Differentiating Scleroderma from other diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: M. Khurram Afzal, MD [2]

Overview

Scleroderma must be differentiated from other diseases that cause skin thickening, sclerodactyly, edema, and symptoms of GERD such as scleredema, scleromyxedema, eosinophilic fasciitis, chronic graft-versus-host disease, drug induced scleroderma, scleroderma overlap syndromes, diabetic cheiroarthropathy, myxedema, and nephrogenic systemic fibrosis.

Differentiating Scleroderma from other Diseases

Scleroderma must be differentiated from other diseases that cause skin thickening, sclerodactyly, edema, and symptoms of GERD such as scleredema, scleromyxedema, eosinophilic fasciitis, chronic graft-versus-host disease, drug induced scleroderma, scleroderma overlap syndromes, diabetic cheiroarthropathy, myxedema, and nephrogenic systemic fibrosis.

Differentiating Scleroderma from other Diseases

		Symptoms			Physical examination				Lab Findings		Imaging	Histopathology
Diseases		Clinical manifestations							Para-clinical findings				Gold standard	Additional findings
		Symptoms			Physical examination				Para-clinical findings
		Skin thickening	Raynaud phenomenon	Heart burn	Edema (swelling)	Sclerodactyly	Telangiectasia	Impaired mobility	Autoantibodies	Blood indices	Imaging	Histopathology
Scleroderma^[1]^[2]	Limited cutaneous systemic sclerosis (CREST syndrome)	+ (induration)	+	+	+/-	+	+	+/-	Anti-centromere antibody Antinuclear antibody (ANA)	Anemia Elevated creatinine level	Nailfold microvascular changes on nailfold video capillaroscopy (NVC)^[3] Chest HRCT scan showing evidence of pulmonary fibrosis	Nailfold microvascular changes Dilated capillary loops Microhemmorhages	American College of Rheumatology (ACR)/ European League Against Rheumatism (EULAR) classification criteria^[4]	Interstitial lung disease Pulmonary hypertension Calcinosis Dyspnea
Scleroderma^[1]^[2]	Diffuse cutaneous systemic sclerosis	+ (induration)	+	+	+/-	+	+	+/-	Anti-topoisomerase-I (Scl-70) antibody Anti-RNA polymerase III antibody Antinuclear antibody (ANA)	Anemia Elevated creatinine level	Nailfold microvascular changes on nailfold video capillaroscopy (NVC)^[5] Chest HRCT scan showing evidence of pulmonary fibrosis	Nailfold microvascular changes Dilated capillary loops Microhemmorhages	American College of Rheumatology (ACR)/ European League Against Rheumatism (EULAR) classification criteria^[4]	Interstitial lung disease Pulmonary hypertension Scleroderma renal crisis Dyspnea
Systemic diseases	Scleredema (Buschke's disease)^[6]	+	-	-	+	-	-	+	N/A	Fasting blood sugar HbA1C	N/A	Normal epidermis Thickened dermis with swelling of collagen Fibroblast proliferation is absent in the dermis	Skin biopsy	Symmetrical skin thickening Trunk, shoulders, upper back, face Fingers are spared Immobility of shoulders and chest Associated with viral URTI and diabetes mellitus type 1, monoclonal gammopathy
	Scleromyxedema (lichen myxedematosus)^[7]^[8]	+ (waxy yellow-red papules)	+/-	+/-	+	-	-	-	N/A	Monoclonal gammopathy (IgG-lambda) Normal TSH	N/A	Fibroblast proliferation in the dermis Mucin deposition in the dermis	Skin biopsy	Associated with malignancies AL amyloidosis Normal thyroid function Scalp and head are affected
