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Morphea
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<h2 id="signs-and-symptoms">Signs and symptoms</h2> <p>Morphea most often presents as <a href="/facts/Skin_condition/Vkr5XpeG">macules</a> or plaques a few centimeters in diameter, but also may occur as bands or in <a href="/facts/Guttation/5HfB9wJF">guttate</a> lesions or nodules.<a class="footnote-ref" id="fnref:3" href="#fn:3"><sup>3</sup></a>: 171 </p><p>Morphea is a thickening and hardening of the skin and <a href="/facts/Subcutaneous_tissue/EPYjXN3G">subcutaneous tissues</a> from excessive <a href="/facts/Collagen/KsyAb72K">collagen</a> deposition. Morphea includes specific conditions ranging from very small <a href="/facts/Skin_plaque/Vkr5XpeG">plaques</a> only involving the skin to widespread <a href="/facts/Disease/55eeQlGL">disease</a> causing functional and cosmetic <a href="/facts/Deformity/tfApzexF">deformities</a>. Morphea discriminates from <a href="/facts/Systemic_scleroderma/K4UQIlxk">systemic sclerosis</a> by its supposed lack of <a href="/facts/Organ_(biology)/FUYsLaxz">internal organ</a> involvement.<a class="footnote-ref" id="fnref:4" href="#fn:4"><sup>4</sup></a> This classification scheme does not include the mixed form of morphea in which different morphologies of <a href="/facts/Skin_condition/Vkr5XpeG">skin lesions</a> are present in the same individual. Up to 15% of morphea <a href="/facts/Patient/b0SWyyVD">patients</a> may fall into this previously unrecognized category.<a class="footnote-ref" id="fnref:5" href="#fn:5"><sup>5</sup></a> </p> <h2 id="cause">Cause</h2> <p><a href="/facts/Physician/qJ3woFvG">Physicians</a> and scientists do not know what causes morphea. Case reports and observational studies suggest there is a higher frequency of family history of autoimmune diseases in patients with morphea.<a class="footnote-ref" id="fnref:6" href="#fn:6"><sup>6</sup></a> Tests for <a href="/facts/Autoantibody/gkMT0XyQ">autoantibodies</a> associated with morphea have shown results in higher frequencies of anti-histone and anti-topoisomerase IIa antibodies.<a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a> Case reports of morphea co-existing with other systemic autoimmune diseases such as primary biliary cirrhosis, vitiligo, and systemic lupus erythematosus lend support to morphea as an autoimmune disease.<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a><a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a><a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a> </p><p><i><a href="/facts/Borrelia_burgdorferi/sSvh5CyA">Borrelia burgdorferi</a></i> infection may be relevant for the induction of a distinct autoimmune type of scleroderma; it may be called "<i>Borrelia</i>-associated early onset morphea" and is characterized by the combination of disease onset at younger age, infection with <i>B. burgdorferi</i>, and evident autoimmune phenomena as reflected by high-titer antinuclear antibodies.<a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a> </p> <h2 id="diagnosis">Diagnosis</h2> <h3>Classification</h3> <ul><li>Morphea–lichen sclerosus et atrophicus overlap is characterized by both lesions of morphea and lichen sclerosus et atrophicus, most commonly seen in women.<a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a>: 171 </li> <li>Generalized morphea is characterized by widespread indurated plaques and pigmentary changes, sometimes associated with muscle atrophy, but without visceral involvement.<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a>: 171 </li> <li>Morphea profunda involves deep <a href="/facts/Subcutaneous_tissue/EPYjXN3G">subcutaneous tissue</a>, including <a href="/facts/Fascia/KnQE4bPq">fascia</a>, and there is a clinical overlap with <a href="/facts/Eosinophilic_fasciitis/5TDjRz54">eosinophilic fasciitis</a>, <a href="/facts/Eosinophilia-myalgia_syndrome/Y5l4emjr">eosinophilia-myalgia syndrome</a>, and the Spanish <a href="/facts/Toxic_oil_syndrome/n1e4YVYP">toxic oil syndrome</a>.