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Knobler R, Geroldinger-Simić M, Kreuter A, Hunzelmann N, Moinzadeh P, Rongioletti F, Denton CP, Mouthon L, Cutolo M, Smith V, Gabrielli A, Bagot M, Olesen AB, Foeldvari I, Jalili A, Kähäri V, Kárpáti S, Kofoed K, Olszewska M, Panelius J, Quaglino P, Seneschal J, Sticherling M, Sunderkötter C, Tanew A, Wolf P, Worm M, Skrok A, Rudnicka L, Krieg T. Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes. J Eur Acad Dermatol Venereol 2024; 38:1251-1280. [PMID: 38456584 DOI: 10.1111/jdv.19912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/26/2024] [Indexed: 03/09/2024]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - M Geroldinger-Simić
- Department of Dermatology, Ordensklinikum Linz Elisabethinen, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - P Moinzadeh
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - F Rongioletti
- Vita Salute University IRCSS San Raffaele Hospital, Milan, Italy
| | - C P Denton
- Center for Rheumatology, Royal Free and University College Medical School, London, UK
| | - L Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, APHP-CUP, Hôpital Cochin, Paris, France
- Institut Cochin, Université de Paris Cité, Paris, France
| | - M Cutolo
- Laboratories for Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University Medical School of Genoa, IRCCS San Martino Genoa, Genoa, Italy
| | - V Smith
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - A Gabrielli
- Fondazione di Medicina Molecolare e Terapia Cellulare, Università Politecnica delle Marche, Ancona, Italy
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - A B Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - I Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - A Jalili
- Dermatology & Skin Care Clinic, Buochs, Switzerland
| | - V Kähäri
- Department of Dermatology and Venereology, University of Turku and Turku University Hospital, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- The Skin Clinic, Copenhagen, Denmark
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - J Panelius
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, CNRS, Immuno CencEpT, UMR 5164, Bordeaux, France
| | - M Sticherling
- Department of Dermatology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Tanew
- Private Practice, Vienna, Austria
| | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - M Worm
- Division of Allergy and Immunology, Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - T Krieg
- Department of Dermatology and Venereology, and Translational Matrix Biology, University of Cologne, Cologne, Germany
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Hughes M, Maltez N, Brown E, Hickey V, Shea B, Pauling JD, Proudman S, Merkel PA, Herrick AL. Domain reporting in Systemic Sclerosis-Related Digital Ulcers: An OMERACT Scoping Review. Semin Arthritis Rheum 2023; 61:152220. [PMID: 37236843 DOI: 10.1016/j.semarthrit.2023.152220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Digital ulcers (DUs) are a major cause of pain and disability in patients with systemic sclerosis (SSc). The aim of this scoping review was to evaluate the outcome domains used in studies of SSc-associated DUs. METHODS Electronic databases (EMBASE, MEDLINE and the Cochrane Library) were searched for articles written (1947 onwards) in English relating to SSc-DUs. A minimum of 15 participants for studies of imaging and 25 participants for questionnaire-based studies was required for inclusion. Information on all primary and secondary domains was extracted. RESULTS 4869 manuscripts were identified, of which 40 met the eligibility criteria and were included in the synthesis. Most studies were randomized controlled trials (n=13), or prospective (n=12)/retrospective (n=8) observational studies. Interventions included oral or intravenous drugs (n=25), topical/local treatments (n=5), and surgical interventions (n=2). Approximately half the studies assessed either the count/number of DUs (n=23) and/or improvement in DUs (n=20). Functional impact of DUs was examined in 25% (n=10) of studies. Other domains were related to complications of DUs (n=7), pain (n=6), health-related quality of life (n=4), microvascular assessment/pathophysiology (n=4), global assessment of DUs (n=2), and histopathology (n=1). CONCLUSION This scoping review identified a broad range of disease-related domains used to study SSc-DUs. There is significant heterogeneity in these domains. These data will inform the ongoing work of the OMERACT Vascular Disease in Systemic Sclerosis Working Group to define a core set of disease broad domains to capture the burden of DUs in SSc.
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Affiliation(s)
- Michael Hughes
- Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | - Nancy Maltez
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Beverley Shea
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - John D Pauling
- North Bristol NHS Trust, Bristol, UK; Bristol Medical School, University of Bristol, Bristol, UK
| | - Susanna Proudman
- Discipline of Medicine, University of Adelaide and Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Cutaneous Manifestations of Scleroderma. JOURNAL OF THE DERMATOLOGY NURSES' ASSOCIATION 2023. [DOI: 10.1097/jdn.0000000000000725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Mottaghi P, Hosseinbalam M, Nouri R, Farajzadegan Z. Effectiveness of bosentan in the treatment of systemic sclerosis-related digital ulcers: Systematic review and meta-analysis. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2023; 28:3. [PMID: 36974107 PMCID: PMC10039099 DOI: 10.4103/jrms.jrms_386_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/16/2022] [Accepted: 07/26/2022] [Indexed: 02/04/2023]
Abstract
Background The aim of the present systematic review and meta-analysis was to evaluate the therapeutic efficacy of bosentan, a dual endothelin receptor antagonist, for systemic sclerosis (SSc) patients with digital ulcers (DUs). Materials and Methods A systematic search of MEDLINE, Embase, Web of Science, and Scopus was done using appropriate keywords till September 2021. Weighted mean difference (WMD) as the effect of therapeutic efficacy of bosentan on continuous outcomes was an estimate. Furthermore, the pooled prevalence of diffuse SSc and limited SSc was computed. Fixed or random effects models when appropriate were used for data synthesis. Results Totally, 469 patients, with a mean age ranging from 48.1 to 63.7 years, from 8 studies were included in the systematic review and meta-analysis. The pooled frequency of diffuse SSc and limited SSc was 56% (95% confidence interval [CI]: 39%, 73%) and 44% (95% CI: 27%, 61%). The pooled prevalence of new DUs following bosentan treatment was 21% (95% CI: 10%, 33%). The results of the meta-analysis showed a pooled mean decrease of WMD: -0.09 (95% CI: -0.020, 0.02, P = 0.10), WMD: -2.82 (95% CI: -5.91, 0.27, P = 0.07), and WMD: -6.65 (95% CI: -9.49, -3.82, P < 0.001) in mean SSc-Health Assessment Questionnaire, pain, and Rodnan score, respectively. Our meta-analysis also indicated a significant pooled decrease in the number of new DUs in SSc patients compared to placebo subjects (WMD: -0.89 [95% CI: -1.40, -0.37; P = 0.001]) and baseline values (WMD: -1.34 (95% CI: -1.95, -0.73; P < 0.001). Conclusion Bosentan possibly is an efficacious treatment option for SSc-related DUs. Although further large-scale randomized clinical trials are required to confirm the preliminary finding and underlying mechanisms of action.
