The research, led by Faezeh Khorasanizadeh of the Department of Radiology at Razi Hospital, Tehran University of Medical Sciences, together with colleagues in dermatology, epidemiology, and biostatistics, and in collaboration with Ximena Wortsman of the Universidad de Chile, a pioneer in cutaneous ultrasound, enrolled eighteen patients with newly biopsy-confirmed morphea. Every participant had at least one clinically active plaque at baseline. The investigators deliberately designed the protocol to be practical: rather than imaging every lesion, they selected the most clinically probable active plaque in each patient and compared it with adjacent or contralateral normal skin serving as an internal control. Each patient then underwent grayscale ultrasound, color Doppler ultrasound, and shear-wave elastography at the start of the study and again after six months of treatment, alongside standardized clinical scoring. The study received ethical approval from the institutional review board of Tehran University of Medical Sciences and was conducted in accordance with the Declaration of Helsinki, with written informed consent obtained from all participants and guardians of minors.

The technical logic behind the imaging approach is worth unpacking. High-frequency grayscale ultrasound can resolve the individual layers of the skin with millimeter precision, allowing radiologists to measure dermal thickness, the hallmark of fibrotic thickening in morphea, and hypodermal thickness, which reflects the fat layer beneath. In active lesions, inflammation and edema typically thicken the dermis and can alter the echotexture of the subcutis. Color Doppler ultrasound adds a functional dimension by detecting blood flow; increased vascularity within and beneath a plaque is considered a marker of subclinical inflammatory activity that may persist even when the skin surface appears quiescent. Shear-wave elastography, the most technically sophisticated of the three, works by generating shear waves, a form of transverse mechanical vibration, within the tissue and measuring the speed at which they propagate. Because stiffer tissue transmits shear waves faster than soft tissue, the technique yields a quantitative estimate of tissue elasticity in kilopascals, turning the subjective sensation of hardened skin into a reproducible number.

After six months of follow-up, the results told a clear and clinically meaningful story. Dermal thickness, measured ultrasonographically, decreased significantly alongside a significant fall in mean clinical scores, with p values below 0.05. The LoSAI activity score dropped from a mean of 4.28 plus or minus 3.28 at baseline to 1.44 plus or minus 1.75 after treatment, while the LoSDI damage score declined from 11.39 plus or minus 7.38 to 9.56 plus or minus 6.77. Hypodermal thickness also decreased and skin elasticity increased slightly over the six months, but neither of these secondary changes reached statistical significance. The pattern makes biological sense: inflammation-driven dermal thickening responds to immunosuppressive therapy within months, whereas fibrotic remodeling of the subcutis and restoration of elastic properties are slower processes that may lag behind clinical improvement or, in the case of established damage, never fully reverse.

Perhaps the most intriguing findings emerged from the correlation analyses. Hypodermal thickness correlated negatively with the Physician Global Assessment of Damage, with a Spearman rho of -0.410 and a p value of 0.027, and positively with the LoSAI activity index, with rho of 0.513 and p of 0.004. Hypodermal thickness was also positively correlated with the Physician Global Assessment of Activity before treatment began. After therapy, hypodermal stiffness measured by elastography correlated positively with the LoSDI damage index. Taken together, these relationships suggest that the subcutaneous fat layer, often overlooked in favor of the dermis, carries real diagnostic information: a thicker hypodermis tracks with active disease, while stiffer subcutaneous tissue tracks with accumulated damage. This positions elastography not merely as a research curiosity but as a potential bridge between the activity and damage domains that clinicians must distinguish when deciding whether to escalate, continue, or taper therapy.

Not every result favored the new technology, and the authors were candid about the limitations. When radiologists and dermatologists independently rated disease activity using shear-wave elastography and color Doppler, the inter-rater agreement was poor, with a kappa of just 0.053, barely above chance. This discordance likely reflects the steep learning curve of cutaneous ultrasound, differences in probe positioning and pressure, and the absence of universally standardized scoring protocols across specialties. It is a sobering reminder that a measurement technique is only as objective as the protocol governing its use. The authors also emphasized that their cohort was small, with only eighteen patients, all of whom had plaque-type or linear morphea, the most common subtypes. Generalizing to rarer variants such as generalized, deep, or pansclerotic morphea will require larger and more diverse cohorts, and the six-month follow-up window may be too short to capture slower changes in elasticity and subcutaneous architecture.

