Localized scleroderma and dermal fillers in HOF
Quick facts
- What it is
- An autoimmune disease that hardens and thins the skin and, at times, deeper tissues; on the face, the localized form (morphea) can leave depressed and asymmetric areas.
- Why it matters in HOF
- A procedure during active disease can reactivate inflammation, and hardened tissue responds unpredictably to the injected volume.
- Usual approach
- Avoid injecting during disease activity and discuss the case with the physician who follows the patient before any decision.
- Attention
- Systemic scleroderma is a different condition, with its own risks (smaller mouth, thin skin, poor circulation); the assessment is distinct.
Localized scleroderma, also called morphea, is an autoimmune disease in which the immune system attacks connective tissue and causes fibrosis. The skin hardens, thins, or retracts, and in some cases the underlying tissues (fat, muscle, and bone) are also affected. When it reaches the face, the result can be a depressed, rigid, or asymmetric area, and it is common for the patient to arrive at the HOF office wanting to "fill the hole."
This is one of the topics where the rule of looking before acting matters most. There is no safe public protocol to teach, and the evidence is limited to case reports and small series. This guide is a review: it organizes the forms of the disease, what changes in planning, and when the conversation needs to include the physician who follows the patient. The final decision belongs to the qualified professional, according to the rules of their professional council.
Which forms of scleroderma reach HOF?
Two facial presentations are the most remembered. The linear form, en coup de sabre, produces a depressed band on the forehead and scalp, resembling a vertical cut. Parry-Romberg syndrome involves progressive atrophy of one side of the face, with loss of fat and sometimes muscle and bone. They can coexist or overlap. Systemic scleroderma is a different condition: it affects the skin more diffusely, can narrow the mouth opening, and can affect circulation and internal organs.
| Condition | Facial appearance | What is of concern in HOF |
|---|---|---|
| Plaque morphea on the face | Hardened area, altered color | Rigid, inelastic skin, unpredictable response |
| En coup de sabre | Vertical groove on the forehead or scalp | Deep atrophy, disease that may progress |
| Parry-Romberg | Thinner half of the face, volume loss | Progressive asymmetry and disease with phases |
| Systemic scleroderma | Tight skin, smaller mouth, thin lips | Poor perfusion, thin skin, its own vascular risk |
The table is a mental map, not a diagnostic criterion. Diagnosis and classification belong to the physician (rheumatology or dermatology); in HOF, the role is to recognize the condition, ask questions, and not treat blindly.
Why is disease activity the central point?
Morphea has phases. In the active phase, there is inflammation: purplish or reddish borders, a recent increase in the area, worsening over weeks or months. In the inactive phase, the lesion is stable and leaves the sequela (thinned skin, volume loss). The person following the patient decides which phase they are in, with clinical examination and, when indicated, additional tests.
The reasoning for caution is simple: an invasive procedure in the area can act as a trigger for inflammation in active autoimmune disease, and fibrotic tissue has low compliance, which makes the injected volume hard to predict. So the prudent recommendation is not to treat during activity and, once the disease is quiet, to make the decision together with the specialist.
What to ask in the medical history?
The medical history in HOF tends to overlook rare autoimmune diseases, because the patient does not always connect the "hole in the forehead" with a disease. Ask directly.
If the answer points to an uninvestigated disease, the right step is to refer for diagnosis, not to inject. This protects the patient and protects you.
Which products come into the conversation and what are the risks?
In the literature, reports of correcting facial atrophy in morphea mainly involve resorbable fillers, fat grafting, and, more cautiously, other materials, always with stable disease and planned case by case. Hyaluronic acid is often cited for the advantage of being reversible with hyaluronidase, which gives a safety margin. Permanent or hard-to-remove materials are discouraged in autoimmune disease, precisely because of the lack of reversibility.
The specific risks of the condition:
- Inflammatory reactivation of the disease in the treated area;
- Poor healing and bruising in thinned, inelastic tissue;
- Irregular result, because fibrosis prevents the product from settling as it would in healthy skin;
- Vascular compression, if the tissue has low compliance and the volume is excessive;
- Usual complications of any injectable, such as swelling, nodules, and vascular occlusion, on terrain where vascularization may be altered.
Collagen biostimulation raises an additional question: inducing controlled fibrosis in someone with a fibrosing disease is an idea that calls for extra caution and should not be attempted without the specialist's agreement. There is no evidence to support a routine in that direction.
How to conduct the conversation with the patient and with the physician?
The patient with facial scleroderma often carries real aesthetic distress, and so quickly accepts the idea of "correcting." Your role is to explain that the initial focus is for the disease to be quiet, and that correction, if it comes, is partial and done in stages. Aligning expectations is the greatest gain, and the consent should record that the result is unpredictable in this tissue. See informed consent and consent and LGPD for photos.
Communication with the physician can be short: the patient's name, the area, what you are thinking of doing, which material, and the direct question "is there any contraindication at this time?". Keep the answer in the patient record. In doubtful cases, a reasoned, documented refusal is also a safety measure. The reasoning is similar to that for neuromuscular diseases and toxin and other conditions in which the patient requires a shared decision.
How to plan realistically?
If the joint decision is to treat, the plan usually has some characteristics: few areas at a time, small and conservative volumes, long intervals between sessions to assess the tissue's response, standardized photos at each stage, and a frank conversation about what will not change. The realistic goal is to soften the contour and asymmetry, not to normalize the face.
Where Harmy helps and where it does not
Harmy generates an illustrative 2D projection from a frontal photo. In a face with asymmetric atrophy, the projection can give an idea of what a volume in a specific area would change, but it does not predict the behavior of fibrotic tissue and does not replace the specialist's judgment. Use the simulation with great care in these cases and make clear to the patient that it is illustrative. For other at-risk patients, the reasoning is the same: the tool supports the conversation, it does not define the management.
Summary
Localized scleroderma on the face is not an absolute contraindication forever, but it requires: stable disease, a decision shared with whoever follows the patient, reversible material when possible, conservative volumes, and honest expectations. When in doubt, refer. For the patient-facing text, see scleroderma and facial harmonization; for other autoimmune diseases in the medical history, medical history in HOF.
Frequently asked questions
Can fillers be used in someone with localized scleroderma?
There is no single answer. In general, the discussion only begins with the disease stable for a period defined by the physician who follows the patient, and the decision is individual. During the active phase, procedures in the area are usually avoided.
Can filler make scleroderma worse?
There is concern that an invasive procedure could reactivate inflammation in an autoimmune disease, hence the caution. The topic has little high-quality evidence, which reinforces the need for a joint decision with the specialist.
What is the difference between morphea and systemic scleroderma?
Morphea (localized scleroderma) affects the skin and nearby tissues in delimited areas. Systemic scleroderma affects the skin more diffusely and can involve internal organs and vessels. They are different conditions, with different care.
Can hyaluronidase be used if there is a problem with the filler in this patient?
Hyaluronidase only breaks down hyaluronic acid and must be available whenever it is used. In a patient with autoimmune disease, its use and the assessment of a complication call for even more care and, often, the specialist's support.
Harmy images are illustrative simulations generated by AI from the patient's photo to support the conversation between practitioner and patient. They are not a promise of results. Indication, technique, product and volume are solely the decision of the licensed practitioner. This content is for information only and does not replace a clinical assessment.