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Stöcker JK, Schouffoer AA, Spierings J, Schriemer MR, Potjewijd J, de Pundert L, van den Hoogen FHJ, Nijhuis-van der Sanden MWG, Staal JB, Satink T, Vonk MC, van den Ende CHM. Evidence and consensus-based recommendations for non-pharmacological treatment of fatigue, hand function loss, Raynaud's phenomenon and digital ulcers in patients with systemic sclerosis. Rheumatology (Oxford) 2022; 61:1476-1486. [PMID: 34260723 PMCID: PMC8996778 DOI: 10.1093/rheumatology/keab537] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/25/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE SSc is a complex CTD affecting mental and physical health. Fatigue, hand function loss, and RP are the most prevalent disease-specific symptoms of systemic sclerosis. This study aimed to develop consensus and evidence-based recommendations for non-pharmacological treatment of these symptoms. METHODS A multidisciplinary task force was installed comprising 20 Dutch experts. After agreeing on the method for formulating the recommendations, clinically relevant questions about patient education and treatments were inventoried. During a face-to-face task force meeting, draft recommendations were generated through a systematically structured discussion, following the nominal group technique. To support the recommendations, an extensive literature search was conducted in MEDLINE and six other databases until September 2020, and 20 key systematic reviews, randomized controlled trials, and published recommendations were selected. Moreover, 13 Dutch medical specialists were consulted on non-pharmacological advice regarding RP and digital ulcers. For each recommendation, the level of evidence and the level of agreement was determined. RESULTS Forty-one evidence and consensus-based recommendations were developed, and 34, concerning treatments and patient education of fatigue, hand function loss, and RP/digital ulcers-related problems, were approved by the task force. CONCLUSIONS These 34 recommendations provide guidance on non-pharmacological treatment of three of the most frequently described symptoms in patients with systemic sclerosis. The proposed recommendations can guide referrals to health professionals, inform the content of non-pharmacological interventions, and can be used in the development of national and international postgraduate educational offerings.
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Affiliation(s)
- Juliane K Stöcker
- Department of Research, Sint Maartenskliniek
- Musculoskeletal Rehabilitation Research Group, HAN University of Applied Sciences
- Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen
| | - Anne A Schouffoer
- Department of Rheumatology, Leiden University Medical Center, Leiden
- Department of Rheumatology, Haga Teaching Hospital, The Hague
| | - Julia Spierings
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Inflammation, Centre for Rheumatology and Connective Tissue Diseases, Royal Free and University College London, London, UK
| | - Marisca R Schriemer
- Department of Research, Sint Maartenskliniek
- National Association for People with Lupus, Systemic Sclerosis, Antiphospholipid Syndrome, and Mixed Connective Tissue Disease, Utrecht
| | - Judith Potjewijd
- Department of Clinical Immunology, Maastricht University Medical Center, Maastricht
| | - Lian de Pundert
- Department of Physical Therapy, Haga Teaching Hospital, The Hague
- Department of Rehabilitation, Physical Therapy Science and Sport, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht
| | - Frank H J van den Hoogen
- Department of Research, Sint Maartenskliniek
- Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen
| | | | - J Bart Staal
- Musculoskeletal Rehabilitation Research Group, HAN University of Applied Sciences
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center
| | - Ton Satink
- Research Group Neuro Rehabilitation, HAN University of Applied Sciences, Nijmegen
- European Masters of Science in Occupational Therapy, Amsterdam, The Netherlands
| | - Madelon C Vonk
- Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen
| | - Cornelia H M van den Ende
- Department of Research, Sint Maartenskliniek
- Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen
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Vanhaecke A, Debusschere C, Cutolo M, Smith V. Predictive value of laser speckle contrast analysis in systemic sclerosis. A systematic review and pilot study. Eur J Clin Invest 2022; 52:e13672. [PMID: 34424550 DOI: 10.1111/eci.13672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/20/2021] [Accepted: 08/22/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess whether tools to functionally examine the microcirculation, such as laser speckle contrast analysis (LASCA), are predictive of ischaemic digital trophic lesions ([i]DTL) in patients with systemic sclerosis (SSc). METHODS First, a systematic review (according to PRISMA) was conducted to identify studies describing a link between LASCA and SSc-related (i)DTL. In the additional pilot study, consecutive SSc patients underwent clinical and LASCA examinations (to assess the peripheral blood perfusion [PBP] of both hands) at enrolment. For one year, a monthly telephone survey was conducted to investigate (i)DTL occurrence. Logistic regression and ROC analysis were performed. RESULTS None of the three manuscripts retained through the systematic review examined the predictive value of LASCA for future (i)DTL. In our pilot study, 7/106 (6.6%) SSc patients developed at least one iDTL during follow-up, with PBP not found to be predictive (OR = 0.995, p = .418; ROC-AUC = 0.597). Post hoc, when only patients not taking vasodilators were analysed (n = 57), all three who developed iDTL had an average PBP ≤ 70 PU, while only 9/54 (16.7%) patients without iDTL occurrence had such values. CONCLUSION A predictive role of LASCA for (i)DTL has not yet been described in the literature and could also not be attested by our additional pilot study, due to a lower-than-expected iDTL incidence in our day-to-day SSc population in which patients were allowed to continue their vasodilator medication. However, the promising observations in the subgroup of vasodilator-naïve patients encourage further investigation of this potential added value of LASCA.