<a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a>: 171 Morphea profunda shows little response to <a href="/facts/Corticosteroids/jeL2QeIL">corticosteroids</a> and tends to run a more chronic debilitating course.<a class="footnote-ref" id="fnref:15" href="#fn:15"><sup>15</sup></a>: 171 </li> <li>Pansclerotic morphea is manifested by sclerosis of the dermis, panniculus, fascia, muscle, and at times, the bone, all causing disabling limitation of motion of joints.<a class="footnote-ref" id="fnref:16" href="#fn:16"><sup>16</sup></a>: 171 </li> <li>Linear <a href="/facts/Scleroderma/GdGjCVCF">scleroderma</a> is a type of localised scleroderma<a class="footnote-ref" id="fnref:17" href="#fn:17"><sup>17</sup></a> which is an <a href="/facts/Autoimmune_disease/sojBeQ7t">autoimmune disease</a> characterized by a line of thickened skin which can affect the bones and muscles underneath it. It most often occurs in the arms, legs, or forehead, and may occur in more than one area. It is also most likely to be on just one side of the body. Linear scleroderma generally first appears in young children.<a class="footnote-ref" id="fnref:18" href="#fn:18"><sup>18</sup></a></li> <li>Frontal linear scleroderma (also known as en coup de sabre or morphea en coup de sabre) is a type of <a href="/facts/Linear_scleroderma/NPFeNrcM">linear scleroderma</a> characterized by a linear band of atrophy and a furrow in the skin that occurs in the frontal or frontoparietal <a href="/facts/Scalp/yfnQt0n5">scalp</a>.<a class="footnote-ref" id="fnref:19" href="#fn:19"><sup>19</sup></a><a class="footnote-ref" id="fnref:20" href="#fn:20"><sup>20</sup></a> Multiple lesions of <i>en coup de sabre</i> may coexist in a single patient, with one report suggesting that the lesions followed <a href="/facts/Blaschko%2527s_lines/jdkzRqv1">Blaschko's lines</a>.<a class="footnote-ref" id="fnref:21" href="#fn:21"><sup>21</sup></a> It gets its name from the perceived similarity to a <a href="/facts/Sabre/eswDHNcf">sabre</a> wound.<a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a></li></ul> <ul><li>Atrophoderma of Pasini and Pierini (also known as "Dyschromic and atrophic variation of scleroderma,"<a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a> "Morphea plana atrophica,"<a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a> "Sclérodermie atrophique d'emblée"<a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a>) is a disease characterized by large <a href="/facts/Lesion/WJDFnyLk">lesions</a> with a sharp peripheral border dropping into a depression with no outpouching, which, on <a href="/facts/Biopsy/A0TdRRlr">biopsy</a>, elastin is normal, while collagen may be thickened.<a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a> Atrophoderma of Pasini and Pierini affects less than 200,000 Americans and is classified as a rare disease by <a href="http://rarediseases.info.nih.gov">http://rarediseases.info.nih.gov</a>. The disease results in round or oval patches of hyper-pigmented skin. The darkened skin patches may sometimes have a bluish or purplish hue when they first appear and are often smooth to the touch and hairless.</li></ul> <h2 id="treatment">Treatment</h2> <p>Throughout the years, many different treatments have been tried for morphea including topical, intra-lesional, and systemic corticosteroids. Antimalarials such as hydroxychloroquine or chloroquine have been used. Other immunomodulators such as <a href="/facts/Methotrexate/LoDvhRKX">methotrexate</a>, topical <a href="/facts/Tacrolimus/Apj3X5S6">tacrolimus</a>, and <a href="/facts/Penicillamine/1N0ErBRB">penicillamine</a> have been tried. Children and teenagers with active morphea (linear scleroderma, generalised morphea and mixed morphea: linear and circumscribed) may experience greater improvement of disease activity or damage with oral methotrexate plus <a href="/facts/Prednisone/eGgPIauI">prednisone</a> than with placebo plus prednisone.