Systemic sclerosis: is there a treatment yet?

Novel Therapeutic Strategies in the Treatment of Systemic Sclerosis

Systemic sclerosis is a connective tissue disease of unknown origin and with an unpredictable course, with both cutaneous and internal organ manifestations. Despite the enormous progress in rheumatology and clinical immunology, the background of this disease is largely unknown, and no specific therapy exists. The therapeutic approach aims to treat and preserve the function of internal organs, and this approach is commonly referred to as organ-based treatment. However, in modern times, data from other branches of medicine may offer insight into how to treat disease-related complications, making it possible to find new drugs to treat this disease. In this review, we present therapeutic options aiming to stop the progression of fibrotic processes, restore the aberrant immune response, stop improper signalling from proinflammatory cytokines, and halt the production of disease-related autoantibodies.

Double-blind, placebo-controlled study of oral calcitriol for the treatment of localized and systemic scleroderma

BACKGROUND

Various treatments including corticosteroids, nonsteroidal anti-inflammatory drugs, D-penicillamine, interferon gamma, cyclosporine, and cytostatic drugs have been used with limited success in both morphea and systemic sclerosis (SSc).

OBJECTIVE

We investigated the effect of treatment with oral calcitriol in patients with localized or systemic scleroderma.

METHODS

A randomized, double-blind, placebo-controlled study of 9 months' duration with a 6-month follow-up was performed at the Department of Dermatology. A total of 27 patients (7 patients with SSc and 20 with morphea) were selected on a minimal skin score of 3 for patients with morphea and 12 for those with SSc. Each patient received calcitriol (0.75 microg/day for 6 months plus 1.25 microg/day for 3 months) or placebo for 9 months. Efficacy parameters included skin score, measurement of serum markers of collagen synthesis and degradation and, additional for the patients with SSc, oral aperture measurements, lung function studies, and esophagus motility.

RESULTS

The skin score in patients with morphea after 9 months' treatment showed no significant difference between the placebo and calcitriol groups (mean percentage reduction [SD] in skin score in the placebo group was -29.3 [57.9]; in the calcitriol group it was -19.4 [46.6]). The small group of patients with SSc was inadequate to allow us to draw any conclusions regarding efficacy. No significant change was found in the serum markers of collagen metabolism.

CONCLUSION

In this study calcitriol was not more effective than placebo in patients with morphea. Because of the small group of patients with SSc treated, no conclusions regarding efficacy in SSc can be drawn.

[Pulmonary involvement in systemic scleroderma. Part I. Chronic fibrosing interstitial lung disease]

INTRODUCTION

Chronic pulmonary interstitial fibrosis is the most frequent respiratory manifestation in systemic sclerosis, occurring in 80% of cases. It remains a severe complication of the disease and is the primary cause of mortality related to respiratory insufficiency in 20 to 60% of cases.

CURRENT KNOWLEDGE AND KEY POINTS

The date of onset of interstitial lung disease remains undetermined, and only in rare cases does it reveal the presence of systemic sclerosis. The clinical signs are only observable at a later stage, when at least 50% of the lung parenchyma is affected. The methods of choice adopted for early diagnosis of this disease are high resolution computed tomography and pulmonary functional investigations; they should be carried out during the preliminary investigation and at follow-up once a year. Moreover, high resolution computed tomography also provides prognostic data, for there is a correlation between the type of lesion and its severity as determined by high resolution computed tomography and by histological findings. The value of other methods of investigation, in particular bronchoalveolar lavage, has not yet been clearly established. The association of cyclophosphamide and corticoids is currently being evaluated (indications, administration modalities, duration), and this combination may be the most effective treatment.

FUTURE PROSPECTS AND PROJECTS

Interstitial lung disease is one of the major causes of morbidity and mortality in systemic sclerosis. Early diagnosis and management of this disease is therefore of utmost importance.

Treatment of systemic sclerosis

Guidelines for the conduct of clinical trials in progressive systemic sclerosis have been recommended to determine drug efficacy better. To date, the results of disease-modifying drugs in scleroderma have been disappointing. The treatment of esophagitis has been revolutionized by omeprazole. Raynaud's phenomenon can be treated with calcium channel blockers and iloprost. Scleroderma renal crisis can be treated with aggressive blood pressure control using angiotensin converting enzyme inhibitors. The best treatment for rapidly progressive scleroderma lung is still unknown. Future treatments in scleroderma should be tested with the use of recommended guidelines.