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Affiliation(s)
- Amber Vanhaecke
- Department of Internal Medicine, Ghent University, Ghent, Belgium.,Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Claire Debusschere
- Department of Internal Medicine, Ghent University, Ghent, Belgium.,Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University, Ghent, Belgium.,Department of Rheumatology, Ghent University Hospital, Ghent, Belgium.,Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center, Ghent, Belgium
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Sulli A, Paolino S, Pizzorni C, Ferrari G, Pacini G, Pesce G, Carmisciano L, Smith V, Cutolo M. Progression of nailfold capillaroscopic patterns and correlation with organ involvement in systemic sclerosis: a 12 year study. Rheumatology (Oxford) 2020; 59:1051-1058. [PMID: 31750929 DOI: 10.1093/rheumatology/kez374] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/18/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The aim of this observational study was to investigate the evolution of scleroderma microangiopathy throughout different nailfold videocapillaroscopy (NVC) patterns ('early', 'active', 'late') as well as the prevalence of organ involvement in SSc patients during a 12-year follow-up. METHODS Thirty-four SSc patients showing at baseline (first capillaroscopic analysis) the 'early' NVC pattern of microangiopathy were enrolled and followed for 12 years (s.d. 2). Complete NVC analysis and clinical and serological findings were collected. Patients were in a standard therapeutic care setting. Statistical analysis was carried out by non-parametric tests. RESULTS After a 12-year follow-up, the 'early' NVC pattern changed from baseline in 76% of the patients. The NVC pattern was found to be 'active' in 9 patients (26%), 'late' in 13 (38%) and characterized by non-specific capillary abnormalities in 4 (12%). In the subgroup whose microangiopathy progressed from the 'early' to the 'late' NVC pattern, the median time of progression from the 'early' to the 'active' pattern was significantly shorter (11 months) when compared with patients who progressed from the 'early' to the 'active' NVC pattern (55 months) (P = 0.002). The median time of progression between NVC patterns was significantly shorter in SSc patients showing either a nucleolar ANA pattern or Scl70 autoantibodies (P = 0.048). Organ involvement was progressively greater in SSc patients with 'early', 'active' and 'late' NVC patterns, respectively. CONCLUSIONS This longitudinal study confirms over a 12-year follow-up the evolution of specific NVC patterns associated with the progressive severity of organ involvement in SSc patients in a standard clinical care setting.
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Affiliation(s)
- A Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - S Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - C Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - G Ferrari
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - G Pacini
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - G Pesce
- Laboratory for Autoimmunity, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova
| | - L Carmisciano
- Biostatistics Section, Department of Health Sciences, University of Genova, Genova, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Department of Internal Medicine, VIB Inflammation Research Centre - Ghent University, Ghent, Belgium
| | - M Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
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8
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Hughes M, Alcacer-Pitarch B, Allanore Y, Baron M, Boin F, Bruni C, Chung L, Del Galdo F, Denton CP, Matucci-Cerinic M. Digital ulcers: should debridement be a standard of care in systemic sclerosis? THE LANCET. RHEUMATOLOGY 2020; 2:e302-e307. [PMID: 38273475 DOI: 10.1016/s2665-9913(19)30164-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/25/2019] [Accepted: 12/27/2019] [Indexed: 01/02/2023]
Abstract
Digital ulcers are a serious, recurrent complication in patients with systemic sclerosis. They are often slow to heal and exquisitely painful. Local wound care, such as debridement of the wound bed, is an essential component in the management of digital ulcers in systemic sclerosis. However, digital ulcer debridement is not a standard of care, and there is substantial international variation in the use of this approach. In this Viewpoint, we discuss the assessment of the wound bed and different methods of debridement using the model of tissue management, infection and inflammation, moisture control, and wound edge or epidermal advancement, known as TIME. We highlight the challenges in standard practice and the need for research into local wound care for this type of ulceration, before suggesting a potential roadmap to develop a standardised approach to support ulcer debridement in systemic sclerosis. Debridement might be the missing component in optimising the management of digital ulcers and we propose that the approach should be rigorously investigated as a standard of care in this common complication of systemic sclerosis.
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Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Begonya Alcacer-Pitarch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Biomedical Research Centre, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Yannick Allanore
- Department of Rheumatology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Murray Baron
- Division of Rheumatology, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Francesco Boin
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Cosimo Bruni
- Division of Rheumatology, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine and Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Biomedical Research Centre, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Christopher P Denton
- Department of Rheumatology, Royal Free Hospital, University College London, London, UK
| | - Marco Matucci-Cerinic
- Division of Rheumatology, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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9
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Hughes M, Pauling JD, Jones J, Denton CP, Domsic RT, Frech TM, Herrick AL, Khanna D, Matucci‐Cerinic M, McKenzie L, Saketkoo LA, Gooberman‐Hill R, Moore A. Multicenter Qualitative Study Exploring the Patient Experience of Digital Ulcers in Systemic Sclerosis. Arthritis Care Res (Hoboken) 2020; 72:723-733. [DOI: 10.1002/acr.24127] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/10/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Michael Hughes
- University of Manchester, Manchester, Royal Hallamshire Hospital, and Sheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
| | - John D. Pauling
- Royal National Hospital for Rheumatic Diseases and University of Bath Bath UK
| | | | | | | | - Tracy M. Frech
- University of Utah and Salt Lake Veterans Affairs Medical Center Salt Lake City
| | - Ariane L. Herrick
- University of ManchesterSalford Royal NHS Foundation Trust, and Manchester Academic Health Science Centre Manchester UK
| | | | | | - Lorraine McKenzie
- Patient representative (contact via Dr. Herrick, University of Manchester, Manchester, UK)
| | - Lesley Ann Saketkoo
- Tulane University School of MedicineNew Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, and University Medical Center Comprehensive Pulmonary Hypertension Center New Orleans Louisiana
| | - Rachael Gooberman‐Hill
- Bristol Medical School, NIHR Bristol Biomedical Research Centre, and University Hospitals Bristol NHS Foundation Trust Bristol UK
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Abstract
Raynaud phenomenon is a symptom complex caused by impaired digital perfusion and can occur as a primary phenomenon or secondary to a wide range of underlying causes. Raynaud phenomenon occurs in virtually all patients with systemic sclerosis (SSc) and is often the earliest clinical manifestation to occur. Careful assessment is required in patients with Raynaud phenomenon to avoid missing secondary causes such as SSc. Digital ulcers are a painful and disabling visible manifestation of digital vascular injury in patients with SSc. Progress has been made in the classification and assessment of digital ulcers and in understanding ulcer pathogenesis, and there are a wide range of treatments available to both prevent and heal digital ulcers, some of which are also used in Raynaud phenomenon management. In this Review, the assessment of patients with Raynaud phenomenon is discussed, including 'red flags' that are suggestive of SSc. The pathogenesis, classification and assessment of SSc-associated digital ulcers are also covered, alongside an overview of management approaches for SSc-associated Raynaud phenomenon and digital ulcers. Finally, unmet needs are discussed and the concept of a unified vascular phenotype in which therapies that affect the vasculature to support disease modification strategies is introduced.
