroderma in children has effectively been treated with oral calcitriol. The use of phenytoin has been advocated, especially for linear morphea. Long-term treatment with oral p-aminobenzoate has been suggested, but the results are unclear.
Topical tocoretinate for 6 months to 3 years may be beneficial for treating skin sclerosis. [13] The following agents have been reported to be beneficial in morphea:
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D-penicillamine
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Corticosteroids
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Phenytoin
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Aminobenzoate potassium
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Dimethyl sulfoxide
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Vitamin E
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Disodium edetate
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Sulfasalazine
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Cyclofenil
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Methotrexate
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Colchicine
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Antimalarials
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Azathioprine
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Griseofulvin
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Penicillin
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Chlorambucil
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Cyclophosphamide
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Etretinate
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Isotretinoin
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Interferon alfa and gamma
No treatment seems to alter the natural course of localized scleroderma, but reports indicate that moderate doses of systemic or locally injected corticosteroids, d-penicillamine, and photochemotherapy with 8-methoxypsolaren have been helpful in decreasing the degree of inflammation and fibrosis.
Antimalarials
Class Summary
These agents have anti-inflammatory properties and inhibit multiple functions of phagocytes, including reactive oxygen species release.
Hydroxychloroquine (Plaquenil)
Treats malaria, rheumatoid arthritis, systemic lupus erythematosus, and juvenile chronic arthritis. Use in localized fibrosing disorders has not been well characterized, but several reports indicate some efficacy. Response to antimalarials is slow, so it can take up to 6 months for full effect.
Corticosteroids
Class Summary
These agents have potent anti-inflammatory and immunosuppressive properties. They inhibit lymphocyte proliferation and delayed-type hypersensitivity and cause changes in WBC traffic and Fc receptor suppression.
Prednisone (Orasone, Deltasone, Sterapred)
Constitutes main therapy for multiple inflammatory and autoimmune disorders including vasculitis, systemic lupus erythematosus, inflammatory myopathies, and polymyalgia rheumatica. May be useful in localized and regional fibrosing disorders by inhibiting inflammatory response.
Triamcinolone (Aristocort)
Can be helpful in inhibiting inflammation and fibrosis in localized fibrosing conditions. Repeated administrations might be necessary.
Immunosuppressives/disease-modifying antirheumatic drugs
Class Summary
These agents have anti-inflammatory and immunosuppressive properties. Some drugs may have antifibrotic effects.
D-Penicillamine (Cuprimine)
Used to treat rheumatoid arthritis and shown to have some benefit in systemic sclerosis. Its mode of action is unknown, but seems to modulate the immune system via sulfhydryl exchange reactions in various cells.
Azathioprine (Imuran)
Purine analog and derivative of 6-mercaptopurine. Has immunosuppressive effects by inhibiting purine synthesis in cells. Used for treating systemic lupus erythematosus, rheumatoid arthritis, vasculitis, and inflammatory myopathies and preventing allograft rejection.
Sulfasalazine (Azulfidine)
Sulfonamide derivative with anti-inflammatory properties. Useful for treating rheumatoid arthritis, spondyloarthropathies, and inflammatory bowel disease. Effects on localized fibrosing conditions are not well characterized.
Methotrexate (Rheumatrex)
This drug reversibly inhibits dihydrofolate reductase; limits the availability of 1-carbon fragments necessary for synthesis of purines and the conversion of deoxyuridylate to thymidylate in the synthesis of DNA and cell reproduction. Extensively used for cancer treatment, rheumatoid arthritis, psoriasis, and as a steroid-sparing agent in various autoimmune conditions.
Cyclophosphamide (Cytoxan, Neosar)
Synthetic nitrogen mustard alkylating agent used for treating severe lupus complications, vasculitis, refractory rheumatoid arthritis, scleroderma lung disease, and myopathies. Its role in localized forms of fibrosis has not been well characterized. It is indicated only for severe inflammatory lesions that do not respond to other agents.
Colchicine
Inhibits microtubule formation in leukocytes and decreases joint inflammation. Drug has no direct analgesic properties. Useful in gout, skin vasculitis, and Behçet disease. Has been advocated to have an antifibrotic effect with potential therapeutic implications in generalized or localized fibrosing disorders.
Tacrolimus (Prograft, Protopic)
Used to treat atopic dermatitis and for prophylaxis of renal and kidney transplant rejection.
Topical Skin Product
Class Summary
Agents such as imiquimod may induce mediators of immune processes.
Imiquimod (Aldara)
Topical antiviral agent. Induces secretion of interferon alpha and other cytokines; mechanism of action is unknown.
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This photograph shows morphea en plaque on the trunk of a patient. There is a distinctive border separating the plaque from the surrounding normal skin (reproduced with permission of Mayo Clinic Proceedings).
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This photograph shows generalized morphea on the trunk of a patient (reproduced with permission from Mayo Clinic Proceedings).
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CT scan of the abdomen showing the typical paraaortic mass of retroperitoneal fibrosis.