Why does an objective biomarker matter so much for morphea specifically? Current treatment typically involves systemic corticosteroids combined with methotrexate or, increasingly, other immunomodulators, a regimen that carries real toxicity and demands months of commitment. Because clinical scores are subjective and damage can masquerade as activity, physicians risk both overtreating patients whose disease has already burned out and undertreating those with smoldering subclinical inflammation that continues to cause irreversible fibrosis. Ultrasound-based measures could change this calculus in several ways: by providing early, quantitative evidence of response within weeks rather than months; by identifying subclinical activity that warrants continued therapy even when the skin looks better; and by serving as surrogate endpoints in clinical trials, where the rarity of morphea has long made adequately powered studies difficult. Prior work by Wortsman and colleagues on the Ultrasound Morphea Activity Scoring system, and by other groups applying shear-wave elastography in both localized and systemic scleroderma, has laid the groundwork, but this study is among the first to track patients longitudinally through treatment with a multimodal protocol.

The study also fits into a broader movement in dermatology toward quantitative, imaging-based assessment of skin disease. Thermal imaging has been explored for detecting inflammation in localized scleroderma, dermoscopy offers clues to disease stage, and 50-megahertz ultrasound has documented improvement after ultraviolet A1 phototherapy. In systemic sclerosis, elastography is being evaluated as a measure of skin strain and fibrosis severity, raising the possibility of a shared imaging vocabulary across the sclerosing diseases. A recent consensus statement on the diagnosis and treatment of sclerosing skin diseases underscores how much remains unsettled in monitoring these conditions, and the authors of the current study position their work as a preliminary but prospective step toward filling that gap with tools that are already available in most radiology departments.

For now, the take-home message is measured but promising. In this preliminary prospective cohort, dermal thickness measured with high-frequency ultrasound emerged as the strongest candidate for an objective marker of treatment response in morphea, while color Doppler and shear-wave elastography showed potential as adjunctive tools whose clinical utility remains exploratory. The authors themselves stress that validation in larger cohorts is essential before these techniques enter routine practice, and the poor inter-rater agreement highlights the need for standardized acquisition and scoring protocols, ideally with dedicated training for both radiologists and dermatologists. Still, the direction of travel is unmistakable. If subsequent studies confirm these findings, the era of guessing whether a morphea plaque is truly quiet could give way to an era in which a handheld probe, a quantitative elasticity map, and a few millimeters of measured dermis tell clinicians exactly what the immune system is doing beneath the skin, and whether the treatment they have chosen is actually working.

Subject of Research: Ultrasound and shear-wave elastography for monitoring treatment response in morphea

Article Title: Ultrasound and shear-wave elastography as a tool for evaluating response to treatment of morphea: a preliminary report of a prospective study

Article References: Khorasanizadeh, F., Sharifi, M. A., Vahabi, S. M., Ansari, M. S., Ghandi, N., Hosseini, F., Etesami, I., & Wortsman, X. (2026). Ultrasound and shear-wave elastography as a tool for evaluating response to treatment of morphea: a preliminary report of a prospective study. Archives of Dermatological Research, 318(1), Article 457. https://doi.org/10.1007/s00403-026-04919-7

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04919-7

Keywords: morphea, localized scleroderma, ultrasound, shear-wave elastography, color Doppler, dermal thickness, LoSAI, LoSDI, treatment response, biomarkers, dermatology, skin fibrosis

The review, led by Kyle Maas of Vanderbilt University School of Medicine together with co-first authors Anish Sharma and Sahil Kapur, synthesizes the current state of point-of-care ultrasound in hidradenitis suppurativa, or HS. The disease affects an estimated 0.05 to 4.10 percent of the population and carries a heavy burden of comorbidities, including metabolic disease, diabetes, and arthritis. First described by the French surgeon Velpeau in 1839 and named by Verneuil in 1854, HS was long misattributed to infected sweat glands. By 1975 it had been recognized as a follicular occlusion disorder, part of a tetrad that includes acne conglobata, perifolliculitis of the scalp, and pilonidal cysts. Despite rapid advances in therapy, the diagnostic delay remains stubborn, and patients who miss the therapeutic window of opportunity may suffer irreversible immune-mediated tissue destruction, secondary infections, restricted mobility, and, rarely, squamous cell carcinoma in chronically inflamed skin.