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Ngcozana T, Ong VH, Denton CP. Improving access to digital ulcer care through nurse-led clinic: a service evaluation. Musculoskeletal Care 2020; 18:92-97. [PMID: 31961999 DOI: 10.1002/msc.1433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Digital ulcers (DU) remain one of the most burdensome co-morbidities in systemic sclerosis. The objectives of the study were to describe patient-level stratification and to evaluate a nurse-led DU clinic service development. METHODS A nurse-led digital ulcer clinic was established to identify patients with DU and manage them. Patients were recruited through scleroderma clinics, GP referrals, and self-referrals. The clinic involved patients being treated with appropriate treatment. Patients were stratified according to their DU risk level based on number and severity of ulcers. Among these, 22 patients were asked to complete a patient satisfaction survey. Data were analyzed descriptively. RESULTS Seventy-five patients were seen in the clinic, 46 (61%) were 56 years of age and above. Patients were identified as high (23%), medium (51%) or low risk (26%) for development of DU. The duration of DU history was from 7 months to 40 years. Prior to attending the nurse-led DU clinic, 90% of patients had received up to six courses of antibiotics for their DU, 76% had attended A&E, and 90% had unscheduled appointments. 90% had been seen by the GP due to DU and subsequently required hospital admissions. During the nurse-led clinic follow-up, only two patients had emergency admission. All patients reported that their needs in personal care of DU were met. CONCLUSION There are a significant number of people with SSc who have DUs affecting their quality of life as well as needing more healthcare services. A dedicated specialist nurse-led DU clinic may improve overall care of patients.
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Affiliation(s)
- Tanaka Ngcozana
- Rheumatology Department, Royal Free NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Voon H Ong
- Rheumatology Department, Royal Free NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Christopher P Denton
- Rheumatology Department, Royal Free NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
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12
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Exploring the feasibility of an exercise programme including aerobic and resistance training in people with limited cutaneous systemic sclerosis. Clin Rheumatol 2020; 39:1889-1898. [PMID: 31933034 PMCID: PMC7237402 DOI: 10.1007/s10067-019-04921-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/23/2019] [Accepted: 12/27/2019] [Indexed: 01/05/2023]
Abstract
Objectives It is suggested that exercise can improve the vascular function and quality of life (QoL) in people with systemic sclerosis (SSc), potentially offering clinical benefits to this population. Yet the feasibility of such an intervention remains untested. Therefore, the purpose of this study is to examine the feasibility of a combined exercise protocol (aerobic and resistance training) in people with limited cutaneous SSc (lcSSc). Methods Thirty-two lcSSc patients (66.5 ± 12 years old) were randomly allocated in two groups (exercise and control group). The exercise group underwent a 12-week exercise programme, twice per week. All patients performed the baseline, three- and six-month follow-up measurements where functional ability, body composition and QoL were assessed. Participants’ experiences were explored through interviews. Results Compliance was 92.6% with no dropouts. The individuals’ confidence to participate in the study’s exercise protocol for twice per week was 95%. The average value for the physical activity enjoyment scale was 103 ± 10 out of 119 (highest score). The mean values for the intention to engage in exercise twice per week were 6.4 ± 1 (likely) out of 7 (very likely). QoL for the exercise group showed to have a better life satisfaction, less anxiety and Raynaud’s phenomenon-accompanied pain. Conclusions Our results suggest that a combined exercise protocol was feasible for people with lcSSc, with no adverse events, resulting in high adherence and low attrition rates, high enjoyment levels and intentions for future engagement to this exercise. Thus, the specific protocol is a safe adjunct therapy for people with lcSSc. Trial registration:ClinicalTrials.gov (NCT number): NCT03058887, February 23, 2017, https://clinicaltrials.gov/ct2/show/NCT03058887?term=NCT03058887&rank=1Key Points • High-intensity interval training in combination with resistance training constitutes a feasible exercise protocol for people with lcSSc. • Overall, the exercise programme demonstrated high adherence and enjoyment levels and low attrition rates. • The exercise protocol was proved to be safe with no adverse events for people with lcSSc. |
Electronic supplementary material The online version of this article (10.1007/s10067-019-04921-7) contains supplementary material, which is available to authorized users.
