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progressive facial hemiatrophy ( pfh ) was described initially by parry in 1825 . in 1846 , romberg described the same as a syndrome .
eulenberg , in 1871 , coined the name  progressive facial hemiatrophy. we describe a case series of six patient presenting to us who were diagnosed as having pfh .
the clinical features , history , and relevant investigations including serological findings of the patients are highlighted .
six patients presenting to our outpatient department were diagnosed with progressive facial hemiatrophy ( pfh ) .
the clinical features , history , and relevant investigations including serological findings of the patients are highlighted in table 1 .
patient demographics , clinical , and serological features all the six patients in our series were female .
there was no significant family history of similar disease in the family in any of the patients .
the age of onset of the disease ranged from eight to twenty - six years .
hyperpigmentation was seen in the patients and was a major concern for all of them .
the cheek was involved in five of the patients , the forehead in two , and the nose in one .
bone involvement was not clinically evident in any patient ; however , the youngest patient showed minimal bone atrophy on radiography .
the auto - antibody profile showed a positive screen for anti - nuclear - antibodies in one patient ; however , no specific positivity was seen on anti - nuclear - antibody profile testing , which included  anti - single - stranded dna ( anti - ssdna ) , anti - double - stranded dna ( anti - dsdna ) , anti - centromere ( aca ) , anti -scl-70 , anti - jo / la , and anti - u1rnp .
right - sided pfa , mainly cheek and jaw right - sided pfa , mainly cheek and jaw right - sided pfa , mainly cheek left - sided pfa , mainly cheek and forehead the different treatment options tried by the patients included topical steroids , topical vitamin e preparations , anti - malarials , and topical calcipotriene .
two of the patients were referred for plastic surgery , for surgical management with autologous fat / fascial grafts , with subjectively satisfactory results .
it has been described as a slowly progressive atrophy of the skin , subcutaneous tissue , and muscle , involving one side of the face , typically presenting during the first or second decade of life .
it is characterized by the unilateral atrophy of the skin , subcutaneous tissue or the underlying bony structures , often accompanied by hyperpigmentation of the skin .
this syndrome has many features of linear scleroderma  en coup de saber, but is distinguished by a more extensive involvement of the lower face with only slight cutaneous sclerosis .
it is often difficult to differentiate between scleroderma of the  en coup de sabre type and pfh .
total hemi - facial involvement , neurological features , and ocular changes are more characteristic of pfh.[58 ] histopathological features that might contribute to differentiating the two conditions include : connective tissue fibrosis , adnexal atrophy , and mononuclear cell infiltrates , which are present more commonly in scleroderma of the  en coup de sabre. in our series we have included only those cases that did not show histological evidence of sclerosis .
all the patients in our series considered the associated hyperpigmentation of the skin to be a major problem .
however , pfh has been reported in one of a monozygotic twin pair , suggesting that genetic factors are not involved in its etiology . in our study none of the patients had any significant associated family history of a similar condition .
cory et al , hypothesized that a noninfectious , unilateral inflammatory process , possibly associated with a chronic vasomotor disturbance and sympathetic nerve chain inflammation , was a major factor in the pathogenesis of this syndrome .
there is a hypothesis that there are probably different subcategories among patients presenting with pfh .
even as some cases may be autoimmune in nature many of the cases are likely to be idiopathic and big majorities have only facial atrophy , with no evidence of eye or cns involvement .
sahin et al , reported a case of progressive hemifacial atrophy occurring in a 30-year - old woman , in whom the etiology was thought to be lyme disease .
no sure link was established between these two disease states , but their coincident occurrence in this patient was noted .
the authors suggested that the etiology of the parry - romberg syndrome could involve borreliosis .
however , pfh has been reported from many areas , which are non - endemic for borreliosis , hence , making the significance of this association questionable .
the association of idiopathic / progressive facial hemiatrophy with various auto - antibodies has been reported . however , the significance or specificity of the association is debatable , especially as many of these cases have been diagnosed as overlaps of the parry romberg syndrome ( prs ) and linear scleroderma . in the study by garcia - de la torre et al , in a series of prs cases ,
the rheumatoid factor was positive in 36% , anti - histone antibody positivity was seen in 21% , and anti centromere antibody positivity in 14% . they did not find any positivity for the anti - ds - dna antibody .
gonul et al , reported a case of a 21-year - old caucasian man with hemifacial atrophy on the right side .
serological studies with anti - single - stranded dna ( anti - ssdna ) , anti - double - stranded dna ( anti - dsdna ) , anticentromere ( aca ) , and antinuclear ( ana ) antibodies were conducted .
anti - dsdna antibodies were found to be positive , but the others were negative . the rheumatoid factor ( rf ) was also negative .
some other reports also showed positivity to anti - ds - dna . in our series only one patient had
a positive anti - nuclear - antibody ( ana ) screen , however , none of the patients showed specific positivity in an ana profile test , which included  anti - single - stranded dna ( anti - ssdna ) , anti - double - stranded dna ( anti - dsdna ) , anticentromere ( aca ) , anti - scl-70 , anti - jo / la , and anti - u1rnp .
management of pfh comprises of a long - term follow - up of somatic disorders , and prevention of psychological problems .
treatment of pfh is symptomatic and mainly consists of plastic surgery after the disease activity has stopped .
various modalities of treatment have been tried for pfh , with varying results ; however , very often these are prescribed under the assumption of associated localized scleroderma .
these include intralesional or systemic products , such as , glucocorticoids , vitamin e , vitamin d derivatives , phenytoin , retinoids , penicillin , griseofulvin , interferons , d - penicillamine , antimalarials , and phototherapy .
surgical treatment is probably the only option in cases of definite pfh , parry - romberg syndrome or atrophic stages of localized scleroderma .
various surgical options used with varying results include  simple / composite grafts ( dermal and dermal - fat grafts ) , local or free flap surgery , injection of autologous tissues / lipofilling , paraffin , silicone , or polyalkylimide gel / poly - l - lactic acid.[1517 ] in our case series different medical options had been tried , including topical / intralesional steroids , anti - malarials , topical vitamin e preparations , and topical vitamin d analogs .
two of the patients had been referred for plastic surgery , as both had deep subcutaneous involvement ( without bone involvement ) .
both the patients had a fat / fascial graft done , with satisfactory cosmetic results .
it is essential to differentiate the condition from localized scleroderma , as the medical options used in the latter may have no benefits in pfh .
patient counseling is essential , so that the patients understand the nature of the disease and the prognosis .
six female patients diagnosed with progressive facial hemiatrophy are presented here . 
 the clinical and serological features are highlighted , and treatment options for the condition are discussed . 
 we would like to highlight the need to differentiate the condition from localized scleroderma and the with limitation of its medical management .