LAUSR

ing disorder affecting the deep dermis and subcutis, mild perivascular lymphocytic infiltrates with scattered plasma cells, areas of calcification and degenerative changes in vessels. Magnetic resonance imaging of the right hip demonstrated ulceration to fascia with inflammation of the adjacent gluteus maximus muscle. Blood tests demonstrated positive speckled antinuclear antibodies (1:1280). Extractable nuclear antigens, immunoglobulins and antineutrophil cytoplasmic antibodies were negative. Serum complement, amylase and alpha-1 antitrypsin levels were normal. Although recurrent inflammation and infection of the gluteal injection sites that could have contributed to scarring were noted, the extent of the sclerosis beyond injection sites, with a finding of strongly positive speckled antinuclear antibodies seen in the active phase, supported a diagnosis of deep morphoea. Various therapies including a course of oral prednisolone, oral doxycycline and subcutaneous methotrexate at a dose of 10mg weekly for 9 months did not have a significant benefit in softening of the plaques or reduction in ulceration. Methotrexate was not escalated due to recurrent wound infection with methicillin-resistant Staphylococcus aureus and was discontinued due to lack of efficacy. Attempts at debridement and skin grafting by plastic surgery were unsuccessful due to a fibrotic wound bed. Morphoea is well-documented to occur at sites of injections, from which it is hypothesised that tissue damage triggers a self-amplifying cycle of fibrosis rather than a hypersensitivity reaction. Cyclizine is commonly delivered subcutaneously, despite being a known irritant in extravasation. Due to the distribution around injection sites, we propose that cyclizine injections are the cause of morphoea in this case, which has not been reported previously. Methotrexate with or without prednisolone is recommended for the treatment of deep morphoea by the European Dermatology Forum. Phototherapy with UVA-1 or narrow-band UVB may be similarly effective in adults and children with active morphoea, but the pathology is likely to be too deep in the subgroup of deep morphoea to respond to this modality. Dystrophic calcification and ulceration are reported complications of morphoea, and it is likely that the comorbidities of diabetes and malnutrition have significantly contributed to the ongoing lack of healing of ulceration in this challenging case.