0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

Practice Gaps —The Hard Task of Measuring Cutaneous Fibrosis FREE

Jason P. Lott, MD; Michael Girardi, MD
[+] Author Affiliations

Author Affiliations: Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.


Arch Dermatol. 2011;147(9):1115-1116. doi:10.1001/archdermatol.2011.244.
Text Size: A A A
Published online

Cutaneous fibrosing disorders (CFDs) —including scleroderma, chronic graft-vs-host disease, and nephrogenic systemic fibrosis —are devastating skin diseases, variably involving subcutaneous tissues and internal organs and potentially resulting in debilitating morbidity and substantial mortality. Provision of effective interventions for management of cutaneous complications of CFDs, including progressive skin induration, joint restriction, cutaneous dysesthesias, and recalcitrant pruritus, remains challenging. Fortunately, several pharmacologic agents in development purportedly inhibit the underlying cytokine cascades that lead to abnormal collagen production, and others may potentially even permit the reversal of established fibrosis.

Evaluating the response of patients with CFD to these novel therapies will require accurate and reproducible assessment of skin disease activity and damage —measures that, to date, are largely lacking. However, the dermatologic community has developed reliable clinical instruments for quantifying skin disease activity in several other chronic skin conditions, notably the Psoriasis Area and Severity Index (PASI) for psoriasis and the Severity Weighted Assessment Tool (SWAT) for mycosis fungoides. Moreover, use of full-body digital imaging and analysis to identify and precisely quantify areas of involved skin has continued to improve the accuracy of these tools.

Unfortunately, such instruments have proven difficult to export to the realm of CFD, which may harbor dermal, subcutaneous, and fascial involvement that is often not easily appreciated by visual inspection and palpation alone.1 Various technologies have been developed to address these challenges, including durometers for measuring skin hardness and/or tautness, cutometers for quantifying skin elasticity, and ultrasonographic devices for assessing local dermal and subcuta-neous blood flow, as outlined by Nezafati et al, but each requires multiple, time-consuming measurements that are subject to significant interuser and intrauser variability as well as within-patient sampling error. Thermographic global heat mapping partially overcomes these problems through simultaneous assessment of large areas of skin, but it too is also prone to error.

Clearly, an unmet need for patients with CFD are new devices and accompanying strategies for efficient and objective assessment of skin fibrosis. Ideally, measurement of disease activity and therapeutic response in patients with CFD would combine (1) automated full-body scanning, (2) global superficial cutaneous assessments (eg, epidermal integrity, barrier function), and (3) global evaluation of the dermis and subcutis (eg, elasticity, induration, blood flow) —yielding data to develop and improve scoring metrics to guide ongoing patient care. Recent experimental techniques such as scanning laser vibrometry and surface wave analysis2 are probable steps in the right direction and may yield benefit if incorporated into new multimodal assessment paradigms.

At present, dermatologists should strive to augment their clinical assessment of CFD activity (including, for example, estimates of joint-mobility, range-of-motion, and quality-of-life surveys) with 1 or more of the existing technologies to monitor their patients' disease activity. The resulting gestalt will, for now, have to suffice.

ARTICLE INFORMATION

Correspondence: Dr Girardi, Department of Dermatology, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06520 (girardi@yale.edu).

Financial Disclosure: None reported.

Fett N, Werth VP. Update on morphea: part II. Outcome measures and treatment.  J Am Acad Dermatol. 2011;64(2):231-244
PubMed   |  Link to Article
Zhang X, Osborn TG, Pittelkow MR, Qiang B, Kinnick RR, Greenleaf JF. Quantitative assessment of scleroderma by surface wave technique.  Med Eng Phys. 2011;33(1):31-37
PubMed   |  Link to Article

Figures

Tables

References

Fett N, Werth VP. Update on morphea: part II. Outcome measures and treatment.  J Am Acad Dermatol. 2011;64(2):231-244
PubMed   |  Link to Article
Zhang X, Osborn TG, Pittelkow MR, Qiang B, Kinnick RR, Greenleaf JF. Quantitative assessment of scleroderma by surface wave technique.  Med Eng Phys. 2011;33(1):31-37
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 1

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Functions of galectin-3 and its role in fibrotic diseases. J Pharmacol Exp Ther Published online Sep 5, 2014.;