Background Digital ulcers are frequent and recurrent complication in systemic sclerosis (SSc) and are the main cause of pain, impaired function of the hand and disability in SSc.
Objectives To evaluate the frequency and evolution of digital ulcers in SSc.
Methods The current study is a retrospective analysis of 60 SSc patients (47 patients with limited form of SSc, 8 patients with diffuse form of the disease and 5 patients with overlap syndrome, mean age 54.5±14.2 years, 52 women and 8 men), treated in the Clinic of Rheumatology, Kerckhoff clinic, Bad Nauheim, Germany and in the Department in Rheumatology, MHAT “Health”, Medical section “Palmed”, Plovdiv, Bulgaria. The frequency, evolution and the applied therapeutic strategy have been analyzed.
Results During the follow-up for a period between 1 and 6 years digital ulcers were registered in 29% (14/47) of the patients with limited form of the disease, in 75% (6/8) with diffuse form of SSc and in 20% (1/5) from the patients with overlap syndrome (common frequency - 21/60, 35%). The most often observed digital ulcers were ischemic lesion at the fingerpads (76%, 16/21) and ulcerations over bony prominenences of the hands (23%, 5/21), which may be found simultaneously. More rare type of digital ulcers, but with more severe course regarding the pain, function impairment and duration of healing are the necrotic lesions, which were found in 23% (5/21) of the cases. In 38% (8/21) of the patients with digital ulcers showed local and systemic signs of inflammation, which required administration of antibiotics. In one patient (4.76%, 1/21) an osteomyelitis developed and an amputation of the distal phalanx was performed (4.76%, 1/21). Digital ulcers at the feet were found significantly less frequent as compared with hands - in 10% of the patients (6/60, p<0.05). The period of healing of the digital ulcers in the srudied group was 3.39±2.39 months (range 2-12 months).
The treatment regimen of SSc patients with digital ulcers included:
Vasodilators – dihydropyridine calcium channel blockers with high vasoselectivity – felodipine, amlopdipine – monotherapy or in combination with venous inhibitor of phosphodiesterase – pentoxifyllin (n=7); venous prostaglandin (10-days courses) (n=9).
Local antiseptic treatment.
Antiplatelet drug – low dose aspirin, clopidogrel.
In cases with development of necrotic lesions - anticoagulant – enoxaparin, nadroparin.
Antibiotics in cases of infection or necrotic lesions - quinolone, lincosamides – clindamycin, metronidazole (oral or venous).
Discontinuation of treatment with immunosupressors.
Surgical treatment – debridement, excision of the underlying calcinosis, amputation.
The recovery requires timely complex treatment, which includes vasodilator, local therapy, antiplatelet drug, in cases of infection – antibiotic and in cases with necrotic lesion – anticoagulant and antibiotic.
Conclusions Digital ulcers are frequent and recurrent complication in SSc and are the main cause for impaired function and disability in these patients. The therapeutic approach in SSc patients with digital ulcers is a challenge for the rheumatologist and only the complex measures lead to positive outcome.
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Galluccio F, Matucci-Cerinic M. Autoimmun Rev. 2011;10(5):241-3.
Disclosure of Interest None Declared