The Isomorphic Response in Morphealike Chronic Graft-vs-Host Disease

Patel, Asha R.; Pavletić, Steven Z.; Turner, Maria L.; Cowen, Edward W.

doi:10.1001/archderm.144.9.1229

Cited by 15 publications

(12 citation statements)

References 5 publications

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“…The reported incidence of sclerotic symptoms among patients who manifest cGvHD symptoms is approximately 14% 10,11. However, 58 of 81 (72%) patients with skin involvement evaluated at the NIH via a cross-sectional cGvHD study of patients who have undergone a previous stem cell transplantation (Protocol NCT00331968) presented with evidence of superficial and/or deep sclerotic skin disease (72%)12 based on NIH consensus staging criteria, suggesting that skin sclerosis is a significant problem for a subset of patients with recalcitrant disease 3…”

Section: Discussionmentioning

confidence: 99%

Rippled skin, fasciitis, and joint contractures

Patel

Avila

Malech

et al. 2008

Journal of the American Academy of Dermatology

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A 41 year-old man was referred to the National Institutes of Health (NIH) for evaluation of extensive skin thickening and rippled appearance of his upper extremities, torso, and lower extremities. The patient was day +671 status post a myeloablative 6/6 HLA-matched related (sister) peripheral blood stem cell transplant for acute myelogenous leukemia. The conditioning regimen consisted of busulfan and cyclophosphamide and graft-versus-host disease prophylaxis included tacrolimus and a short course of methotrexate.The patient's cutaneous symptoms began approximately eight months post-transplant with the onset of "red dots" on his skin accompanied by decreased range of motion at the wrists. A biopsy a patch on the right forearm demonstrated non-specific histologic findings of a mild superficial perivascular infiltrate with rare neutrophils. Prior to the NIH consultation, the patient had been treated with oral steroids, hydroxychloroquine sulfate, rituximab, thalidomide, and physical therapy without benefit. He had not been treated with phototherapy. Rather, the patient reported that the skin changes and range of motion at several joints continued to worsen, resulting in significant functional limitations. His immunosuppression regimen at the time of referral consisted of methylprednisolone 32 mg daily, tacrolimus 1.5 mg twice daily, hydroxychloroquine 200 mg twice daily, mycophenolate mofetil 1 g twice daily, and thalidomide 200 mg in the evening. Physical ExaminationPhysical exam was remarkable for a widespread puckered, cellulite-like appearance of the bilateral inner upper arm, majority of the anterior torso, bilateral flanks, medial buttocks, and

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Section: Discussionmentioning

confidence: 99%

Rippled skin, fasciitis, and joint contractures

Patel

Avila

Malech

et al. 2008

Journal of the American Academy of Dermatology

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“…Sclerotic type cGVHD has been shown to occur in an isotopic fashion with ionizing radiation, repeated needle sticks, and varicella-zoster virus infection as well as in an isomorphic fashion at areas of skin friction (waistband and brassiere line). 7, 8 As seen in Table IV, greater than 40% of patients with trauma induced lesions had them on the breast implying a potential preferential distribution, however its significance is difficult to ascertain due to the strong female predominance of affected patients who would be more likely to have procedures in those areas. Also of interest, children, in which the subtype is predominantly linear, were underrepresented in the trauma induced morphea group relative to the overall MAC cohort.…”

Section: Discussionmentioning

confidence: 99%

“…These classifications were based on definitions in the literature 5, 6 and recent studies of sclerotic-type GVHD. 7, 8 …”

Section: Methodsmentioning

confidence: 99%

The role of skin trauma in the distribution of morphea lesions: A cross-sectional survey of the Morphea in Adults and Children cohort IV

Grabell

Hsieh

Andrew

et al. 2014

Journal of the American Academy of Dermatology

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Background Skin trauma may play a role in the development of morphea lesions. The association between trauma and the distribution of cutaneous lesions has never been examined. Objective Determine whether patients enrolled in the Morphea in Adults and Children (MAC) cohort exhibit skin lesions distributed in areas of prior (isotopic) or ongoing (isomorphic) trauma. Methods Cross-sectional analysis of the MAC cohort. Results Of 329 patients in the MAC cohort, 52 (16%) had trauma associated lesions at the onset of disease. Patients with lesions in an isotopic distribution had greater clinical severity as measured by a clinical outcome measure (mean modified Rodnan Skin Score of 13.8 vs. 5.3, P=0.004, 95% CI=3.08-13.92) and impact on life quality (mean Dermatology Life Quality Index 8.4 vs. 4.1, P=0.009, 95% CI 1.18-7.50) than those with an isomorphic distribution. Most frequent associated trauma were chronic friction (isomorphic) and surgery/isotopic. Limitations Recall bias for patient reported events. Conclusion Sixteen percent of patients in the MAC cohort developed initial morphea lesions at sites of skin trauma. If these findings can be confirmed in additional series, they suggest that elective procedures and excessive skin trauma or friction might be avoided in these patients.

