Derm Cases · Dermatology / Paediatric dermatology / Rheumatology interface
OSCE — ivory plaques with lilac ring: diagnose morphea and separate from systemic sclerosis
An 8-minute OSCE station on recognising plaque and linear morphea, distinguishing localised scleroderma from systemic sclerosis (no Raynaud/internal organ disease), grading activity, and initiating methotrexate plus corticosteroids for linear disease in children to prevent deformity.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on recognising plaque and linear morphea, distinguishing localised scleroderma from systemic sclerosis (no Raynaud/internal organ disease), grading activity, and initiating methotrexate plus corticosteroids for linear disease in children to prevent deformity.
Brief (to candidate)
A 9-year-old girl has a linear indurated band down the left arm with skin tightness and early limb circumference discrepancy. Her mother asks if this is 'systemic sclerosis'. A second adult vignette shows an ivory plaque on the trunk with a violaceous lilac border. You have 8 minutes to diagnose morphea subtypes, separate from systemic sclerosis, and start disease-modifying therapy for linear disease.
[8]Candidate instructions
- Describe classic plaque morphea morphology.
- Explain why this is not systemic sclerosis.
- Recognise linear morphea / en coup de sabre / Parry–Romberg risks in children.
- Outline activity assessment and first-line therapy by subtype.
- State methotrexate + corticosteroid indication and monitoring.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Plaque morphea | Ivory indurated plaque with active violaceous lilac ring; later hyper/hypopigmentation and atrophy; most common adult form[1][3] |
| Not SSc | Morphea = localised skin/subcutis fibrosis without Raynaud, sclerodactyly pattern of SSc, nailfold capillary changes of SSc, or SSc-specific internal organ disease/autoantibodies as the defining framework |
| Linear / paediatric | Linear limb disease → growth discrepancy, contracture; en coup de sabre forehead linear band; Parry–Romberg hemifacial atrophy; screen eye/neuro if craniofacial |
| Therapy — limited plaque | Topical/high-potency steroids, calcipotriol, phototherapy (UVA1/NB-UVB as available) for superficial limited disease |
| Therapy — linear/deep/active | Early methotrexate ± systemic corticosteroids to prevent irreversible deformity in children; consider mycophenolate or other escalation if refractory; multidisciplinary (derm, rheum, physio, ophthalmology)[5][6] |
| Monitoring | Serial photography, limb measurements, LoSCAT/activity tools when used; MTX labs (FBC/LFT); functional rehab |
| Safety communication | Reassure not the same disease as systemic sclerosis, but emphasise urgency of treating active linear disease in growth years |
Model key actions
- Diagnose morphea (lilac ring / ivory plaque or linear band) and explicitly exclude systemic sclerosis features.[1]
- For linear paediatric morphea, start early systemic therapy (MTX ± steroids) to prevent growth deformity.[5][6]
- Screen craniofacial disease for eye/CNS involvement; arrange rehab follow-up.
Common errors
- Labelling morphea as systemic sclerosis and over-investigating for SSc internal disease without clinical indication.
- Watching linear childhood disease 'conservatively' until contracture/limb discrepancy is fixed.
- Using only mild topicals for deep/linear active disease.
- Missing en coup de sabre ocular/neuro screen.
- No physiotherapy plan for functional impairment.
References6ShowHide
- [1]Papara C, De Luca DA, Bieber K, et al. Morphea: The 2023 update. Frontiers in Medicine, 2023.PMID 36860340
- [3]Careta MF, Romiti R. Localized scleroderma: clinical spectrum and therapeutic update. Anais Brasileiros de Dermatologia, 2015.PMID 25672301
- [5]Albuquerque JVG, Andriolo BN, Vasconcellos MR, et al. Interventions for morphea. Cochrane Database of Systematic Reviews, 2019.PMID 31309547
- [6]Kaushik A, Mahajan R, De D, Handa S. Paediatric morphoea: a holistic review. Part 2: diagnosis, measures of disease activity and management. Clinical and Experimental Dermatology, 2020.PMID 32449205
- [7]Seese RR, Glaser D, Furtado A, Thakkar K, et al. Unilateral Neuroimaging Findings in Pediatric Craniofacial Scleroderma: Parry-Romberg Syndrome and En Coup de Sabre J Child Neurol, 2020.PMID 32527172
- [8]Vasquez-Canizares N, Li SC. Juvenile Localized Scleroderma: Updates and Differences from Adult-Onset Disease Rheum Dis Clin North Am, 2021.PMID 34635302