Research Letter
Attitudes and trends in the treatment of morphea: a national survey
To the Editor: Patients with morphea (localized scleroderma) are routinely seen by dermatologists and rheumatologists. A recent publication of a patient-based survey showed treatment choices potentially influenced by specialty training, with dermatologists prescribing more topical treatments and phototherapy and rheumatologists more systemic immunosuppressives.1 A recent cross-sectional survey of pediatric rheumatologists showed general agreement in using methotrexate and systemic corticosteroids.2 However, no studies have examined morphea practice trends across both specialties from the providers’ point of view; therefore, we surveyed adult and pediatric dermatologists and rheumatologists to determine these trends.
Survey questions were based on those published by Li et al (with permission), and modified with feedback from reviewers at the UT Southwestern dermatology department.2 An Institutional Review Board- approved, web-based survey (SurveyMonkey.com) was emailed to 1244 randomly-selected members of the American Academy of Dermatology, American College of Rheumatology, and Society for Pediatric Dermatology. 271 paper surveys were mailed to randomly-selected members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) due to non-availability of member email addresses. Excluding those who opted out of the web-based survey, a total of 228 web-based and 51 paper surveys were returned, giving an 18.8% response rate.
Table I shows survey respondent demographics; Table II shows respondents’ first-line treatments for plaque, linear (including En Coup de Sabre and Parry-Romberg), and generalized morphea. For plaque morphea, more rheumatologists (adult and pediatric) reported prescribing methotrexate with or without systemic steroids (P < .0001 and P = .0272, respectively), while more dermatologists (adult and pediatric) reported prescribing topical steroids (P < .0001). For linear morphea, more dermatologists (adult and pediatric) reported prescribing topical steroids (P = .0033) and phototherapy (P = .0456), however, pediatric dermatologists and rheumatologists reported use of methotrexate with or without systemic steroids (P = .0007 and P < .0001, respectively). For generalized morphea, fewer dermatologists prescribed methotrexate with (P = .0078) or without (P = .0142) systemic steroids than pediatric dermatologists or rheumatologists (adult and pediatric); only dermatologists (adult and pediatric) reported phototherapy use (P = .0007).
Table I.
Demographic characteristics of specialists treating morphea patients
| Characteristic | Dermatologist | Dermatologist (Pediatric) | Rheumatologist | Rheumatologist (Pediatric) |
|---|---|---|---|---|
| No of respondents, n (%) | 74 (31.0) | 61 (25.5) | 52 (21.8) | 52 (21.8) |
| Training | ||||
| Number of years since completion of residency, mean ± SD | 22.2 ± 10.4 | 18.5 ± 8.3 | 24.6 ± 10.9 | 20.9 ± 10.3 |
| No of respondents who completed fellowships, n (%) | 13 (17.6) | 31 (50.8) | 48 (92.3) | 49 (94.2) |
| Practice Setting, n (%) | ||||
| Solo | 26 (35.1) | 5 (8.2) | 10 (19.2) | * |
| Partnership/Group | 31 (41.9) | 16 (26.2) | 13 (25.0) | * |
| Multi-specialty | 11 (14.9) | 14 (23.0) | 10 (19.2) | * |
| Academic | 12 (16.2) | 36 (59.0) | 16 (30.8) | * |
| Other | 1 (1.4) | 2 (3.3) | 5 (9.6) | * |
| No of morphea patients seen per year, n (%) | ||||
| ≤ 5 | 46 (62.2) | 13 (21.3) | 41 (78.8) | 25 (48.1) |
| 6-20 | 24 (32.4) | 35 (57.4) | 11 (21.2) | 22 (42.3) |
| 21-50 | 4 (5.4) | 12 (19.7) | 0 | 4 (7.7) |
| > 50 | 0 | 1 (1.6) | 0 | 1 (1.9) |
| Morphea Patients, n (%) | ||||
| Pediatric (< 18 y) | 1 (1.4) | 37 (60.7) | 1 (1.9) | 49 (94.2) |
| Adult (18 + y) | 15 (20.3) | 0 | 47 (90.4) | 0 |
| Both | 58 (78.4) | 24 (39.3) | 4 (7.7) | 3 (5.8) |
question not assessed for pediatric rheumatologists
Denominator used to calculate percentages for Practice Setting, No of morphea patients seen per year, and Morphea patients was total number of respondents in that respective specialty.
Table II.
