Concomitant appearance of morphea and vitiligo in a patient with autoimmune thyroiditis

Morphea is a rare fibrosing disorder affecting the skin and underlying tissue. Also called localized scleroderma, morphea is characterized by lesions, which are initially erythematous or dusky violaceous patches eventually turning into hypopigmented sclerotic plaques with a typical lilac-coloured border. Generalized morphea is a rare subtype of morphea characterized by more than four le-sions occurring in two or more body sites. Although it has not been fully elucidated yet, it is increasingly perceived that autoimmunity plays the central role in the pathogen-esis of both morphea and vitiligo. Here, we present a case of generalized morphea accompanied by generalized vitiligo in a patient with autoimmune thyroiditis. These three putatively autoim-mune diseases in a single patient presumably signify an autoimmune phenomenon in their pathogenesis, which should be further investigated [1–3]. A 62-year-old woman came to our outpatient clinic with a history of two months of purplish discolorations over her trunk. While her family history was unremark-able, past medical history revealed evidence of stable vitiligo, type 2 diabetes mellitus (DM) and autoimmune thyroiditis, which were well-controlled with metformin of 500 mg twice a day and levothyroxine 75 µg once a day. The onset of vitiligo occurred at least 10 years ago, for which she had received topical corticosteroids, topical im-munomodulators, systemic corticosteroids, phototherapy and natural home remedies without improvement. Upon dermatological examination we observed multiple depig-mented patches over her central face, upper sternal area, upper and lower extremities, especially dorsal aspects of distal parts including hands and foot. We also observed multiple purplish indurated plaques on her torso, scattered over the abdominal area, lower back, left acromi-al region and right inframammarial area (Figures 1, 2). Lilac-coloured edge and central hyperpigmentation, which are typical features of plaque type morphea [2] were obvious (Figure 2). Laboratory studies including complete blood count and differential erythrocyte sedimentation rate and urinalysis revealed no abnormalities. A complete serum chemistry profile was within normal limits except high postprandial glucose levels (161 mg/dl (0–140)) and low-density lipoprotein (LDL) cholesterol levels (117 mg/dl (0–100)). Serologic tests for hepatitis B, C, and Borrelia burgdorferi were negative. The thyroid panel was normal , on the other hand anti-thyroglobulin (anti-Tg) and anti-thyroid peroxidase (anti-TPO) values were increased (21.4 IU/ml and 814.3 IU/ml, respectively). Anti-nuclear antibody (ANA), anti-double stranded DNA antibody (anti-dsDNA), and antibodies to saline-extracted antigens (ENA panel), and rheumatoid factor were negative. C3, C4 levels, chest X-ray and electrocardiogram were normal. A lesional skin …