Should I get a second opinion before filler? Linear Scleroderma (En Coup De Sabre) Concerns (Photos)

Question

I've seen a dermatologist about a very deep grooves that have developed in my forehead (36M, white, non-smoker, long-term retinol user). I had been concerned about Linear Scleroderma (En Coup De Sabre) but had this completely dismissed with the derm explaining this is very rare in non-Asians and granular tissue would be palpable. The groove is tender to touch with headaches in the region. They would not provide a biopsy. I'm extremely self conscious of the line feeling it is very aging and obviously botox would do nothing - I'm looking into fillers but would it be wort getting a second opinion on the En Coup De Sabre? If so is there anything to explain to the derm to get this taken seriously? Prior to the dermatologist I had seen a rheumatologist, who after completing antibody tests (negative) was also highly skeptical.

Anna Chacon, MD, FAAD · Answer

Based on what you describe, yes, I think a second dermatologic opinion is reasonable before proceeding with filler, particularly because the groove is described as relatively deep, tender, and associated with headaches.

En coup de sabre (linear scleroderma) is uncommon, but the fact that it is uncommon in a particular population does not by itself exclude the diagnosis. Also, the absence of positive autoimmune antibodies does not completely rule out localized scleroderma. The diagnosis is primarily clinical, sometimes supported by a biopsy or imaging when the presentation is uncertain.

The features I would want a dermatologist to specifically assess are whether there is skin discoloration, induration or firmness, textural change, hair loss involving the eyebrow/scalp, progression of the indentation, or involvement of deeper tissues. A stable anatomical groove with normal-appearing and normal-textured skin would be more reassuring for a structural contour issue, but tenderness and headaches make it reasonable to take a closer look before treating the appearance.

When you see another dermatologist, I would explain it very simply: “This is a new/deep linear indentation that is tender and associated with headaches, and I would like to make sure localized scleroderma or another inflammatory process has been adequately excluded before having filler placed.” Bringing photographs showing how the area has changed over time can also be very helpful.

I would not rush into filler until the diagnosis is reasonably clear. If this is purely an anatomical contour or soft-tissue depression, filler may eventually be an option. However, if there is an underlying inflammatory or sclerosing process, treating the cause should come first. Filler in the forehead also requires particular caution because of the vascular anatomy and the rare but serious risk of vascular occlusion and vision complications.

Given the symptoms you've described, getting that second opinion before cosmetic correction is a sensible and cautious approach.

Should I get a second opinion before filler? Linear Scleroderma (En Coup De Sabre) Concerns (Photos)

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