Morphea treatment. Respondents’ preferred first-line treatments.
| Treatment | Dermatologist, % | Pediatric Dermatologist, % | Rheumatologist, % | Pediatric Rheumatologist, % | p-value (bold if < 0.05) |
|---|---|---|---|---|---|
| Plaque morphea | |||||
| Methotrexate | 0 | 2.1 | 22.2 | 34.6 | 0.0272 |
| Methotrexate + systemic steroids | 0 | 2.1 | 11.1 | 13.5 | < 0.0001 |
| Systemic steroids | 0 | 0 | 0 | 3.8 | 0.1882 |
| Antimalarials/antibiotics | 2.5 | 0 | 19.4 | 3.8 | 0.0009 |
| Topical steroids | 92.5 | 74.5 | 22.2 | 21.2 | < 0.0001 |
| Phototherapy | 0 | 2.1 | 0 | 0 | 0.4336 |
| Linear morphea (including En Coup de Sabre and Parry-Romberg | |||||
| Methotrexate | 15.0 | 21.3 | 13.9 | 46.2 | < 0.0001 |
| Methotrexate + systemic steroids | 15.0 | 57.4 | 8.3 | 38.5 | 0.0007 |
| Systemic steroids | 7.5 | 0 | 2.8 | 11.5 | 0.0740 |
| Antimalarials/antibiotics | 5.0 | 0 | 5.6 | 0 | 0.1473 |
| Topical steroids | 22.5 | 10.6 | 2.8 | 1.9 | 0.0033 |
| Phototherapy | 2.5 | 8.5 | 0 | 0 | 0.0456 |
| Generalized morphea | |||||
| Methotrexate | 15.0 | 23.4 | 19.4 | 42.3 | 0.0142 |
| Methotrexate + systemic steroids | 7.5 | 38.3 | 30.6 | 34.6 | 0.0078 |
| Systemic steroids | 10.0 | 2.1 | 16.7 | 11.5 | 0.1531 |
| Antimalarials/antibiotics | 10.0 | 4.3 | 5.6 | 1.9 | 0.3723 |
| Topical steroids | 10.0 | 6.4 | 2.8 | 1.9 | 0.3080 |
| Phototherapy | 20.0 | 10.6 | 0 | 0 | 0.0007 |
Dermatologist: n = 40
Pediatric Dermatologist: n = 47
Rheumatologist: n = 36
Pediatric Rheumatologist: n = 52
In summary, surveyed dermatologists (adult and pediatric) reported preference for topical treatments, while rheumatologists (adult and pediatric) reported preference for systemic immunosuppressives. These differences were minimized among pediatric providers, who reported greater use of systemic immunosuppressives in moderate-to-severe morphea subtypes. Pediatric providers may more closely follow published treatment plans due to increased awareness of morphea.3 Limitations of this survey include the differences of the 4 subspecialty groups in terms of practice setting and number of morphea patients seen per year, which could also affect treatment choices; the low response rate prevents significant conclusions to be made from sub-analyzing the subspecialties based on these variables. These results underscore the need for comparative studies for better treatment evidence, and multidisciplinary input for generalizability.
Acknowledgments
Funding Sources:
Research for this manuscript was supported in part by NIH Grant No. K23AR056303-4.
Footnotes
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Conflict of Interest Disclosure: None declared
Author Contributions:
Concept and Design: Nicole Strickland, Gopal Patel, Amanda Strickland, Heidi Jacobe
Analysis: Nicole Strickland, Gopal Patel, Amanda Strickland, Heidi Jacobe
Drafting of manuscript: Nicole Strickland, Gopal Patel, Amanda Strickland, Heidi Jacobe
This study has not been presented or published previously.
REFERENCES
- 1.Johnson W, Jacobe H. Morphea in adults and children cohort II: Patients with morphea experience delay in diagnosis and large variation in treatment. J Am Acad Dermatol. 2012;67(5):881–9. doi: 10.1016/j.jaad.2012.01.011. [DOI] [PubMed] [Google Scholar]
- 2.Li SC, Feldman BM, Higgins GC, Haines KA, Punaro MG, O'Neil KM. Treatment of pediatric localized scleroderma: results of a survey of North American pediatric rheumatologists. J Rheumatol. 2010;37(1):175–81. doi: 10.3899/jrheum.090708. [DOI] [PubMed] [Google Scholar]
- 3.Christen-Zaech S, Hakim MD, Afsar FS, Paller AS. Pediatric morphea (localized scleroderma): review of 136 patients. J Am Acad Dermatol. 2008;59(3):385–96. doi: 10.1016/j.jaad.2008.05.005. [DOI] [PubMed] [Google Scholar]