	Eosinophilic fasciitis^[9]^[10]	+ (orange peel-peau d'orange appearance)	-	-	+	-	-	-	N/A	Eosinophilia (peripheral blood smear)	Normal appearance on nailfold video capillaroscopy (NVC)	Fascia is edematous and infiltrated by eosinophils	Skin biopsy	Fasciitis present on the trunk sparing extremities Visible collapse of superficial veins when the limb is elevated Hands and feet are not involved
	Chronic graft-versus-host disease^[11]^[12]	+ (induration)	-	-	-	-	-	+	Antinuclear antibody (ANA) Anti-mitochondrial antibody	Increased serum bilirubin concentration	N/A	Thick collagen bundles in the dermis Normal appearing epidermis	Skin biopsy	Occurs after allogeneic hematopoietic transplantation Pulmonary fibrosis Esophageal sclerosis
	Drug-induced scleroderma^[13]^[14]	+	+	+/-	+/-	+	+/-	-	N/A	N/A	N/A	IgG and complement deposits on epidermal keratinocytes	Skin biopsy	Bleomycin Cancer chemotherapeutic drugs Skin changes present on trunk and extremities
Scleroderma overlap syndromes^[15]^[16]^[17]^[18]	Scleroderma-systemic lupus erythematosus overlap	+ (rash)	+	+	+/-	+	+	+/-	Anti-Ro52 antibody Antinuclear antibody (ANA) Anti-Smith antibody Anti-dsDNA antibody Antiphospholipid antibody Anti-centromere antibody (ACA) Anti-topoisomerase-I (Scl-70) antibody Anti-RNA polymerase III antibody	Decreased C3, C4 and CH50 Anemia	N/A	Inflammation at the dermal-epidermal junction	Anti-Ro52 antibody Anti-dsDNA antibody	Malar (butterfly) rash Arthritis
	Scleroderma-polymyositis overlap	+ (rash)	+	+	+/-	+	+	+/-	Anti-Ro52 antibody Antinuclear antibody (ANA) Anti-Jo-1 antibody Anti-SRP antibody Anti-Mi-2 antibody Anti-centromere antibody (ACA) Anti-topoisomerase-I (Scl-70) antibody Anti-RNA polymerase III antibody	Elevated creatine kinase Aldolase Anemia	N/A	Inflammation at the dermal-epidermal junction Atrophy of the epidermis Perivascular infiltrate in the dermis Necrosis and atrophy of endomysial connective tissue on muscle biopsy	Anti-Ro52 antibody Muscle biopsy	Symmetric proximal muscle weakness
	Scleroderma-rheumatoid arthritis overlap	+ (rash)	+	+	+/-	+	+	+/-	Anti-Ro52 antibody Antinuclear antibody (ANA) Rheumatoid factor (RF) +ve Anti-CCP antibody Anti-centromere antibody (ACA) Anti-topoisomerase-I (Scl-70) antibody Anti-RNA polymerase III antibody	Elevated ESR Anemia	N/A	Inflammation at the dermal-epidermal junction	Anti-Ro52 antibody Anti-CCP antibody	Clinical findings that suggest rheumatoid arthritis (RA) but do not fulfill the ACR criteria for RA^[19]
Endocrine disorders	Diabetic cheiroarthropathy^[20]^[21]	+ (waxy skin)	-	-	-	+	-	+	N/A	Fasting blood sugar ≥126 mg/dL HbA1C ≥ 6.5%	N/A	N/A	Fasting blood sugar ≥126 mg/dL HbA1C ≥ 6.5%	Long standing type I diabetes mellitus Skin thickening of fingers Flexion contractures on fingers
Endocrine disorders	Myxedema^[22]	+ (coarse skin)	-	-	+	-	-	-	Anti-TPO antibody Anti-Tg antibody	Anemia Serum TSH elevated	N/A	Atrophied epidermis Hyperkeratosis	Serum TSH	Hypothyroidism Nonpitting edema present
Renal diseases	Nephrogenic systemic fibrosis^[23]	+ (induration)	-	-	+	+	-	-	N/A	Elevated C-reactive protein Elevated ESR Decreased serum albumin Decreased creatinine clearance	N/A	Fibrosis of dermis Accumulation of CD34 positive fibroblasts	Skin biopsy	Skin changes on extremities and trunk (involves hand and feet) Affects patients with advanced dialysis dependent renal failure Gadolinium containing contrast exposure is a risk factor Internal organ fibrosis can occur