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13
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Mouthon L, Poiraudeau S, Vernon M, Papadakis K, Perchenet L, Khanna D. Psychometric validation of the Hand Disability in Systemic Sclerosis-Digital Ulcers (HDISS-DU®) patient-reported outcome instrument. Arthritis Res Ther 2020; 22:3. [PMID: 31907061 PMCID: PMC6945532 DOI: 10.1186/s13075-019-2087-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/09/2019] [Indexed: 01/11/2023] Open
Abstract
Background We aimed to develop a patient-reported outcome measure, in accordance with the US Food and Drug Administration guidance, to capture the impact of systemic sclerosis-related digital ulcers (SSc-DUs) on hand function. Psychometric analyses were conducted to evaluate and document the measurement properties of the resulting instrument—the Hand Disability in Systemic Sclerosis-Digital Ulcers (HDISS-DU®). Methods The HDISS-DU was developed through a series of confirmatory, qualitative concept-elicitation interviews (N = 36) to provide supportive evidence that the instrument captures all relevant issues and functional limitations relating to SSc-DUs in this patient population. Psychometric analyses used blinded data from two randomised, controlled, phase 3 trials in patients with SSc-DUs (N = 517). The analyses included assessment of reliability, construct validity, responsiveness and thresholds for meaningful change. Results Qualitative interviews confirmed that the HDISS-DU had good content coverage and patients understood the HDISS-DU instructions, items and response scale. The HDISS-DU demonstrated excellent internal consistency and test-retest reliability, with satisfactory construct validity. Overall, the HDISS-DU was highly responsive to change in digital ulcer severity: the no-change group (for other criterion measures) had mean differences and effect sizes close to 0, while mean differences were mostly negative (indicating improvement) for the improvement groups (for other criterion measures) and vice versa. The preliminary threshold for meaningful change was a 0.50 difference in HDISS-DU score. Conclusions Using data from two large studies of SSc-DU patients, these psychometric analyses support the reliability, validity, discriminating ability and responsiveness to change of the HDISS-DU for evaluating treatment outcomes in future clinical studies and clinical practice.
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Affiliation(s)
- Luc Mouthon
- Department of Internal Medicine, Reference Center for Rare Systemic Autoimmune Diseases of Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Serge Poiraudeau
- Department of Rehabilitation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | | | | | | | - Dinesh Khanna
- Department of Internal Medicine, University of Michigan Scleroderma Program, Suite 7C27, 300 North Ingalls Street, Ann Arbor, MI, USA.
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14
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Exploring the patient experience of digital ulcers in systemic sclerosis. Semin Arthritis Rheum 2019; 48:888-894. [DOI: 10.1016/j.semarthrit.2018.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/23/2018] [Accepted: 08/07/2018] [Indexed: 12/11/2022]
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15
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Horimoto AMC, de Souza AS, Rodrigues SH, Kayser C. Risk of digital ulcers occurrence in systemic sclerosis: a cross-sectional study. Adv Rheumatol 2019; 59:14. [DOI: 10.1186/s42358-019-0057-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/14/2019] [Indexed: 11/10/2022] Open
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16
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Hughes M, Moore T, Manning J, Wilkinson J, Watson S, Samraj P, Dinsdale G, Roberts C, Rhodes LE, Herrick AL, Murray A. A feasibility study of a novel low-level light therapy for digital ulcers in systemic sclerosis. J DERMATOL TREAT 2018; 30:251-257. [PMID: 29862855 PMCID: PMC6484448 DOI: 10.1080/09546634.2018.1484875] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Locally acting, well-tolerated treatments for systemic sclerosis (SSc) digital ulcers (DUs) are needed. Objectives: Our primary aim was to investigate the safety, feasibility, and tolerability of a novel low-level light therapy (LTTT). A secondary aim was to tentatively assess efficacy. Methods: A custom-built device comprising infrared (850 nm), red (660 nm), and violet (405 nm) LEDs was utilized. DUs were irradiated with 10 J/cm2 twice weekly for 3 weeks, with follow-up at weeks 4 and 8. Any safety concerns were documented. Patient opinion on time to deliver, feasibility, and pain visual analogue score (VAS; 0–100, 100 most severe) was collected. Patient and clinician DU global assessment VAS were documented. DUs were evaluated by laser Doppler perfusion imaging pre- and post-irradiation. Results: In all, 14 DUs in eight patients received a total of 46 light exposures, with no safety concerns. All patients considered LTTT ‘took just the right amount of time’ and was ‘feasible’, with a low associated mean pain VAS of 1.6 (SD: 5.2). Patient and clinician global DC VAS improved during the study (mean change: –7.1 and –5.2, respectively, both p < .001). DU perfusion significantly increased post-irradiation. Conclusions: LTTT for DUs is safe, feasible, and well tolerated. There was an early tentative suggestion of treatment efficacy.
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Affiliation(s)
- M Hughes
- a Centre for Musculoskeletal Research , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK
| | - T Moore
- b Department of Rheumatology , Salford Royal NHS Foundation Trust , Salford , UK
| | - J Manning
- b Department of Rheumatology , Salford Royal NHS Foundation Trust , Salford , UK
| | - J Wilkinson
- c Research and Development , Salford Royal NHS Foundation Trust , Salford , UK
| | - S Watson
- d Medical Physics Department and University of Manchester , Manchester Academic Health Science Centre , Salford Royal NHS Foundation Trust , UK
| | - P Samraj
- e Medical Physics Department , Salford Royal NHS Foundation Trust , UK
| | - G Dinsdale
- a Centre for Musculoskeletal Research , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK
| | - C Roberts
- f Centre for Biostatistics , Institute of Population Health, School of Medicine, The University of Manchester , Manchester , UK
| | - L E Rhodes
- g Photobiology Unit, Dermatology Centre, Division of Musculoskeletal and Dermatological Sciences , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK
| | - A L Herrick
- a Centre for Musculoskeletal Research , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK.,h NIHR Manchester Musculoskeletal Biomedical Research Centre , Central Manchester NHS Foundation Trust , Manchester Academic Health Science Centre , UK
| | - A Murray
- a Centre for Musculoskeletal Research , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK.,i Photon Science Institute , The University of Manchester , UK
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17
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Hughes M, Murray A, Denton CP, Herrick AL. Should all digital ulcers be included in future clinical trials of systemic sclerosis-related digital vasculopathy? Med Hypotheses 2018; 116:101-104. [PMID: 29857890 DOI: 10.1016/j.mehy.2018.04.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/25/2018] [Accepted: 04/30/2018] [Indexed: 11/24/2022]
Abstract
Digital ulcers (DU) are a common manifestation of systemic sclerosis (SSc) and occur at a variety of locations including the fingertips and over the extensor aspects of the hands. However, most recent clinical trials have included only fingertip DUs as these are believed to be ischaemic in aetiology, and therefore likely to benefit from treatment with vasoactive drug therapies. There is an emerging evidence base to suggest that all DUs in SSc could share an ischaemic component which is potentially responsive to vascular therapy. Our hypothesis is that is that DUs occurring at sites other than the fingertips, in particular, those overlying the extensor aspect of the hands, may also have a potentially reversible ischaemic component. We review the evidence under the headings: 'microvascular imaging', 'structural microvascular' and, 'functional vascular disease', 'macrovascular involvement' and 'vascular associates'. Based upon the current evidence, we would encourage the expert SSc community to reconsider the rationale for including only fingertip DUs in future SSc clinical trials, and suggest an agenda for future research.