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“…The patients include other men with waistband-associated chronic GVHD and women with brassiere band and/or waistband-related chronic GVHD [1, 2, 11, 14]; of note, similar to the reported patient with isomorphic (waistband) and idiopathic (right forearm and hand) sclerotic-type GVHD, other individuals with concurrent isomorphic chronic cutaneous GVHD and idiopathic sclerotic-type GVHD have been observed [11]. The source of injury associated with isomorphic sclerotic-type GVHD has also been the sites of injections of subcutaneous interferon alpha on the abdomen [15], previous subclavian or central venous catheter placement without [14] or with [11] subsequent cellulitis, repeated needle sticks to obtain blood from the right antecubital fossa [11], suction blisters [16], and Bacillus Calmette Guerin therapy [16].…”

Section: Discussionmentioning

confidence: 99%

“…Chronic sclerotic-type cutaneous GVHD can occur at sites of repetitive skin friction [2]. A man with isomorphic cutaneous GVHD presenting as sclerotic-type skin lesions on the waistband is described and chronic GVHD of the skin appearing in a cutaneous immunocompromised district is reviewed.…”

Section: Introductionmentioning

confidence: 99%

Isomorphic Sclerotic-Type Cutaneous Chronic Graft-Versus-Host Disease: Report and Review of Chronic Graft-Versus-Host Disease in a Cutaneous Immunocompromised District

Cohen

2013

Dermatol Ther (Heidelb)

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BackgroundPatients who have received a hematopoietic cell transplantation can develop graft-versus-host disease (GVHD). The liver, the gastrointestinal tract, and/or the skin can be affected by GVHD. Chronic sclerotic-type cutaneous GVHD can occur at sites of repetitive skin friction.PurposeTo describe isomorphic sclerotic-type GVHD and review chronic GVHD appearing in a cutaneous immunocompromised district.MethodsThe clinical features of a 74-year-old man with mantle cell lymphoma who developed chronic sclerotic-type cutaneous GVHD localized to the waistband area—which had been exposed to repetitive skin injury—after a second hematopoietic cell transplantation are reported. Using the PubMed database, an extensive literature search was performed on chronic GVHD.Case report and reviewThe cutaneous immunocompromised district is an area of skin whose local effective immunity has been altered, thereby permitting the development of a dysimmune reaction, infection, or tumor at the site. A cutaneous isomorphic response refers to a disease-associated skin lesion occurring at the site of physical injury that is morphologically similar to the existing condition. Cutaneous chronic GVHD can occur at sites of repetitive skin trauma as an isomorphic response. The patient developed sclerotic-type GVHD in a cutaneous area that had previously experienced repeated irritation, friction, and pressure. Isomorphic sclerotic-type GVHD—in either the waistband area or brassiere area or both—has also been observed in other patients. In addition, cutaneous chronic GVHD has been described not only at the location of a previous, unrelated, and healed skin disease as an isotopic response, but also at the cutaneous site of earlier exposure to radiotherapy or ultraviolet radiation as an isoradiotopic response.ConclusionSclerotic and nonsclerotic skin lesions of chronic GVHD can occur not only as an isomorphic response, but also as either an isotopic response or an isoradiotopic response in a cutaneous immunocompromised district.

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The Isomorphic Response in Morphealike Chronic Graft-vs-Host Disease

Cited by 15 publications

References 5 publications

Rippled skin, fasciitis, and joint contractures

Rippled skin, fasciitis, and joint contractures

The role of skin trauma in the distribution of morphea lesions: A cross-sectional survey of the Morphea in Adults and Children cohort IV

Isomorphic Sclerotic-Type Cutaneous Chronic Graft-Versus-Host Disease: Report and Review of Chronic Graft-Versus-Host Disease in a Cutaneous Immunocompromised District

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