References

↑ LeRoy EC, Black C, Fleischmajer R, Jablonska S, Krieg T, Medsger TA, Rowell N, Wollheim F (February 1988). "Scleroderma (systemic sclerosis): classification, subsets and pathogenesis". J. Rheumatol. 15 (2): 202–5. PMID 3361530.
↑ Black CM (August 1993). "Scleroderma--clinical aspects". J. Intern. Med. 234 (2): 115–8. PMID 8340733.
↑ Cutolo M, Sulli A, Smith V (April 2013). "How to perform and interpret capillaroscopy". Best Pract Res Clin Rheumatol. 27 (2): 237–48. doi:10.1016/j.berh.2013.03.001. PMID 23731933.
↑ ^4.0 ^4.1 van den Hoogen F, Khanna D, Fransen J, Johnson SR, Baron M, Tyndall A, Matucci-Cerinic M, Naden RP, Medsger TA, Carreira PE, Riemekasten G, Clements PJ, Denton CP, Distler O, Allanore Y, Furst DE, Gabrielli A, Mayes MD, van Laar JM, Seibold JR, Czirjak L, Steen VD, Inanc M, Kowal-Bielecka O, Müller-Ladner U, Valentini G, Veale DJ, Vonk MC, Walker UA, Chung L, Collier DH, Ellen Csuka M, Fessler BJ, Guiducci S, Herrick A, Hsu VM, Jimenez S, Kahaleh B, Merkel PA, Sierakowski S, Silver RM, Simms RW, Varga J, Pope JE (November 2013). "2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative". Ann. Rheum. Dis. 72 (11): 1747–55. doi:10.1136/annrheumdis-2013-204424. PMID 24092682.
↑ Cutolo M, Sulli A, Smith V (April 2013). "How to perform and interpret capillaroscopy". Best Pract Res Clin Rheumatol. 27 (2): 237–48. doi:10.1016/j.berh.2013.03.001. PMID 23731933.
↑ Rongioletti F, Kaiser F, Cinotti E, Metze D, Battistella M, Calzavara-Pinton PG, Damevska K, Girolomoni G, André J, Perrot JL, Kempf W, Cavelier-Balloy B (December 2015). "Scleredema. A multicentre study of characteristics, comorbidities, course and therapy in 44 patients". J Eur Acad Dermatol Venereol. 29 (12): 2399–404. doi:10.1111/jdv.13272. PMID 26304054.
↑ Rongioletti F, Rebora A (February 2001). "Updated classification of papular mucinosis, lichen myxedematosus, and scleromyxedema". J. Am. Acad. Dermatol. 44 (2): 273–81. doi:10.1067/mjd.2001.111630. PMID 11174386.
↑ Gabriel SE, Perry HO, Oleson GB, Bowles CA (January 1988). "Scleromyxedema: a scleroderma-like disorder with systemic manifestations". Medicine (Baltimore). 67 (1): 58–65. PMID 3336281.
↑ Herson S, Brechignac S, Piette JC, Mouthon JM, Coutellier A, Bletry O, Godeau P (June 1990). "Capillary microscopy during eosinophilic fasciitis in 15 patients: distinction from systemic scleroderma". Am. J. Med. 88 (6): 598–600. PMID 2346160.
↑ Falanga V, Medsger TA (October 1987). "Frequency, levels, and significance of blood eosinophilia in systemic sclerosis, localized scleroderma, and eosinophilic fasciitis". J. Am. Acad. Dermatol. 17 (4): 648–56. PMID 3668010.
↑ Schaffer JV, McNiff JM, Seropian S, Cooper DL, Bolognia JL (October 2005). "Lichen sclerosus and eosinophilic fasciitis as manifestations of chronic graft-versus-host disease: expanding the sclerodermoid spectrum". J. Am. Acad. Dermatol. 53 (4): 591–601. doi:10.1016/j.jaad.2005.06.015. PMID 16198778.
↑ Martires KJ, Baird K, Steinberg SM, Grkovic L, Joe GO, Williams KM, Mitchell SA, Datiles M, Hakim FT, Pavletic SZ, Cowen EW (October 2011). "Sclerotic-type chronic GVHD of the skin: clinical risk factors, laboratory markers, and burden of disease". Blood. 118 (15): 4250–7. doi:10.1182/blood-2011-04-350249. PMC 3204741. PMID 21791415.