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Affiliation(s)
- Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Andrea Murray
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; Photon Science Institute, The University of Manchester, UK
| | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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18
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Wilkinson JD, Leggett SA, Marjanovic EJ, Moore TL, Allen J, Anderson ME, Britton J, Buch MH, Del Galdo F, Denton CP, Dinsdale G, Griffiths B, Hall F, Howell K, MacDonald A, McHugh NJ, Manning JB, Pauling JD, Roberts C, Shipley JA, Herrick AL, Murray AK. A Multicenter Study of the Validity and Reliability of Responses to Hand Cold Challenge as Measured by Laser Speckle Contrast Imaging and Thermography: Outcome Measures for Systemic Sclerosis-Related Raynaud's Phenomenon. Arthritis Rheumatol 2018; 70:903-911. [PMID: 29457381 PMCID: PMC6001804 DOI: 10.1002/art.40457] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 02/13/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Reliable and objective outcome measures to facilitate clinical trials of novel treatments for systemic sclerosis (SSc)-related Raynaud's phenomenon (RP) are badly needed. Laser speckle contrast imaging (LSCI) and thermography are noninvasive measures of perfusion that have shown excellent potential. This multicenter study was undertaken to determine the reliability and validity of a hand cold challenge protocol using LSCI, standard thermography, and low-cost cell phone/mobile phone thermography (henceforth referred to as mobile thermography) in patients with SSc-related RP. METHODS Patients with RP secondary to SSc were recruited from 6 UK tertiary care centers. The patients underwent cold challenge on 2 consecutive days. Changes in cutaneous blood flow/skin temperature at each visit were imaged simultaneously using LSCI, standard thermography, and mobile thermography. Measurements included area under the curve (AUC) for reperfusion/rewarming and maximum blood flow rate/skin temperature after rewarming (MAX). Test-retest reliability was assessed using intraclass correlation coefficients (ICCs). Estimated latent correlations (estimated from multilevel models, taking values between -1 and 1; denoted as rho values) were used to assess the convergent validity of LSCI and thermography. RESULTS In total, 159 patients (77% with limited cutaneous SSc) were recruited (84% female, median age 63.3 years). LSCI and standard thermography both had substantial reliability, with ICCs for the reperfusion/rewarming AUC of 0.67 (95% confidence interval [95% CI] 0.54, 0.76) and 0.68 (95% CI 0.58, 0.80), respectively, and ICCs for the MAX of 0.64 (95% CI 0.52, 0.75) and 0.72 (95% CI 0.64, 0.81), respectively. Very high latent correlations were present for the AUCs of LSCI and thermography (ρ = 0.94; 95% CI 0.87, 1.00) and for the AUCs of standard and mobile thermography (ρ = 0.98; 95% CI 0.94, 1.00). CONCLUSION This is the first multicenter study to examine the reliability and validity of cold challenge using LSCI and thermography in patients with SSc-related RP. LSCI and thermography both demonstrated good potential as outcome measures. LSCI, standard thermography, and mobile thermography had very high convergent validity.
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Affiliation(s)
- Jack D Wilkinson
- University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah A Leggett
- University of Manchester, Manchester, UK, and Salford Royal Foundation, NHS Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Elizabeth J Marjanovic
- University of Manchester, Manchester, UK, and Salford Royal Foundation, NHS Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Tonia L Moore
- University of Manchester, Manchester, UK, and Salford Royal Foundation, NHS Trust, Manchester Academic Health Science Centre, Salford, UK
| | - John Allen
- Freeman Hospital and Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Maya H Buch
- NIHR Leeds Musculoskeletal Biomedical Research Unit and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, UK
| | - Francesco Del Galdo
- NIHR Leeds Musculoskeletal Biomedical Research Unit and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, UK
| | | | - Graham Dinsdale
- University of Manchester, Manchester, UK, and Salford Royal Foundation, NHS Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Bridgett Griffiths
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Frances Hall
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kevin Howell
- University College London Medical School, London, UK
| | - Audrey MacDonald
- Freeman Hospital and Newcastle University, Newcastle upon Tyne, UK
| | - Neil J McHugh
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UK
| | - Joanne B Manning
- University of Manchester, Manchester, UK, and Salford Royal Foundation, NHS Trust, Manchester Academic Health Science Centre, Salford, UK
| | - John D Pauling
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust and University of Bath, Bath, UK
| | - Christopher Roberts
- University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jacqueline A Shipley
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UK
| | - Ariane L Herrick
- University of Manchester and NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Salford Royal Foundation, NHS Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Andrea K Murray
- University of Manchester, Manchester, UK, and Salford Royal Foundation, NHS Trust, Manchester Academic Health Science Centre, Salford, UK
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19
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Pearson DR, Werth VP, Pappas-Taffer L. Systemic sclerosis: Current concepts of skin and systemic manifestations. Clin Dermatol 2018; 36:459-474. [PMID: 30047430 DOI: 10.1016/j.clindermatol.2018.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Systemic sclerosis is an uncommon autoimmune connective tissue disease with multiorgan system involvement and significant associated morbidity and mortality. Cutaneous signs and clinical manifestations are of particular importance, as they may be recognized before systemic manifestations, allowing earlier risk stratification into the limited and diffuse cutaneous subtypes, as well as earlier initiation of treatment. Important cutaneous manifestations include Raynaud's phenomenon, digital ulcers, cutaneous sclerosis, calcinosis cutis, telangiectasias, pruritus, and dyspigmentation. Despite investigation of a wide variety of treatments, no FDA-approved pharmacologic therapies exist for systemic sclerosis, and data from high-quality studies are limited. In the following review, we will discuss skin-directed therapies. Although there is evidence to support specific treatments for Raynaud's phenomenon, digital ulcers, and cutaneous sclerosis, there are limited rigorous studies evaluating the treatment of other cutaneous signs and clinical manifestations. Additional randomized-controlled trials and large observational studies are necessary to develop future evidence-based treatment options.
