Radiation-induced morphea L94.0

Radiation-induced morphea (RIM) is a rare and underestimated skin complication of radiotherapy.

The pathogenesis is still unclear, but there are several theories to explain this phenomenon. The available data suggest that the abnormally high secretion of some cytokines (interleukin 4, interleukin 5, transforming growth factor) induced by radiation causes extensive fibrosis after fibroblast activation.

The clinical presentation includes sclerosis of the skin and subcutaneous adipose tissue limited to the radiation field, often accompanied by pain in the area, which can affect the patient's quality of life. There is no clear correlation between the radiotherapy dose, fractionation regimen, use of a boost, age, presence of other dermatologic conditions or other connective tissue diseases and the occurrence of RIM (Spalek M et al. 2015).

Histologic confirmation is critical to differentiate RIM from similar looking diseases such as chronic radiation dermatitis, recurrence of underlying carcinoma; radiation recall dermatitis.

There is no clear treatment regimen for this disease. The clinical outcome after therapy is often unsatisfactory. Commonly used methods and agents include: topical and systemic steroids, calcineurin inhibitors, systemic immunosuppressants including methotrexate, tacrolimus, heparin, hyaluronidase, phototherapy (UVA, UVA1, UVB, PUVA), systemic antibiotics, imiquimod, mycophenolate mofetil, photophoresis.

Case description for picture no. 3

66-year-old female patient, medication: Letrozole, RR-lowering agent, ASA 100, moderate nicotine abuse.

Zn. n. Breast cancer right, BET, ax. SLNE, adjuvant radiotherapy over 6 weeks, 5x/week total 50 Gy/58.75 Gy, followed by slight erythema.

Approx. three months later onset of increasing skin edema, prescription of lymph drainage and compression bra.

Seven months later, full picture (see above): brown hyperpigmentation, shiny armor-like hardened skin with considerable sclerosis and shrinkage. Sono: tissue edema. MMG not possible due to lack of compressibility.

Punch biopsy: fibrosis, vascular proliferate, hyperkeratosis, slight chronic inflammation. Inflammation, findings consistent with radiation dermatitis.

In the meantime, antibiotic treatment with clindamycin as part of a rehabilitation program for suspected mastitis, no improvement.

Therapy trial with mometasone furoate cream topically over several weeks led to a clear improvement with fading of the hyperpigmentation and overall softer skin.

Long-term goal: ablation and plastic reconstruction.

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