Linear scleroderma in an adolescent woman treated with methotrexate and excimer laser

A 17-year-old Caucasian woman presented for evaluation and treatment of a tender expanding linear plaque on her left flank. Biopsy findings were consistent with morphea. Treatment initially included intralesional steroid injections and topical calcipotriene ointment, followed by methotrexate and excimer laser. The lesion decreased in size considerably with relief of symptomatic discomfort by 7 months. An excisional biopsy of a persistent eroded papule on the superior aspect of the morphea plaque revealed dermal thickening and sclerosis with superimposed perforation of a calcified nodule. Localized scleroderma, or morphea, is an autoimmune disease of the skin and underlying subcutaneous tissue primarily affecting the pediatric population. The excimer laser has been reported to effectively treat a variety of dermatologic conditions, including morphea. Its mechanism of action may be via depletion of T cells, altering apoptosis-mediating molecules and decreasing cytokine expression. Methotrexate is also useful for the acute and deep forms of morphea and has been shown to decrease levels of inter leukins-2 and -6, tenascin, and mast cells. This patient had a good clinical response with a combination of these two modalities. The epidermal perforation with transepidermal elimination of calcified necrotic collagen is a unique complication that may have been secondary to this combination treatment modality.