What makes ultrasound so compelling is its ability to detect disease before it becomes visible. High-frequency ultrasound operating at around 15 megahertz can identify subclinical enlargement of the deepest portion of hair follicles—changes that precede any lump or boil a patient or physician can feel. In one study cited by the review, ultrasound detected subclinical lesions in two of twelve individuals tested, and in both cases the findings changed management decisions. For people at elevated risk of HS—those with a suggestive symptom history but no overt lesions, a family history of the disease, or risk factors such as obesity, smoking, or autoinflammatory conditions—sonographic screening could theoretically prompt earlier medical intervention. The authors are careful, however, to temper expectations: detecting subclinical abnormalities is not itself an outcome, and no large-scale study has yet shown that earlier sonographic detection alters the natural history of the disease, reduces surgery or antibiotic exposure, or improves quality of life. Outside research settings, they conclude, such screening remains investigational.

Where ultrasound’s technical power truly shines is in characterizing established lesions. Each lesion type in HS has a distinct sonographic signature. Abscesses appear as hypoechoic fluid pockets, while sinus tracts—clinically synonymous with fistulas and most often visualized on ultrasound as tunnels—show up as hypoechoic channels that can be traced through the dermis and hypodermis. Hyperechoic scarring and residual hair tracts within tunnels help delineate these structures from surrounding tissue. At 15 megahertz, ultrasound can even identify tombstone comedones, the blackheads that sit atop inflamed, scarred skin bases, and granulated tissue appearing as hypoechoic oval lesions. This level of anatomic detail supports staging and severity assessment in selected patients, particularly when clinical examination alone cannot define the depth and extent of disease and surgical planning is on the table.

The review also traces the evolution of ultrasound-based severity scoring. Ten years ago, the Sonographic Scoring System of Hidradenitis Suppurativa, or SOS-HS, first proposed ultrasound criteria for the disease, and imaging of fluid collections, fistulas, and pseudocysts showed agreement with dermatologists’ clinical scores—while clinical scores tended to underestimate disease severity. Last year, a modified version, mSOS-HS, introduced two major changes. First, it shifted emphasis from the number of affected body regions to the magnitude of ultrasound activity, captured in a new Hidradenitis Suppurativa Activity score, or US-HSA, which uses standardized color Doppler to compare baseline and follow-up lesions. The US-HSA criteria evaluate perilesional echogenicity, dermal vascularity, peripheral blood flow, spread of lesions, and lesion size and appearance. Second, the system added a severity level IIIb, defined as five or more non-communicated tunnels or three or more communicated tunnels—the most severe stage, requiring urgent treatment. Still, the authors caution that formal multi-center data on interobserver agreement remain limited, and HS remains fundamentally a clinical diagnosis; ultrasound criteria are meant to complement, not replace, established clinical standards.

Beyond diagnosis and staging, ultrasound is proving valuable as a non-invasive biomarker of disease activity. Power Doppler ultrasound, which visualizes blood flow, correlates significantly with pain scores, abscess and nodule counts, the number of draining tunnels, and even the dermal inflammatory cell count on matched biopsy specimens. Ultra-high-frequency ultrasound at 48 and 70 megahertz pushes resolution further still, detecting epidermal lesions smaller than 0.1 millimeters, edema, micro-tunnels, drop lesions, and microcysts, and distinguishing pseudocysts from small fluid collections. Access to such probes, however, is confined to a small number of specialized centers, and even standard high-frequency probes remain largely restricted to academic dermatology, constraining broader implementation.

