Digital ulcers, or open sores on the fingers and toes that do not heal, are common complications of systemic sclerosis. Approximately 30% of patients with systemic sclerosis have digital ulcers, most commonly on the fingertips or on the elbows due to taut skin or trauma. These painful sores can lead to impaired hand function, making digital ulcers a prominent complication for patients to manage.
Despite the prominence of digital ulcers in systemic sclerosis patients, there are no approved medications indicated to treat this uncomfortable symptom. As reviewed by “Optimal Management of Digital Ulcers in Systemic Sclerosis,” in the journal Therapeutics and Clinical Risk Management, therapeutic options are designed to prevent or reduce the burden of digital ulcerations in patients with systemic sclerosis. They fall into three categories: nonpharmacologic, pharmacologic, and surgical.
Nonpharmacologic treatments are as simple as avoiding triggers such as smoking, being in the cold for too long, or taking medications that promote vasoconstriction of the blood vessels. Pharmacologic treatments include calcium channel blockers, phosphodiesterase inhibitors, prostacyclin analogs, and endothelin receptor analogs. Most commonly, calcium channel blockers are the treatment of choice for systemic sclerosis patients, as they promote vasodilation to bring blood flow into the affected area. “A 16-week randomized study comparing oral nifedipine with intravenous iloprost in patients with Raynaud’s phenomenon-associated skin lesions secondary to scleroderma showed that both drugs appeared to reduce the number of skin ulcers,” wrote the authors of the present study. However, these pharmacological agents are hindered by the nonspecific vasodilation that can lead to side effects.
As a more extreme means to stop vasoconstriction that shuts off blood flow to the fingers, some patients undergo sympathectomies to block the spontaneous signals responsible for vasospasms. While these procedures used to be quite invasive, surgeons can now conduct the surgery using endoscopic thoracic sympathectomy techniques. The surgeon cuts the adventitia in the area of the digital ulcer, preventing sympathetic nervous system fibers from inducing vasoconstriction.
Without approved therapies for digital ulcers, it seems pharmaceutical companies may be interested in developing treatments for these unserved patients. However, clinical trials are difficult to design to test therapies for their efficacy in treating digital ulcers. This is largely due to the challenge of defining active digital ulcers and the hesitance of pharmaceutical companies to commit entire trials to digital ulcers in systemic sclerosis patients. It may be that the prevalence of digital ulcers is decreasing, as a ten-year study identified a reduction in percent of systemic sclerosis patients affected by digital ulcers from 54% to 16.5%.
Regardless, nonpharmacologic, pharmacologic, and surgical interventions are important for managing the patients who are affected by this complication.