↑ Finch WR, Rodnan GP, Buckingham RB, Prince RK, Winkelstein A (1980). "Bleomycin-induced scleroderma". J. Rheumatol. 7 (5): 651–9. PMID 6160247.
↑ Passiu G, Cauli A, Atzeni F, Aledda M, Dessole G, Sanna G, Nurchis P, Vacca A, Garau P, Laudadio M, Mathieu A (1999). "Bleomycin-induced scleroderma: report of a case with a chronic course rather than the typical acute/subacute self-limiting form". Clin. Rheumatol. 18 (5): 422–4. PMID 10524560.
↑ Satoh M, Chan EK, Sobel ES, Kimpel DL, Yamasaki Y, Narain S, Mansoor R, Reeves WH (September 2007). "Clinical implication of autoantibodies in patients with systemic rheumatic diseases". Expert Rev Clin Immunol. 3 (5): 721–38. doi:10.1586/1744666X.3.5.721. PMID 20477023.
↑ Moinzadeh P, Aberer E, Ahmadi-Simab K, Blank N, Distler JH, Fierlbeck G, Genth E, Guenther C, Hein R, Henes J, Herich L, Herrgott I, Koetter I, Kreuter A, Krieg T, Kuhr K, Lorenz HM, Meier F, Melchers I, Mensing H, Mueller-Ladner U, Pfeiffer C, Riemekasten G, Sárdy M, Schmalzing M, Sunderkoetter C, Susok L, Tarner IH, Vaith P, Worm M, Wozel G, Zeidler G, Hunzelmann N (April 2015). "Disease progression in systemic sclerosis-overlap syndrome is significantly different from limited and diffuse cutaneous systemic sclerosis". Ann. Rheum. Dis. 74 (4): 730–7. doi:10.1136/annrheumdis-2013-204487. PMC 4392314. PMID 24389298.
↑ Foocharoen C, Netwijitpan S, Mahakkanukrauh A, Suwannaroj S, Nanagara R (September 2016). "Clinical characteristics of scleroderma overlap syndromes: comparisons with pure scleroderma". Int J Rheum Dis. 19 (9): 913–23. doi:10.1111/1756-185X.12884. PMID 27126733.
↑ Pakozdi A, Nihtyanova S, Moinzadeh P, Ong VH, Black CM, Denton CP (November 2011). "Clinical and serological hallmarks of systemic sclerosis overlap syndromes". J. Rheumatol. 38 (11): 2406–9. doi:10.3899/jrheum.101248. PMID 21844148.
↑ Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, Birnbaum NS, Burmester GR, Bykerk VP, Cohen MD, Combe B, Costenbader KH, Dougados M, Emery P, Ferraccioli G, Hazes JM, Hobbs K, Huizinga TW, Kavanaugh A, Kay J, Kvien TK, Laing T, Mease P, Ménard HA, Moreland LW, Naden RL, Pincus T, Smolen JS, Stanislawska-Biernat E, Symmons D, Tak PP, Upchurch KS, Vencovský J, Wolfe F, Hawker G (September 2010). "2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative". Arthritis Rheum. 62 (9): 2569–81. doi:10.1002/art.27584. PMID 20872595.
↑ Seibold JR (November 1982). "Digital sclerosis in children with insulin-dependent diabetes mellitus". Arthritis Rheum. 25 (11): 1357–61. PMID 6753855.
↑ Jelinek JE (April 1993). "The skin in diabetes". Diabet. Med. 10 (3): 201–13. PMID 8485952.
↑ Heymann WR (June 1992). "Cutaneous manifestations of thyroid disease". J. Am. Acad. Dermatol. 26 (6): 885–902. PMID 1607406.
↑ Galan A, Cowper SE, Bucala R (November 2006). "Nephrogenic systemic fibrosis (nephrogenic fibrosing dermopathy)". Curr Opin Rheumatol. 18 (6): 614–7. doi:10.1097/01.bor.0000245725.94887.8d. PMID 17053507.

