What questions should be asked in the history of a 13-year-old female presenting with facial morphea?

History Questions for 13-Year-Old Female with Facial Morphea

When evaluating a 13-year-old female with facial morphea, prioritize questions that assess disease extent, functional impact, systemic involvement, and potential triggers, as these directly determine treatment intensity and prognosis. 1, 2

Disease Characteristics and Progression

• Onset and duration: When did the skin changes first appear, and how rapidly have they progressed? 1 Linear morphea in children can progress rapidly and cause severe disability, making timing critical for treatment decisions. 2, 3

• Location and extent: Where exactly on the face are the lesions located (forehead, cheek, jaw)? Do they cross the midline? Are they linear or plaque-like? 1 Linear facial morphea (en coup de sabre) can cause significant disfigurement and requires aggressive systemic therapy. 1, 2

• Symptoms: Is there pain, itching, or a sensation of tightness in the affected areas? 4 While morphea is often asymptomatic, facial morphea profunda can cause painful trigeminal neuropathy. 4

• Progression pattern: Has the lesion been expanding, and are there new lesions appearing elsewhere on the body? 1, 3 This determines whether the disease is active and requires immediate systemic treatment. 1

Functional and Cosmetic Impact

• Facial movement: Has she noticed difficulty moving her face, opening her mouth fully, or chewing? 2 Facial morphea can cause contractures and functional disability requiring aggressive treatment. 1, 2

• Eye involvement: Can she close her eyes completely? Any vision changes? 2 Periorbital involvement can lead to serious complications. 2

• Jaw function: Any limitation in jaw opening or pain with eating? 2 Temporomandibular involvement can cause severe functional impairment. 2

• Psychological impact: How is this affecting her emotionally and socially? 1 Facial involvement in adolescents carries significant psychological morbidity and warrants aggressive treatment. 1

Extracutaneous Manifestations

• Neurological symptoms: Any headaches, seizures, or changes in sensation on the face? 4 Facial morphea can be associated with neurological complications including trigeminal neuropathy. 4

• Joint symptoms: Any joint pain, stiffness, or swelling in the limbs? 1 Linear morphea can extend beyond the face and cause musculoskeletal involvement. 2, 3

• Other skin lesions: Are there any similar lesions on the trunk, limbs, or other body areas? 1, 3 This would indicate more extensive disease requiring systemic therapy. 1

Potential Triggers and Associated Conditions

• Recent infections: Any recent viral illnesses or tick bites? 5 Borrelia burgdorferi infection has been associated with morphea development, particularly in endemic areas. 5

• Travel history: Has she traveled to areas where Lyme disease is common? 5 Up to 25% of facial palsies in endemic regions are due to Lyme disease, which can precede morphea. 5

• Trauma history: Any prior facial trauma, surgery, or radiation to the area? 6 Morphea can Koebnerize at sites of trauma. 6

• Autoimmune history: Does she or any family member have autoimmune diseases (lupus, rheumatoid arthritis, thyroid disease)? 5 Genetic predisposition to autoimmunity is part of morphea pathogenesis. 5

Previous Treatments and Medical History

• Prior treatments: Has she tried any topical or systemic medications for this condition? What was the response? 1 This guides second-line therapy decisions if first-line treatments have failed. 1

• Medication history: Is she currently taking any medications? 1 This is important before initiating methotrexate or other immunosuppressants. 1

• Vaccination status: Is she up to date on vaccinations? 1 Live vaccines should be administered before starting immunosuppressive therapy. 1

Critical Red Flags to Exclude Alternative Diagnoses

• Multiple cranial nerve symptoms: Any double vision, dizziness, difficulty swallowing, or weakness in other parts of the face? 7, 8 These suggest central nervous system pathology rather than isolated morphea. 7, 8

• Bilateral facial involvement: Is both sides of the face affected? 8 Bilateral involvement is extremely rare in morphea and suggests alternative diagnoses like Guillain-Barré syndrome. 8

• Rapid progression beyond 72 hours: Did the facial changes develop suddenly over less than 3 days? 8 This pattern suggests Bell's palsy or stroke rather than morphea. 8