Early multidisciplinary approach needed for digital ulcers in systemic sclerosis

Digital ulcers in patients with systemic sclerosis often need early assessment and systemic treatments, according to a review published in JAMA Dermatology.

“Systemic sclerosis (SSc) is a heterogeneous disease characterized by prominent vascular alterations (often referred to as vasculopathy), skin sclerosis and immune system (both innate and adaptive) dysfunction. In SSC, digital vasculopathy is represented by Raynaud phenomenon, digital ulcers (DUs) and critical digital ischemia,” Michael Hughes, PhD, consultant rheumatologist at Royal Hallamshire Hospital in Sheffield, England, and colleagues wrote. “In SSC, DUs may lead to substantial tissue loss. Therefore, DUs require a multidisciplinary approach, including specialist nursing and patient education.”

The review identified 527 articles published regarding digital ulcers and systemic sclerosis. Half of patients with SSc have a history of DUs.

A structured clinical approach is recommended in treating DUs, which includes definition, classification and categorization, followed by a multidisciplinary treatment plan.

Classification into groups, including those derived from digital pitting scars, solely ischemic DUs, those derived from underlying calcinosis and those derived from gangrene, can help in management and treatment, according to the researchers.

A comprehensive history and physical exam to determine the duration of the lesion, level of pain, sleep disturbance and any reported discharge are important.

“Early treatment is needed to maintain function, preserve quality of life and avoid evolution to gangrene, infection and potential diffusion (septicemia),” the authors wrote.

This includes a multidisciplinary team, analgesic therapy, rehabilitation, a review of background vasodilation, macrovascular disease assessment and wound bed management.

Both pharmacologic and local therapies are beneficial treatments for DUs.

“Digital ulcers are a sign of disease progression and evolution and a serious complication in patients with SSC and often are challenging to treat,” the authors wrote. “Therefore, early careful DU assessment, wound bed management and systemic treatment are necessary to modify the clinical course of DUs.”