Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2023;13(2):e2023075 1 Rapid Progression of Localized Morphea to Disseminated Plaque-Type Morphea Following COVID-19 Infection Hoda Rahimi1, Leila Rezaie Shirmard2, Mehrdad Ashayer1, Sajjad Barin3 1 Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2 Department of Pharmaceutics, School of Pharmacy, Ardabil University of Medical Sciences, Ardabil, Iran 3 Department of Pathology, Ardabil University of Medical Sciences, Ardabil, Iran Key words: COVID-19, morphea, plaque, autoimmune disorders Citation: Rahimi H, Rezaie Shirmard L, Ashayer M, Barin S. Rapid Progression of Localized Morphea to Disseminated Plaque-Type Morphea Following COVID-19 Infection. Dermatol Pract Concept. 2023;13(2):e2023075. DOI: https://doi.org/10.5826/dpc.1302a75 Accepted: June 20, 2022; Published: April 2023 Copyright: ©2023 Rahimi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Mehrdad Ashayer, MD, Dermatologist, Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Shohada-e Tajrish Hospital, Shahrdari St, 1989934148, Tehran, Iran. Tel: +98-21- 22744394 E-mail: m.ashayer@yahoo.com Introduction Since the emerging of the SARS-CoV-2 pandemic, differ- ent COVID‐19‐associated manifestations have been re- ported, involving nervous, hematologic, and endocrine systems [1]. As the largest organ of the body, the skin has not been an exception and is reported to be involved in COVID-19 patients with diverse manifestations, including maculopapular, vesicular, lichenoid, urticarial, vasculitis, and chilblain-like lesions [2,3]. Herein, we report a stable case of localized morphea which progressed rapidly to disseminated morphea following COVID-19 infection. Case Presentation A 45-year-old female patient was referred to our dermatol- ogy clinic due to asymptomatic bilateral sclerotic cutane- ous lesions on the trunk and lower extremities. The patient reported a single small lesion on her trunk from 1 year ago (which was neither enlarged nor distributed), so she did not visit a physician. Seven months later, she was infected with the SARS-CoV-2 virus, presenting with mild symp- toms (including myalgia, headache, and sore throat) with- out any lung involvement, which was confirmed by reverse transcriptase–polymerase chain reaction (RT-PCR). She received palliative treatment in addition to azithromycin 250mg/d for 1 week, and her symptoms were resolved without any sequel. After 2 months, her cutaneous lesion spread rapidly involving her trunk and lower extremities. She did not have any systemic signs or symptoms. Her familial and personal history was negative for any auto- immune disease. The physical examination revealed several brownish and violaceous plaques with firm ivory centers. The lesions showed symmetrical and bilateral distribution, which tend to coalescence with islands of sparing normal skin (Figure 1). 2 Research Letter | Dermatol Pract Concept. 2023;13(2):e2023075 Figure 1. (A,B) Violaceous plaques with firm ivory centers tend to coalescence with islands of sparing normal skin on the trunk (A) and the leg (B) of the patient. Figure 2. Thickening of dermal collagen bundles running parallel to the skin surface (A) (H&E x4), with scattered, perivascular, and peri- adnexal lymphoplasmacytic infiltration which extended into the hypodermis. Some eccrine glands appeared atrophic with few surrounding adipocytes (B,C) (H&E x40). Research Letter | Dermatol Pract Concept. 2023;13(2):e2023075 3 A biopsy from one of her new leg lesions revealed thick- ening of dermal collagen bundles running parallel to the skin surface with scattered, perivascular, and periadnexal lymphoplasmacytic infiltration, which extended into the hypodermis. Some eccrine glands appeared atrophic with few surrounding adipocytes, confirming the diagnosis of morphea (Figure 2). Narrow-band UVB therapy started for the patient, but she did not return for follow-up. Conclusions During the recent SARS-CoV-2 pandemic, different COVID‐19‐associated cutaneous disorders have been re- ported [2]. As infections have long been known as the most important environmental trigger in the complex pathophysi- ology of autoimmune diseases, it is not surprising that many of these systemic or cutaneous COVID‐19‐mediated diseases are autoimmune disorders [1]. Among autoimmune connective tissue disorders, several cases of new onset or deterioration of systemic lupus erythe- matosus were reported as a consequence of COVID-19 [1]. However, to date, there are only 2 cases of morphea reported in association with this infection. Pigliacelli et al reported the onset of limited plaque morphea following SARS-CoV-2 infection for the first time [4]. The other case was reported by Lotfi et al as pansclerotic morphea in a patient with lung cancer and COVID-19 infection [5]. However, in this case, due to the presence of a malignant neoplasm, the correlation between morphea and COVID-19 remains questionable. To the best of our knowledge, there is no report of the evolu- tion of localized-type morphea to disseminated plaque-type morphea following COVID-19 infection in the literature. References 1. Yazdanpanah N, Rezaei N. Autoimmune complications of COVID-19. J Med Virol. 2022;94(1):54-62. DOI: 10.1002 /jmv.27292. PMID: 34427929. PMCID: PMC8661629. 2. Rahimi H, Tehranchinia Z. A Comprehensive Review of Cuta- neous Manifestations Associated with COVID-19. Biomed Res Int. 2020;2020:1236520. DOI: 10.1155/2020/1236520. PMID: 32724793. PMCID: PMC7364232. 3. Tehranchinia Z, Asadi-Kani Z, Rahimi H. Lichenoid eruptions with interface dermatitis and necrotic subepidermal blister associ- ated with COVID-19. Dermatol Ther. 2020;33(6):e13828. DOI: 10.1111/dth.13828. PMID: 32542925. PMCID: PMC7323232. 4. Pigliacelli F, Pacifico A, Mariano M, et al. Morphea induced by SARS-CoV-2 infection: A case report. Int J Dermatol. 2021;61(3):377-378. DOI: 10.1111/ijd.15983. PMID: 34783020. PMCID: PMC8653008. 5. Lotfi Z, Haghighi A, Akbarzadehpasha A, et al. Pansclerotic Morphea Following COVID-19: A Case Report and Review of Literature on Rheumatologic and Non-rheumatologic Dermatologic Immune-Mediated Disorders Induced by SARS-CoV-2. Front Med (Lausanne). 2021;;8:728411. DOI: 10.3389/fmed.2021.728411. PMID: 34746174. PMCID: PMC8564069.