Mandibular resorption due to systemic sclerosis. Case report of surgical correction of a secondary open bite deformity

Systemic sclerosis (SSc) is a connective-tissue disorder of unknown origin causing a multisystem disease. While erosions of the distal phalanges are commonly described, resorption of the mandible has been considered an unusual finding. However, systematic radiographic screening of different groups of patients suffering from SSc revealed a resorption incidence of 20-33% of the examined mandibles. Women especially seem to be affected, and the male/female ratio is 1/7. Bilateral condylysis due to SSc has been described in seven cases, or 13.7% of the reported cases. To the best of our knowledge, this is the fourth report of surgical correction of secondary dysgnathia due to systemic sclerosis and the first with a 2-year follow-up period.

Intravenous dexamethasone pulse therapy in diffuse systemic sclerosis. A randomized placebo-controlled study

Thirty-five patients with diffuse systemic sclerosis were studied in a randomized, placebo-controlled, double-blind study. Seventeen patients received intravenous dexamethasone "pulse" therapy, while 18 patients received placebo. Each "pulse" consisted of 100 mg dexamethasone in 250 ml 5% dextrose infused intravenously over 1 h. Pulse therapy was repeated every month for 6 months. Assessment of disease status with various parameters was done at entry and at completion of trial, i.e. after 6 months. Significant improvement in skin involvement was seen in the study group, with the total skin score (TSS) decreasing from 28.5 +/- 12.2 to 25.8 +/- 12.8, while in the control group, TSS increased from 30.6 +/- 13.2 to 34.7 +/- 10. Similarly, significant improvement was noted in the flexion index. Other parametres that included extension index, maximum oral opening, range of movement of joints, functional disability score, Raynaud's phenomenon (frequency and duration), ESR, proteinuria, chest X-ray, ECG, lung function tests, barium swallow and antinuclear antibody were unchanged. Adverse effects of therapy were limited to an increased incidence of minor chest infections. It is concluded that intravenous pulse dexamethasone may be useful in the treatment of diffuse systemic sclerosis.

Early phenotypic activation of circulating helper memory T cells in scleroderma: correlation with disease activity

OBJECTIVES

The differential expression of several accessory/activation molecules (CD26, CD29, CD45RA, CD25, MLR4, HLA-DR) on peripheral blood CD4+ and CD8+ T lymphocytes in patients with scleroderma was compared with that in controls and patients with other connective systemic diseases to look for evidence of the involvement of T cells in the disease process of scleroderma.

METHODS

The two colour expression of surface molecules by circulating T cells was analysed with a panel of monoclonal antibodies and flow cytometry in 17 patients with scleroderma, 10 patients with systemic lupus erythematosus, and five patients with rheumatoid arthritis, and the results compared with those for 10 normal controls. The two colour T CD4+ phenotype was further compared between patients with active and quiescent disease in these patients with scleroderma. The coexpression of surface molecules by CD4+ T cells was also analysed by three colour flow cytometry in eight patients with scleroderma.

RESULTS

Patients with scleroderma showed increased CD4+CD26+ and CD4+CD25+ percentages and absolute numbers and decreased CD8+CD29+ percentages compared with controls. Moreover, a significant correlation between the higher CD4+CD26+ T cell percentage and absolute cell numbers with disease activity was observed. Most of the CD4+ peripheral blood T cells from patients with scleroderma showed the CD26+CD45RA- phenotype by three colour flow cytometry analysis.

CONCLUSIONS

The distinctive pattern of early helper memory T cell activation in these patients with rapidly evolving scleroderma supports the role of a T cell mediated mechanism in the progression of scleroderma.

Remission of scleroderma during chemotherapy for lymphoma

Temporary remission of scleroderma during the successful treatment of an associated malignant lymphoma by chemotherapy is reported in a patient with systemic sclerosis and mixed connective tissue disease. There is a well established relation between malignant disease and polymyositis/dermatomyositis but no overall association with systemic sclerosis or mixed connective tissue disease. Reports of the coexistence of malignancy and systemic sclerosis, however, emphasise a close temporal relation in their occurrence. A review of published work has identified several postulated mechanisms for this relation which may explain the response to chemotherapy.