Treatment of Ulcers In Scleroderma PDF Print E-mail
Thursday, 25 August 2011 22:11
Digital ulcers may develop in Scleroderma patients. Most systemic sclerosis patients will have digital ulcers at some point. In some, ulcers are persistent. Sometimes they progress to gangrene and amputation.

These Scleroderma ulcers are difficult to treat because of vascular disease in Scleroderma. In general, the treatment of scleroderma ulcers should be multi-faceted. It should include non-pharmacological and pharmacological measures. Antibiotics should be used judiciously. Surgical evacuation of pus is sometimes needed. Sometimes debridement is necessary.

Prevention of Scleroderma Ulcers
Ulcer prevention in patients with scleroderma is important. Once ulcers develop, treatment is difficult. Ulcer prevention involves thermal protection and prevention of trauma. Thermal protection is achieved by gloves, socks and hand and feet active warming. Cold exposure should be avoided. Good skin care is essential.

Bosentan has been shown to prevent new digital ulcer formation in patients with systemic sclerosis. It did not promote ulcer healing, though.

Mechanical treatment of scleroderma ulcers
Non-healing ulcers have been treated with Aircast™ arterial compression. These have been shown to improve ulcer healing in persons with critical limb ischemia and upper extremity ulcers.

Pharmacological treatment of scleroderma ulcers
Most patients with systemic sclerosis who develop severe Raynaud’s phenomena or digital ulcers will be offered pharmacological treatment. There are several drugs that have been suggested for the treatment of scleroderma ulcers:
  • Calcium channel antagonists – Di-hydropiridine type calcium channel antagonists have robust data in helping patients with digital ischemia. Medication such as nifedipine should be offered to these patients.
  • Bosentan – Bosentan is an endothelin receptor antagonist. It is well known from the field of pulmonary hypertension. It is recommended in the prevention of digital ulcers, as described above.
  • Sildanefil – Sildanefil is a phosphodiesterase 5 inhibitor. It has vasodilating effects. It is given in sexual dysfunction and pulmonary hypertension. Data for Sildanefil in the treatment of scleroderma ulcers is out there but is less robust. There is also data about Sildanefil and Raynaud’s phenomenon.
  • Iloprost – Iloprost is a vasodilating prostaglandin. It is administered intravenously. It has been shown to reduce the severity of ischemic attacks in patients with systemic sclerosis.

Surgical treatment of scleroderma ulcers
Surgical treatment of scleroderma ulcers involves sympathectomy. Sympathectomy can be thoracic or local, in the hand. Sympathectomy in the hand is called periarterial. It is probably useful for digital ulcers and Raynaud’s phenomena from connective tissue disease. It is probably not useful for ulcers secondary to atherosclerosis. Hand sympathectomy can be done with surgery or with botox injection.

For more on digital ulcers, read one of our previous articles here.

Source: Weinberg, I (2011), "Scleroderma Ulcers Treatment", Vascular Medicine; original article can be viewed here.


 
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