Consultant Dermatologist, John Flynn Medical Centre, Tugun,
Queensland, Australia on Jan
I have never seen the scalp involved quite like this. Intralesional
steroid into the advancing edge might prevent further extension.
Trying to inject fat into this densely sclerotic area seems
a bit of a waste of time but as I do not use the technique my
opinion is probably worthless!
Steven Chow FRCPI, Senior Consultant Dermatologist,
Pantai Medical Centre, Kuala Lumpur, Malaysia on Jan
I have a similar case which turned out to be discoid lupus
of the scalp.
Henry Foong FRCP, Consultant Dermatologist, Ipoh Specialist
Hospital, Ipoh, Malaysia on Jan 27, 2008
I agree intralesional corticosteroid would be useful to halt
the progress of the extension. In addition, I usually check
their serology for ANA and put them on hydroxychloroquine 200mg
bd too. I doubt autologus fat transfer would be useful in this
Stelios Minas MD, Consultant Dermatologist, Limassol,
Cyprus on Jan 27, 2008
I have seen cases like these 3-4 times in Russia. I think it
is a type of en coup de sabre. With regards to treatment I usually
treat with Penicillin (1.2mili a time for course 20 mili) after
that I continue with Plaquenil 200mg bd and Trental 400mg bd
for 2-3 months. Topically, I treat with Dermovate cream and
Elidel cream. Also I treat every other week with mesotherapy
(Trental and Longidasa). I have seen very good effect in some
cases. I don't have experience with surgical intervention but
would be interested to know the place for surgical intervention.
About penicillin I treat with Extencilline-Benzathine benzylpenicillin
(1 200 000 units every 3-4 days I/M for general course 10-20
000 000 units. Personally I like to treat morphea with penicillin
for two reasons: first for Borrelia burgdoferi as associating
with morphea. The second reason is one of the function of penicillin
is destructive synthesis of collagen (we find that penicillin
is stronger about destructive synthesis of collagen than Cuprenil)
as a pathophysiology of morphea is overproduction of collagen
Yes here in Russia elaborate longidasa(www.longidasa.ru-Russian
language). I use Longidasa in mesotherapy (injection technique
- micropapula) for treatment of morphea and lichen sclerosus
et atrophicus with good effects. Usually in combination with
Trental. The only negative of Langidasa is very often can give
Robert Rudolph MD, FACP, Clinical Professor of Dermatology,
University of Pennsylvania, Philadelphia, PA, USA on
Jan 27, 2008
I've not personally seen such a very peculiar distribution.
It certainly seems to follow a pattern which reflects an exogenous
trauma or pressure of some kind. I also wonder if any steroids
had been administered somewhere, by someone, without your being
aware of it.
David Elpern MD, Dermatologist, Skin Clinic, Williamstown,
MA, USA on January 28, 2008
If this is morphea, I think it is different from "en coup
de sabre." It is most unusual, and I would go along with
the person who questioned whether there were some corticosteroid
injections which may have caused atrophy. All this being said
-- there will always be "experiments of one." Unique
I would like to have the slides read by a dermatopathologist.
It would be interesting to hear their differential diagnosis
based on a thorough review of the pathology. I am sure Dr. Bhawan
at Boston University would be willing to do this. Good luck
with this challenging patient!
Shahbaz Janjua MD, Dermatologist, Ayza Skin & Research
Center, Lalamusa, Pakistan on Jaunary 28, 2008
This is an interesting case. I have seen a few cases of en
coup de sabre linear morphea but not a case of horizontal morphea
involving scalp and forehead like this one. I agree with Ian
regarding use of intralesional steroids. In my opinion, a combination
of UVA1 and topical calcipotriene would be worth trying before
any invasive therapy.
Nurul Amin MD, FRCP, Professor of Dermatology, Armed
Forces Medical College, Dhaka, Bangladesh on January
No doubt it is an interesting case .I have seen two or three
en coup de sabre but not band type in forehead . I can remember
one middle-aged lady reported with
localized morphea (5cm X 8cm) on the abdomen, which I treated
with topical calcipotriol and topical steroid with good response.
Arash Abtahian MD, Shiraz, Iran on January
This case is interesting for the initiation point of view and
I have seen some cases showing en coupe de sabre obliquely or
horizontally but not circumferentially. I think for treatment
patient should undergo tissue expansion and resection after
the disease has stopped its activity.
Joel Bamford MD, Dermatologist Adjunct in Family Practice,
Univ Minnesota-Duluth Medical School, Duluth, Minnesota, USA
on Jan 28, 2008
- DLE and steroid atrophy? Pattern on posterior scalp seems
to be atypical.
- Doubt fat injection helpful here.
Looking forward to follow-up,
Serologic LE studies.
Present to local society.
Elena Pope MD FRCPC, Assistant Professor, University
of Toronto, Toronto, Canada on Jan 28, 2008
Very challenging case. I am not sure it is morphea. We had
very good results in sclerotic lesions with topical imiquimod
applied 5 times a week. It may work better than intralesional
steroids which are likely to cause more atrophy.
Meera Mahalingam MD, Associate Professor of Dermatology
and Pathology, Boston University, Boston, MA, USA on
Jan 28, 2008
Despite the fact that the photomicrographs appear a tad suboptimal
one can discern the key pathologic finding i.e. homogenization
of dermal collagen. If the mononuclear cell infiltrate included
plasma cells, the histopathology would be fine for morphea.
Nico Mousdicas MD, Associate Professor, Department
of Dermatology, Indiana University-Purdue Indianapolis, Indianapolis,
Indiana, USA on Jan 28, 2008
Very interesting case. Clinically this could be morphea or
lupus profundus. If Morphea I concurr with Dr Minas regarding
antibiotics. I empiricaly give my patients long term doxycycline
or alternantively amoxicillin or erythromycin. I am personally
convinced that morphea is caused by a Borrelia spirochete. I
note in recent articles in the BMJ where they talk about focal
floating microscopy with a sensitivity of up to 98% in picking
up Borrelia versus the low 50% pick up rate with PCR. It would
not harm to give the patient antibiotics empirically once one
is convinced it is morphea.
Omid Zargari MD, Dermatologist, Rasht, Iran
on Jan 29, 2008
To me this does not look morphea. What happened here is originated
form that "tightly fitted bandage"; I think some degrees
of ischemia+infection have made this. Perhaps staged scalp reduction
by an expert surgeon will help this poor woman.
I'm very interested to see before-after pictures of Dr. Minas
for morphea therapy with meso. Thanks for sharing this case.
Khalid Al Hawsawi M.D., Consultant Dermatologist, King
Abdul Aziz Hospital, Makkah, Saudi Arabia on January
Excellent case. I do agree, it is morphea rather than "en
coup de sabre".
Jerry Tan M.D., Adjunct Professor, Department of Dermatology,
University of Western Ontario, Windsor, Canada on Feb
History, location and appearance suggests scarring secondary
to inflammatory response and perhaps infection to tight persistent
bandaging (?infected contact dermatitis). Thankfully, posterior
scalp lesion may be partially masked by hair - however, scar
excision may be worthwhile if still apparent with hair down.
Forehead lesion - test site of intra-lesional corticosteroid;
would opt primarily for cosmetic camouflage otherwise.