Raynaud-Phänomen in der Dermatologie

[The German network for systemic sclerosis (DNSS): current data on diagnostics and therapy]

An essential prerequisite for progress in understanding the pathophysiology and the clinical treatment of rare diseases is the national cooperation of specialized centers. The German network for systemic sclerosis (DNSS) is such an interdisciplinary union of hospitals and research centers with a special interest in systemic sclerosis (SSc). A core activity is the patient register of the DNSS which includes over 3,100 patients. It is one of largest national registers of SSc patients worldwide and comprises prospective data on diagnostics as well as primarily therapy of the patients. The register has now proven to be an extremely successful basis for clinical research and basic studies within the framework of international cooperation. The most important results of the cooperation and the register will be presented in this article.

Comparison of patients with and without digital ulcers in systemic sclerosis: detection of possible risk factors

BACKGROUND

Digital ulcers (DU) are a major complication in the course of systemic sclerosis (SSc). In recent years, efficacious, but expensive therapies (e.g. iloprost, sildenafil, bosentan) have been shown to improve healing or to reduce the recurrence of DU. For optimal management it would be useful to identify the risk factors for DU. Such statistical analyses have been rare because they require a high number of patients.

OBJECTIVES

To identify potential risk factors for DU in patients with SSc.

METHODS

We used the registry of the German Network for Systemic Scleroderma and evaluated the data of 1881 patients included by August 2007. We assessed potential risk factors for DU by comparing patients with (24.1%) and without active DU at time of entry (75.9%).

RESULTS

Multivariate analysis revealed that male sex, presence of pulmonary arterial hypertension (PAH), involvement of the oesophagus, diffuse skin sclerosis (only when PAH was present), anti-Scl70 antibodies, young age at onset of Raynaud's phenomenon (RP), and elevated erythrocyte sedimentation rate (ESR) significantly impacted on the appearance of DU. Certain combinations increased the patients' probability of presenting with DU, with the highest probability (88%) for male patients with early onset of RP, ESR>30 mm h(-1), anti-Scl70 antibodies and PAH. Patients with DU developed RP, skin sclerosis and organ involvement approximately 2-3 years earlier than patients without DU.

CONCLUSIONS

The results reveal possible risk factors for the occurrence of DU in SSc. As DU are prone to local complications, prophylactic vasoactive treatment for patients presenting with these factors may be justified.

The registry of the German Network for Systemic Scleroderma: frequency of disease subsets and patterns of organ involvement

Objective. Systemic sclerosis (SSc) is a rare, heterogeneous disease, which affects different organs and therefore requires interdisciplinary diagnostic and therapeutic management. To improve the detection and follow-up of patients presenting with different disease manifestations, an interdisciplinary registry was founded with contributions from different subspecialties involved in the care of patients with SSc.

Methods. A questionnaire was developed to collect a core set of clinical data to determine the current disease status. Patients were grouped into five descriptive disease subsets, i.e. lcSSc, dcSSc, SSc sine scleroderma, overlap-syndrome and UCTD with scleroderma features.

Results. Of the 1483 patients, 45.5% of patients had lcSSc and 32.7% dcSSc. Overlap syndrome was diagnosed in 10.9% of patients, while 8.8% had an undifferentiated form. SSc sine scleroderma was present in 1.5% of patients. Organ involvement was markedly different between subsets; pulmonary fibrosis for instance was significantly more frequent in dcSSc (56.1%) than in overlap syndrome (30.6%) or lcSSc (20.8%). Pulmonary hypertension was more common in dcSSc (18.5%) compared with lcSSc (14.9%), overlap syndrome (8.2%) and undifferentiated disease (4.1%). Musculoskeletal involvement was typical for overlap syndromes (67.6%). A family history of rheumatic disease was reported in 17.2% of patients and was associated with early disease onset (P < 0.005).

Conclusion. In this nationwide register, a descriptive classification of patients with disease manifestations characteristic of SSc in five groups allows to include a broader spectrum of patients with features of SSc.