Template:WH Template:WS

[pmid3361530-1] LeRoy EC, Black C, Fleischmajer R, Jablonska S, Krieg T, Medsger TA, Rowell N, Wollheim F (February 1988). "Scleroderma (systemic sclerosis): classification, subsets and pathogenesis". J. Rheumatol. 15 (2): 202–5. PMID 3361530.

[pmid8340733-2] Black CM (August 1993). "Scleroderma--clinical aspects". J. Intern. Med. 234 (2): 115–8. PMID 8340733.

[pmid23731933-3] Cutolo M, Sulli A, Smith V (April 2013). "How to perform and interpret capillaroscopy". Best Pract Res Clin Rheumatol. 27 (2): 237–48. doi:10.1016/j.berh.2013.03.001. PMID 23731933.

[pmid24092682-4] 4.0 ^4.1 van den Hoogen F, Khanna D, Fransen J, Johnson SR, Baron M, Tyndall A, Matucci-Cerinic M, Naden RP, Medsger TA, Carreira PE, Riemekasten G, Clements PJ, Denton CP, Distler O, Allanore Y, Furst DE, Gabrielli A, Mayes MD, van Laar JM, Seibold JR, Czirjak L, Steen VD, Inanc M, Kowal-Bielecka O, Müller-Ladner U, Valentini G, Veale DJ, Vonk MC, Walker UA, Chung L, Collier DH, Ellen Csuka M, Fessler BJ, Guiducci S, Herrick A, Hsu VM, Jimenez S, Kahaleh B, Merkel PA, Sierakowski S, Silver RM, Simms RW, Varga J, Pope JE (November 2013). "2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative". Ann. Rheum. Dis. 72 (11): 1747–55. doi:10.1136/annrheumdis-2013-204424. PMID 24092682.

[pmid237319332-5] Cutolo M, Sulli A, Smith V (April 2013). "How to perform and interpret capillaroscopy". Best Pract Res Clin Rheumatol. 27 (2): 237–48. doi:10.1016/j.berh.2013.03.001. PMID 23731933.

[pmid26304054-6] Rongioletti F, Kaiser F, Cinotti E, Metze D, Battistella M, Calzavara-Pinton PG, Damevska K, Girolomoni G, André J, Perrot JL, Kempf W, Cavelier-Balloy B (December 2015). "Scleredema. A multicentre study of characteristics, comorbidities, course and therapy in 44 patients". J Eur Acad Dermatol Venereol. 29 (12): 2399–404. doi:10.1111/jdv.13272. PMID 26304054.

[pmid11174386-7] Rongioletti F, Rebora A (February 2001). "Updated classification of papular mucinosis, lichen myxedematosus, and scleromyxedema". J. Am. Acad. Dermatol. 44 (2): 273–81. doi:10.1067/mjd.2001.111630. PMID 11174386.

[pmid3336281-8] Gabriel SE, Perry HO, Oleson GB, Bowles CA (January 1988). "Scleromyxedema: a scleroderma-like disorder with systemic manifestations". Medicine (Baltimore). 67 (1): 58–65. PMID 3336281.

[pmid2346160-9] Herson S, Brechignac S, Piette JC, Mouthon JM, Coutellier A, Bletry O, Godeau P (June 1990). "Capillary microscopy during eosinophilic fasciitis in 15 patients: distinction from systemic scleroderma". Am. J. Med. 88 (6): 598–600. PMID 2346160.

[pmid3668010-10] Falanga V, Medsger TA (October 1987). "Frequency, levels, and significance of blood eosinophilia in systemic sclerosis, localized scleroderma, and eosinophilic fasciitis". J. Am. Acad. Dermatol. 17 (4): 648–56. PMID 3668010.

[pmid16198778-11] Schaffer JV, McNiff JM, Seropian S, Cooper DL, Bolognia JL (October 2005). "Lichen sclerosus and eosinophilic fasciitis as manifestations of chronic graft-versus-host disease: expanding the sclerodermoid spectrum". J. Am. Acad. Dermatol. 53 (4): 591–601. doi:10.1016/j.jaad.2005.06.015. PMID 16198778.

[pmid21791415-12] Martires KJ, Baird K, Steinberg SM, Grkovic L, Joe GO, Williams KM, Mitchell SA, Datiles M, Hakim FT, Pavletic SZ, Cowen EW (October 2011). "Sclerotic-type chronic GVHD of the skin: clinical risk factors, laboratory markers, and burden of disease". Blood. 118 (15): 4250–7. doi:10.1182/blood-2011-04-350249. PMC 3204741. PMID 21791415.