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Affiliation(s)
- David R Pearson
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa Pappas-Taffer
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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20
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Rodríguez-Franco K, Miranda-Díaz AJ, Hoyos-Restrepo JD, Meléndez GL. Systemic scleroderma: An approach from plastic surgery. REVISTA DE LA FACULTAD DE MEDICINA 2018. [DOI: 10.15446/revfacmed.v66n2.58618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introducción. La esclerosis sistémica (ES) es una enfermedad autoinmune del tejido conectivo que se caracteriza clínicamente por un engrosamiento cutáneo, el cual se da debido a la acumulación de tejido conectivo y puede afectar a otros órganos y a las extremidades. La etiología multifactorial de esta enfermedad corresponde a la interacción de alteraciones en el remodelamiento de la matriz extracelular, función inmunitaria y presencia de vasculopatía proliferativa bajo influencia genética y medioambiental.Objetivo. Realizar una revisión sobre el manejo médico y quirúrgico desde el punto de vista de la cirugía plástica de las lesiones en piel y manos y las alteraciones faciales de los pacientes con ES.Materiales y métodos. Se realizó una búsqueda bibliográfica en las bases de datos Medline, LILACS, PubMed, EMBASE y Current contents con las palabras claves esclerodermia sistémica, cirugía plástica, mano y ulceras.Resultados. La ES requiere manejo multidisciplinario; se presentan casos en los que se indica terapia farmacológica y otros en los que el manejo es quirúrgico complementario.Conclusión. Esta patología afecta de manera importante la piel al provocar lesiones que van desde ulceras digitales hasta atrofia facial, las cuales son susceptibles de manejo por el área de cirugía plástica.
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21
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Simpson V, Hughes M, Wilkinson J, Herrick AL, Dinsdale G. Quantifying Digital Ulcers in Systemic Sclerosis: Reliability of Computer-Assisted Planimetry in Measuring Lesion Size. Arthritis Care Res (Hoboken) 2018; 70:486-490. [DOI: 10.1002/acr.23300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/01/2017] [Indexed: 11/06/2022]
Affiliation(s)
| | - M. Hughes
- University of Manchester; Manchester UK
| | | | - A. L. Herrick
- University of Manchester and Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
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22
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Wangkaew S, Sivasomboon C, Leungwatthananon W, Kasitanon N, Louthrenoo W. Prevalence and predictors of hand involvement in Thai patients with systemic sclerosis. Int J Rheum Dis 2018; 21:240-248. [PMID: 27456855 DOI: 10.1111/1756-185x.12919] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM Data regarding the clinical and radiographic hand involvement in Asian patients with systemic sclerosis (SSc) are limited. Thus, we determined the prevalence of clinical and radiographic hand involvement in Thai SSc patients, comparing diffuse cutaneous SSc (dcSSc) and limited cutaneous SSc (lcSSc). We also determined the factors associated with arthritis, contracture of fingers and digital ulcers. METHOD SSc patients seen at the Rheumatology Clinic, Chiang Mai University, Thailand, from December 2012 to June 2013 were consecutively invited to enroll in the study. After study entry, demographic data, clinical features and hand radiographs were evaluated. RESULT We studied 110 SSc patients (73 dcSSc) with mean ± SD age of 53.2 ± 9.2 years and disease duration from non-Raynaud's phenomenon of 4.9 ± 4.8 years. The prevalence of arthritis, finger contractures and digital ulcers were 10 (9.1%), 47 (42.7%), and 14 (12.7%), respectively. DcSSc patients had significantly more of the following hand complications than lcSSc patients: digital pitting scar (53.4% vs. 27.0%, P = 0.008), digital ulcer (17.8% vs. 2.7%, P = 0.032), traumatic ulcer (27.4% vs. 0%, P < 0.001), acrolysis (45.2% vs. 18.9%, P = 0.007) and flexion contracture (60.3% vs. 8.1%, P < 0.001). Radiographic finger contractures were more prevalent in the dcSSc subset. In multivariate logistic regression analysis, a positive rheumatoid factor was associated with arthritis; dcSSc, arthritis and modified Rodnan skin score (MRSS) > 18 were associated with contracture of fingers. Furthermore, hand MRSS > 4 was associated with digital ulcers. CONCLUSION Our results confirm that dcSSc patients had more severe clinical hand complications than lcSSc. However, radiographic findings were similar among subgroups, except that more finger contractures were seen in dcSSc. Finally, the presence of rheumatoid factor is associated with arthritis, and high MRSS is associated with finger contractures and digital ulcers.