<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a> Some have tried prescription vitamin-D with success. Ultraviolet A (UVA) light, with or without psoralens have also been tried. UVA-1, a more specific wavelength of UVA light, is able to penetrate the deeper portions of the skin and thus, thought to soften the plaques in morphea by acting in two fashions: by causing a systemic immunosuppression from UV light, or by inducing enzymes that naturally degrade the collagen matrix in the skin as part of natural sun-aging of the skin. <a href="http://www.menzilim.org/">[1]</a> <a href="https://web.archive.org/web/20190203072618/https://www.menzilim.org/">Archived</a> 2019-02-03 at the <a href="/facts/Wayback_Machine/nmQ3a6JC">Wayback Machine</a> However, there is limited evidence that UVA‐1 (50 J/cm2), low‐dose UVA‐1 (20 J/cm2), and narrowband UVB differ from each other in effectiveness in treating children and adults with active morphea.<a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a> </p> <h2 id="epidemiology">Epidemiology</h2> <p>Morphea is a form of scleroderma that is more common in women than men, in a ratio 3:1.<a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a> Morphea occurs in childhood as well as in adult life.<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> Morphea is an uncommon condition that is thought to affect 2 to 4 in 100,000 people.<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> Adequate studies on the incidence and prevalence have not been performed. Morphea also may be under-reported, as physicians may be unaware of this disorder, and smaller morphea plaques may be less often referred to a dermatologist or rheumatologist. </p> <h2 id="see-also">See also</h2> <ul><li><a href="/facts/List_of_cutaneous_conditions/U58kszg2">List of cutaneous conditions</a></li></ul> <h2 id="further-reading">Further reading</h2> <ul><li><a href="http://archderm.jamanetwork.com/article.aspx?articleID=1740691">JAMA Dermatology Patient Page.</a> Morphea (Localized Scleroderma. Nicole M. Fett, MD. JAMA Dermatol. 2013;149(9):1124. doi:10.1001/jamadermatol.2013.5079. September 2013</li></ul> <h2 id="external-links">External links</h2> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>Fitzpatrick, Thomas B. (2005). Fitzpatrick's color atlas and synopsis of clinical dermatology (5th ed.). New York: McGraw-Hill Medical Pub. Division. ISBN 978-0-07-144019-6. <a href="978-0-07-144019-6" target="_blank">978-0-07-144019-6</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>Bielsa, Isabel; Ariza, Aurelio (June 2007). "Deep morphea". Seminars in Cutaneous Medicine and Surgery. 26 (2): 90–95. doi:10.1016/j.sder.2007.02.005. ISSN 1085-5629. PMID 17544960. <a href="https://pubmed.ncbi.nlm.nih.gov/17544960" target="_blank">https://pubmed.ncbi.nlm.nih.gov/17544960</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 171. ISBN 0-7216-2921-0. <a href="/wiki/ISBN_(identifier)" target="_blank">/wiki/ISBN_(identifier)</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Peterson LS, Nelson AM, Su WP (1995). "Classification of morphea (localized scleroderma)". Mayo Clin. Proc. 70 (11): 1068–76. doi:10.4065/70.11.1068. PMID 7475336. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Zulian F, Athreya BH, Laxer R (2006). "Juvenile localized scleroderma: clinical and epidemiological features in 750 children. An international study". Rheumatology (Oxford). 45 (5): 614–20. doi:10.1093/rheumatology/kei251. PMID 16368732. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Zulian F, Athreya BH, Laxer R (2006). "Juvenile localized scleroderma: clinical and epidemiological features in 750 children. An international study". Rheumatology (Oxford). 