[pmid6160247-13] Finch WR, Rodnan GP, Buckingham RB, Prince RK, Winkelstein A (1980). "Bleomycin-induced scleroderma". J. Rheumatol. 7 (5): 651–9. PMID 6160247.

[pmid10524560-14] Passiu G, Cauli A, Atzeni F, Aledda M, Dessole G, Sanna G, Nurchis P, Vacca A, Garau P, Laudadio M, Mathieu A (1999). "Bleomycin-induced scleroderma: report of a case with a chronic course rather than the typical acute/subacute self-limiting form". Clin. Rheumatol. 18 (5): 422–4. PMID 10524560.

[pmid20477023-15] Satoh M, Chan EK, Sobel ES, Kimpel DL, Yamasaki Y, Narain S, Mansoor R, Reeves WH (September 2007). "Clinical implication of autoantibodies in patients with systemic rheumatic diseases". Expert Rev Clin Immunol. 3 (5): 721–38. doi:10.1586/1744666X.3.5.721. PMID 20477023.

[pmid24389298-16] Moinzadeh P, Aberer E, Ahmadi-Simab K, Blank N, Distler JH, Fierlbeck G, Genth E, Guenther C, Hein R, Henes J, Herich L, Herrgott I, Koetter I, Kreuter A, Krieg T, Kuhr K, Lorenz HM, Meier F, Melchers I, Mensing H, Mueller-Ladner U, Pfeiffer C, Riemekasten G, Sárdy M, Schmalzing M, Sunderkoetter C, Susok L, Tarner IH, Vaith P, Worm M, Wozel G, Zeidler G, Hunzelmann N (April 2015). "Disease progression in systemic sclerosis-overlap syndrome is significantly different from limited and diffuse cutaneous systemic sclerosis". Ann. Rheum. Dis. 74 (4): 730–7. doi:10.1136/annrheumdis-2013-204487. PMC 4392314. PMID 24389298.

[pmid27126733-17] Foocharoen C, Netwijitpan S, Mahakkanukrauh A, Suwannaroj S, Nanagara R (September 2016). "Clinical characteristics of scleroderma overlap syndromes: comparisons with pure scleroderma". Int J Rheum Dis. 19 (9): 913–23. doi:10.1111/1756-185X.12884. PMID 27126733.

[pmid21844148-18] Pakozdi A, Nihtyanova S, Moinzadeh P, Ong VH, Black CM, Denton CP (November 2011). "Clinical and serological hallmarks of systemic sclerosis overlap syndromes". J. Rheumatol. 38 (11): 2406–9. doi:10.3899/jrheum.101248. PMID 21844148.

[pmid208725952-19] Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, Birnbaum NS, Burmester GR, Bykerk VP, Cohen MD, Combe B, Costenbader KH, Dougados M, Emery P, Ferraccioli G, Hazes JM, Hobbs K, Huizinga TW, Kavanaugh A, Kay J, Kvien TK, Laing T, Mease P, Ménard HA, Moreland LW, Naden RL, Pincus T, Smolen JS, Stanislawska-Biernat E, Symmons D, Tak PP, Upchurch KS, Vencovský J, Wolfe F, Hawker G (September 2010). "2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative". Arthritis Rheum. 62 (9): 2569–81. doi:10.1002/art.27584. PMID 20872595.

[pmid6753855-20] Seibold JR (November 1982). "Digital sclerosis in children with insulin-dependent diabetes mellitus". Arthritis Rheum. 25 (11): 1357–61. PMID 6753855.

[pmid8485952-21] Jelinek JE (April 1993). "The skin in diabetes". Diabet. Med. 10 (3): 201–13. PMID 8485952.

[pmid1607406-22] Heymann WR (June 1992). "Cutaneous manifestations of thyroid disease". J. Am. Acad. Dermatol. 26 (6): 885–902. PMID 1607406.

[pmid17053507-23] Galan A, Cowper SE, Bucala R (November 2006). "Nephrogenic systemic fibrosis (nephrogenic fibrosing dermopathy)". Curr Opin Rheumatol. 18 (6): 614–7. doi:10.1097/01.bor.0000245725.94887.8d. PMID 17053507.

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Differentiating Scleroderma from other diseases

Overview

Differentiating Scleroderma from other Diseases

Differentiating Scleroderma from other Diseases

References

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