Cutaneous microcirculation in systemic sclerosis and response to intra-arterial reserpine

Management of sclerodermal finger ulcers

Ninety-three percent of 59 patients with scleroderma reviewed in this study presented with Raynaud's phenomenon at a mean age of 43 years; 65% of these developed fingertip ulcers within 4 years. Other common findings were sclerodactyly, distal phalangeal resorption, calcinosis cutis, and digital contractures. Medical management of the digital ulcers with systemic and regional vasodilating drugs was unsatisfactory. Sympathectomy, when performed early, temporarily relieved vasospastic pain but did not affect the course of the ulcers. Severe digital pain was the most incapacitating symptom resulting from vasospasm early in the course of the disease and irreversible arterial luminal narrowing later in the course. Conservative fingertip amputations for nonhealing ulcers constituted the management of choice to eradicate the ulcer, to reduce or eliminate the pain, and to return the hand to early useful function. A decision tree for the management of these ulcers is proposed.

The effect of local cooling on digital systolic pressure in patients with Raynaud's syndrome

The effect of local controlled cooling on the digital systolic blood pressure in the hand was studied in 25 healthy volunteers and 25 patients with Raynaud's syndrome. Arterial systolic pressure was indirectly measured using a digital cuff over the proximal phalanx and a photoplethysmographic probe over the digital pulp to detect pulsation. Pressures were measured after occlusion of the circulation (cuff at 180 mmHg) for 5 minutes with water circulating initially at 30 degrees C and then at 10 degrees C. An air filled cuff was used simultaneously on a control finger. The digital systolic pressure at 10 degrees C in the patients was significantly lower (P less than 0.001 Mann-Whitney U test) than in the normal volunteers whilst calculation of the percentage change in pressure induced by cooling the digit to 10 degrees C allowed complete separation between both groups. The range in the controls was +2 per cent to -26 per cent and in the patients, -33 per cent to -100 per cent. The test gives reproducible results (coefficient of variation 5-11 per cent) and offers an objective method of identifying patients with excessive vasospasm due to a cold stimulus. It may prove useful in studying natural history and the effect of drug therapy.