45 (5): 614–20. doi:10.1093/rheumatology/kei251. PMID 16368732. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>Hayakawa I, Hasegawa M, Takehara K, Sato S (2004). "Anti-DNA topoisomerase IIalpha autoantibodies in localized scleroderma". Arthritis Rheum. 50 (1): 227–32. doi:10.1002/art.11432. PMID 14730620. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>Majeed M, Al-Mayouf SM, Al-Sabban E, Bahabri S (2000). "Coexistent linear scleroderma and juvenile systemic lupus erythematosus". Pediatr Dermatol. 17 (6): 456–9. doi:10.1046/j.1525-1470.2000.01820.x. PMID 11123778. S2CID 30359530. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>Bonifati C, Impara G, Morrone A, Pietrangeli A, Carducci M (2006). "Simultaneous occurrence of linear scleroderma and homolateral segmental vitiligo". J Eur Acad Dermatol Venereol. 20 (1): 63–5. doi:10.1111/j.1468-3083.2005.01336.x. PMID 16405610. S2CID 11523611. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>González-López MA, Drake M, González-Vela MC, Armesto S, Llaca HF, Val-Bernal JF (2006). "Generalized morphea and primary biliary cirrhosis coexisting in a male patient". J. Dermatol. 33 (10): 709–13. doi:10.1111/j.1346-8138.2006.00165.x. PMID 17040502. S2CID 29859708. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>Prinz JC, Kutasi Z, Weisenseel P, Pótó L, Battyáni Z, Ruzicka T (2009). ""Borrelia-associated early-onset morphea": a particular type of scleroderma in childhood and adolescence with high titer antinuclear antibodies? Results of a cohort analysis and presentation of three cases". J Am Acad Dermatol. 60 (2): 248–55. doi:10.1016/j.jaad.2008.09.023. PMID 19022534. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:11" class="footnote-back-ref">↩</a></p></li> <li id="fn:12"><p>James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 171. ISBN 0-7216-2921-0. <a href="/wiki/ISBN_(identifier)" target="_blank">/wiki/ISBN_(identifier)</a> <a href="#fnref:12" class="footnote-back-ref">↩</a></p></li> <li id="fn:13"><p>James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 171. ISBN 0-7216-2921-0. <a href="/wiki/ISBN_(identifier)" target="_blank">/wiki/ISBN_(identifier)</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></p></li> <li id="fn:14"><p>James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 171. ISBN 0-7216-2921-0. <a href="/wiki/ISBN_(identifier)" target="_blank">/wiki/ISBN_(identifier)</a> <a href="#fnref:14" class="footnote-back-ref">↩</a></p></li> <li id="fn:15"><p>James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 171. ISBN 0-7216-2921-0. <a href="/wiki/ISBN_(identifier)" target="_blank">/wiki/ISBN_(identifier)</a> <a href="#fnref:15" class="footnote-back-ref">↩</a></p></li> <li id="fn:16"><p>James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 171. ISBN 0-7216-2921-0. <a href="/wiki/ISBN_(identifier)" target="_blank">/wiki/ISBN_(identifier)</a> <a href="#fnref:16" class="footnote-back-ref">↩</a></p></li> <li id="fn:17"><p>"linear scleroderma" at Dorland's Medical Dictionary <a href="https://web.archive.org/web/20090628224336/http://www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?pg=/ppdocs/us/common/dorlands/dorland/seven/000095147.htm" target="_blank">https://web.archive.org/web/20090628224336/http://www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?pg=/ppdocs/us/common/dorlands/dorland/seven/000095147.htm</a> <a href="#fnref:17" class="footnote-back-ref">↩</a></p></li> <li id="fn:18"><p>James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 171. ISBN 0-7216-2921-0. <a href="/wiki/ISBN_(identifier)" target="_blank">/wiki/ISBN_(identifier)</a> <a href="#fnref:18" class="footnote-back-ref">↩</a></p></li> <li id="fn:19"><p>Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1. <a href="978-1-4160-2999-1" target="_blank">978-1-4160-2999-1</a> <a href="#fnref:19" class="footnote-back-ref">↩</a></p></li> <li id="fn:20"><p>Katz, KA (October 2003). "Frontal linear scleroderma (en coup de sabre)". Dermatology Online Journal. 