Ultrasound’s therapeutic role may be its most immediately practical contribution. Preoperative mapping with high-frequency ultrasound helps surgeons distinguish affected tissue from healthy skin before procedures such as carbon dioxide laser surgery, detecting hidden tracts and abscesses and increasing the projected area of skin excision—changes associated with reduced recurrence compared with blind procedures. Ultrasound-guided drainage of abscesses, fine-needle aspirations, core needle biopsies, and intralesional injections of triamcinolone and lincomycin all benefit from real-time imaging; preliminary work suggests ultrasound-guided intralesional therapy achieves significantly higher response rates. The review even proposes monitoring schedules: ultrasound at eight weeks for patients on antibiotics, at weeks four, twelve, and twenty-four for those on biologics, and at multiple time points around surgery to evaluate post-surgical recurrence. These interventions are generally well tolerated, though small procedural risks such as infection, bleeding, or reactions to local anesthetic exist, and some patients with advanced disease report mild to severe discomfort during the examination itself.

To help clinicians navigate this expanding landscape, the authors propose a three-tier framework. The first tier comprises established, selectively useful applications: preoperative mapping for surgical excision, ultrasound-guided drainage, and intralesional injection for deep or recurrent lesions. The second tier includes context-dependent uses such as treatment monitoring with the US-HSA framework, severity staging beyond the Hurley classification, and characterization of lesion components—applications with biological plausibility but predominantly single-center evidence. The third tier is frankly investigational: deep learning-based image interpretation, smartphone-linked portable sonography, contrast-enhanced ultrasound using agents such as hydrogen peroxide to outline tracts, shear wave elastography to measure fibrosis and stiffness, and correlation of sonographic findings with cytokine biomarkers like IL-23, IL-17a, and IL-17F. None of these has been externally validated in independent HS cohorts, and smartphone-linked devices in particular currently show diagnostic accuracy too poor for clinical use.

Compared with alternatives such as magnetic resonance imaging, PET-CT, and infrared thermography, ultrasound offers real-time imaging without ionizing radiation at lower per-examination cost. Yet the review is emphatic that ultrasound is not a universal first-line modality: MRI remains preferred for severe, deep, or anogenital disease and extensive perineal involvement. Practical barriers loom large—comprehensive sonographic evaluation takes more clinic time than physical examination, no formal cost-effectiveness analyses exist, high-frequency probes are frequently unavailable in community practice, and reimbursement for cutaneous ultrasound remains uncertain. The feasibility of routine ultrasound assessment, the authors warn, may be substantially overstated outside specialized centers.

The deepest unresolved question is whether any of this imaging actually makes patients better off. Existing evidence focuses on surrogate endpoints—lesion characterization, staging, monitoring—rather than patient-centered outcomes such as HS Clinical Response, IHS4 scores, recurrence after surgery, medication stewardship, or dermatology-specific quality of life. No study has yet demonstrated that ultrasound-guided management improves such outcomes, leading the authors to describe the technology’s value as plausible but unproven. Two questions should guide future research: in which clinical scenarios does ultrasound change management beyond what examination alone would produce, and do those changes withstand longer-term follow-up and translate into genuine benefit? As artificial intelligence matures—deep learning algorithms already match or exceed the diagnostic accuracy of primary care physicians and approach that of dermatologists for skin conditions—and as 3D reconstruction, cryotherapy mapping, and multimodal imaging with MRI and CT advance, ultrasound’s role in HS could expand dramatically. For now, the message is measured: a powerful tool is finally seeing what clinicians could not, but proving it helps patients is the next, essential step.

Subject of Research: Point-of-care ultrasound imaging for the diagnosis, staging, and treatment planning of hidradenitis suppurativa

Article Title: Point-of-care ultrasound in Hidradenitis Suppurativa: applications for diagnosis, staging, and treatment planning

Article References: Maas, K., Sharma, A., Kapur, S., Kaakarli, H., Tadrousse, K., Sidhu, K. S., Verma, K. K., Unver, L., & Burkhart, C. G. (2026). Point-of-care ultrasound in Hidradenitis Suppurativa: applications for diagnosis, staging, and treatment planning. Archives of Dermatological Research, 318(1), Article 487. https://doi.org/10.1007/s00403-026-04984-y

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04984-y

Keywords: hidradenitis suppurativa, ultrasound, high-frequency ultrasound, color Doppler, US-HSA score, preoperative mapping, dermatology, diagnostic imaging, sinus tracts, artificial intelligence, elastography, treatment monitoring