[Primary and secondary Raynaud's phenomenon]

The term Raynaud's phenomenon describes an abnormal vasospastic response to cold or emotional stress. It is a common condition with a prevalence of 3-5% of the population. Clinically, Raynaud's phenomenon manifests as sharply demarcated colour changes of the skin of the digits that is often accompanied by paraesthesia. Raynaud's phenomenon can be subdivided into primary, or idiopathic, and secondary forms, in the latter of which associated diseases or causes can be identified. The pathogenesis of the disease is incompletely understood. Pathologic changes have been observed primarily in vascular smooth muscle cells, endothelial cells and perineuronal microvasculature. Current therapeutic strategies include supportive treatments, topical therapeutic approaches and systemic medication. Drug therapies with proven efficacy include calcium channel blockers, prostacyclin analogues, fluoxetine, losartan and sildenafil.

[Acral necrosis in metastatic ovarian carcinoma. A single episode of Moschowitz syndrome during gemcitabine chemotherapy]

For some time now, there have been reports of acral necrosis as a paraneoplasia that may occur in association with a number of different malignant tumours. There have also been a series of reports about acral necrosis associated with chemotherapy with various cytostatics. The treatment of choice if these lesions occur is plasmapheresis. Ultimately, the occurrence of thrombotic microangiopathy (TMA) can only be prevented by close monitoring through regular laboratory controls before each new cycle of chemotherapy. In the differential diagnosis, Raynaud's syndrome should be considered as a premonitory paraneoplasia, a risk factor for the occurrence of acral necrosis in patients with a malignant tumour undergoing chemotherapy, particularly patients with ovarian carcinoma receiving gemcitabine treatment.

[The situation of rare skin diseases in Germany]

In Germany a disease is considered to be "rare" when its prevalence is less than 5:10,000. However, as far as genetic skin diseases are concerned, they are often much more uncommon with a prevalence in the range of 1:100,000. Currently considerable deficits prevail in both diagnosis and treatment of rare skin diseases. Driven by scientific research on rare skin diseases and benefiting from start-up grants of the Federal Ministry for Education and Research (BMBF), the following networks for rare skin diseases were formed: a) epidermolysis bullosa, b) ichthyosis and related keratinisation disorders, c) systemic scleroderma. From a scientific point of view these networks are very successful, they publish in high impact journals and at the same time developed into national centres of reference for the respective disease groups, although formally this status does not exist in Germany. Thus, the 5 year start-up grants considerably improved the clinical care for these three skin disease groups. However, now we are confronted with the threat that the newly formed structures will be difficult to maintain, due to lack of adequate financing. In contrast to France, Germany does not have a "national plan for rare diseases"--probably because the federal structure in Germany is difficult to reconcile with "national plans". In France the situation of clinical care for rare diseases is permanently restructured by the establishment of official national reference centres and by allocation of additional financial means to fulfill these national tasks. In our view, a similar approach is also necessary in Germany.

[Raynaud phenomenon in dermatology : Part 2: therapy]

While primary Raynaud phenomenon (RP) only rarely leads to complications, secondary RP when associated with systemic sclerosis (SSc) frequently results in necrosis, ulcers or even gangrene. Therefore timely therapeutic intervention is required. Management of RP includes physical therapy, avoidance of triggers, and a variety of medications, depending on the disease severity. On the basis of published studies and of our own experience we suggest: a) for primary and uncomplicated secondary RP, calcium channel blockers in adequate doses; b) for SSc-associated secondary RP with hypertension, cardial or renal involvement, drugs which interfere with angiotensin; c) in case of concomitant depression, exploitation of the vasodilatory effects of serotonin reuptake inhibitors, d) in presence of ulcers or marked trophic alterations, intravenous administration of iloprost, e) for recalcitrant cases and endangered digits, sildenafil, f) for prevention of severe relapses, the endothelin-receptor antagonist bosentan. The drugs mentioned in c-f are not approved for RP and used off-label. In patients with secondary SSc-associated RP, timely therapy can reduce the percentage of complications such as ulcers or amputations. In addition, timely treatment of RP possibly retards ensuing fibrotic processes.