Morphea in a patient undergoing treatment with ustekinumab

Abstract

IL: interleukin Th17: T-helper 17 UC: ulcerative colitis CASE REPORT A 48-year-old woman with a 20-year history of ulcerative colitis (UC) presented to our autoimmune connective tissue disease clinic for evaluation of a 1year history of hyperpigmented and atrophic patches. Her UC had been treated with multiple therapies, including antibiotics, tofacitinib, and mesalamine. Three years before presentation, the patient experienced a flare of her UC, which was accompanied by a pruritic, erythematous eruption on her scalp, ears, and hands. At this time, treatment with ustekinumab was initiated for both presumed psoriasis and UC flare. The patient responded well to this therapy, with improvement in both her skin condition and UC. After approximately 1 year of ustekinumab treatment, however, the patient had a violaceous, atrophic patch on her back. This patch was biopsied at an outside institution and found to be histologically consistent with morphea. The patch was treated with methotrexate and was initially limited to the single lesion on her back. Despite 2 to 3 months of methotrexate, the morphea did not improve. In fact, as the patient continued to receive ustekinumab injections, the morphea rapidly progressed to include several areas on her trunk and bilateral upper and lower extremities. When she presented to our clinic, the patient’s physical examination was notable for several hyperpigmented and atrophic patches on her bilateral upper extremities, popliteal fossae, and dorsal feet (Fig 1). An indurated plaque was present on her lower back, along with several sclerotic plaques with surrounding erythema on the hips bilaterally.