Pediatric morphea: MRI evaluation of superficial and deep tissue involvement and impact in clinical practice

Pediatric morphea (also known as localized scleroderma) is an inflammatory disorder that can involve not only the skin but also deeper tissues such as fascia, muscle, and bone. Clinical examination often underestimates the depth and activity of disease, creating a need for objective imaging tools to guide management. Despite increasing clinical reliance on MRI, data describing MRI findings and clinical utility in pediatric morphea remains limited.

To characterize superficial and deep tissue abnormalities on MRI in patients with pediatric morphea, assess correlations with clinical disease activity and subtype, evaluate the clinical impact of MRI on management, and propose an optimized MRI protocol.

This retrospective study included 44 pediatric patients with confirmed morphea who underwent MRI over 25 years. Two pediatric radiologists independently evaluated each MRI for predefined superficial and deep imaging features, and interobserver agreement was calculated. Clinical data, including disease activity, subtype, treatment, and MRI utility, were extracted from electronic medical records. Associations between MRI findings and clinical variables were assessed using Fisher's exact test.

Superficial involvement was present in 42/44 (95.5%) of patients, and deep involvement in 26/44 (59.1%). Active deep inflammation was identified in 24/44 (54.5%). No correlation was found between MRI findings and clinical activity, damage, or morphea subtype. Bilateral disease was present in 7/34 (20.6%) of lower extremity studies, most clinically unsuspected. MRI was clinically useful in 41/43 (95.3%) of cases and helped with management in 15/43 (34.9%). Enhancement was considered useful in 17/25 (68.0%) of cases. MRI assessment of skin thickening was limited by voxel size and chemical shift artifact.

MRI is a highly valuable, independent tool for evaluating patients with pediatric morphea, frequently identifying clinically occult deep involvement and influencing management. A simplified, standardized MRI protocol with routine contrast may optimize diagnostic yield.