9 (4): 10. PMID 14594583. <a href="/wiki/PMID_(identifier)" target="_blank">/wiki/PMID_(identifier)</a> <a href="#fnref:20" class="footnote-back-ref">↩</a></p></li> <li id="fn:21"><p>Katz, KA (October 2003). "Frontal linear scleroderma (en coup de sabre)". Dermatology Online Journal. 9 (4): 10. PMID 14594583. <a href="/wiki/PMID_(identifier)" target="_blank">/wiki/PMID_(identifier)</a> <a href="#fnref:21" class="footnote-back-ref">↩</a></p></li> <li id="fn:22"><p>"coup de sabre" at Dorland's Medical Dictionary <a href="https://web.archive.org/web/20090628224336/http://www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?pg=/ppdocs/us/common/dorlands/dorland/nine/000951723.htm" target="_blank">https://web.archive.org/web/20090628224336/http://www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?pg=/ppdocs/us/common/dorlands/dorland/nine/000951723.htm</a> <a href="#fnref:22" class="footnote-back-ref">↩</a></p></li> <li id="fn:23"><p>Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1. <a href="978-1-4160-2999-1" target="_blank">978-1-4160-2999-1</a> <a href="#fnref:23" class="footnote-back-ref">↩</a></p></li> <li id="fn:24"><p>Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1. <a href="978-1-4160-2999-1" target="_blank">978-1-4160-2999-1</a> <a href="#fnref:24" class="footnote-back-ref">↩</a></p></li> <li id="fn:25"><p>Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1. <a href="978-1-4160-2999-1" target="_blank">978-1-4160-2999-1</a> <a href="#fnref:25" class="footnote-back-ref">↩</a></p></li> <li id="fn:26"><p>Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). Page 1029. McGraw-Hill. ISBN 0-07-138076-0. <a href="/wiki/ISBN_(identifier)" target="_blank">/wiki/ISBN_(identifier)</a> <a href="#fnref:26" class="footnote-back-ref">↩</a></p></li> <li id="fn:27"><p>Albuquerque, Julia V de; Andriolo, Brenda NG; Vasconcellos, Monica RA; Civile, Vinicius T; Lyddiatt, Anne; Trevisani, Virginia FM (2019-07-16). "Interventions for morphea". Cochrane Database of Systematic Reviews. 2019 (7): CD005027. doi:10.1002/14651858.cd005027.pub5. ISSN 1465-1858. PMC 6630193. PMID 31309547. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6630193" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6630193</a> <a href="#fnref:27" class="footnote-back-ref">↩</a></p></li> <li id="fn:28"><p>Albuquerque, Julia V de; Andriolo, Brenda NG; Vasconcellos, Monica RA; Civile, Vinicius T; Lyddiatt, Anne; Trevisani, Virginia FM (2019-07-16). "Interventions for morphea". Cochrane Database of Systematic Reviews. 2019 (7): CD005027. doi:10.1002/14651858.cd005027.pub5. ISSN 1465-1858. PMC 6630193. PMID 31309547. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6630193" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6630193</a> <a href="#fnref:28" class="footnote-back-ref">↩</a></p></li> <li id="fn:29"><p>Laxer RM, Zulian F (2006). "Localized scleroderma". Curr Opin Rheumatol. 18 (6): 606–13. doi:10.1097/01.bor.0000245727.40630.c3. PMID 17053506. S2CID 42839634. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:29" class="footnote-back-ref">↩</a></p></li> <li id="fn:30"><p>James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 171. ISBN 0-7216-2921-0. <a href="/wiki/ISBN_(identifier)" target="_blank">/wiki/ISBN_(identifier)</a> <a href="#fnref:30" class="footnote-back-ref">↩</a></p></li> <li id="fn:31"><p>Peterson LS, Nelson AM, Su WP, Mason T, O'Fallon WM, Gabriel SE (1997). "The epidemiology of morphea (localized scleroderma) in Olmsted County 1960-1993". J. Rheumatol. 24 (1): 73–80. PMID 9002014. <a href="/wiki/PMID_(identifier)" target="_blank">/wiki/PMID_(identifier)</a> <a href="#fnref:31" class="footnote-back-ref">↩</a></p></li> </ol>