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Affiliation(s)
- Suparaporn Wangkaew
- Division of Rheumatology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chate Sivasomboon
- Division of Diagnostic Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Wit Leungwatthananon
- Division of Rheumatology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nuntana Kasitanon
- Division of Rheumatology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Worawit Louthrenoo
- Division of Rheumatology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Knobler R, Moinzadeh P, Hunzelmann N, Kreuter A, Cozzio A, Mouthon L, Cutolo M, Rongioletti F, Denton CP, Rudnicka L, Frasin LA, Smith V, Gabrielli A, Aberer E, Bagot M, Bali G, Bouaziz J, Braae Olesen A, Foeldvari I, Frances C, Jalili A, Just U, Kähäri V, Kárpáti S, Kofoed K, Krasowska D, Olszewska M, Orteu C, Panelius J, Parodi A, Petit A, Quaglino P, Ranki A, Sanchez Schmidt JM, Seneschal J, Skrok A, Sticherling M, Sunderkötter C, Taieb A, Tanew A, Wolf P, Worm M, Wutte NJ, Krieg T. European Dermatology Forum S1-guideline on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: localized scleroderma, systemic sclerosis and overlap syndromes. J Eur Acad Dermatol Venereol 2017; 31:1401-1424. [PMID: 28792092 DOI: 10.1111/jdv.14458] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 06/26/2017] [Indexed: 12/13/2022]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present guideline focuses on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, current strategies in the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this guideline provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes of systemic sclerosis with diseases of the rheumatological spectrum.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Moinzadeh
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - A Cozzio
- Department of Dermatology, Venereology and Allergology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - L Mouthon
- Service de Médecine Interne, Centre de référence maladies rares: vascularites et sclérodermie systémique, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - M Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - F Rongioletti
- Dermatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - C P Denton
- Division of Medicine, Centre for Rheumatology, University College London, London, UK
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L A Frasin
- Dermatology Unit, Hospital of Lecco, Lecco, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - A Gabrielli
- Department of Clinical and Molecular Science, Università Politecnica delle Marche, Ancona, Italy
| | - E Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - G Bali
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - J Bouaziz
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - A Braae Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - I Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - C Frances
- Department of Dermatology and Allergology, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - A Jalili
- Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - U Just
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - V Kähäri
- Department of Dermatology and Venereology, Turku University Hospital and University of Turku, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- Department of Dermato-Allergology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - D Krasowska
- Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Lublin, Poland
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - C Orteu
- Department of Dermatology, Connective Tissue Diseases Service, Royal Free Hospital, London, UK
| | - J Panelius
- Department of Dermatology, Allergology and Venereology, University of Helsinki, and Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - A Parodi
- Department of Dermatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - A Petit
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - P Quaglino
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - A Ranki
- Department of Dermatology, Allergology and Venereology, Inflammation Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J M Sanchez Schmidt
- Department of Dermatology, Hospital del Mar-Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - M Sticherling
- Department of Dermatology, University Hospital of Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Taieb
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Tanew
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Wolf
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Worm
- Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - N J Wutte
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - T Krieg
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
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Cutolo M, Herrick AL, Distler O, Becker MO, Beltran E, Carpentier P, Ferri C, Inanç M, Vlachoyiannopoulos P, Chadha-Boreham H, Cottreel E, Pfister T, Rosenberg D, Torres JV, Smith V. Nailfold Videocapillaroscopic Features and Other Clinical Risk Factors for Digital Ulcers in Systemic Sclerosis: A Multicenter, Prospective Cohort Study. Arthritis Rheumatol 2017; 68:2527-39. [PMID: 27111549 PMCID: PMC5129545 DOI: 10.1002/art.39718] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 04/07/2016] [Indexed: 12/22/2022]
Abstract
Objective To identify nailfold videocapillaroscopic features and other clinical risk factors for new digital ulcers (DUs) during a 6‐month period in patients with systemic sclerosis (SSc). Methods In this multicenter, prospective, observational cohort study, the videoCAPillaroscopy (CAP) study, we evaluated 623 patients with SSc from 59 centers (14 countries). Patients were stratified into 2 groups: a DU history group and a no DU history group. At enrollment, patients underwent detailed nailfold videocapillaroscopic evaluation and assessment of demographic characteristics, DU status, and clinical and SSc characteristics. Risk factors for developing new DUs were assessed using univariable and multivariable logistic regression (MLR) analyses. Results Of the 468 patients in the DU history group (mean ± SD age 54.0 ± 13.7 years), 79.5% were female, 59.8% had limited cutaneous SSc, and 22% developed a new DU during follow‐up. The strongest risk factors for new DUs identified by MLR in the DU history group included the mean number of capillaries per millimeter in the middle finger of the dominant hand, the number of DUs (categorized as 0, 1, 2, or ≥3), and the presence of critical digital ischemia. The receiver operating characteristic (ROC) of the area under the curve (AUC) of the final MLR model was 0.738 (95% confidence interval [95% CI] 0.681–0.795). Internal validation through bootstrap generated a ROC AUC of 0.633 (95% CI 0.510–0.756). Conclusion This international prospective study, which included detailed nailfold videocapillaroscopic evaluation and extensive clinical characterization of patients with SSc, identified the mean number of capillaries per millimeter in the middle finger of the dominant hand, the number of DUs at enrollment, and the presence of critical digital ischemia at enrollment as risk factors for the development of new DUs.
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Affiliation(s)
- Maurizio Cutolo
- University of Genoa and IRCCS Azienda Ospedaliera Universitaria San Martino, Genoa, Italy.
| | - Ariane L Herrick
- University of Manchester, Salford Royal NHS Foundation Trust, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust and Manchester Academic Health Science Centre, Manchester, UK
| | | | - Mike O Becker
- University Hospital, Zurich, Switzerland, and Charité University Hospital, Berlin, Germany
| | - Emma Beltran
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | | | | | | | | | | | | | | | - Vanessa Smith
- Ghent University Hospital and Ghent University, Ghent, Belgium.
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Silva I, Teixeira A, Oliveira J, Almeida R, Vasconcelos C. Endothelial dysfunction, microvascular damage and ischemic peripheral vasculopathy in systemic sclerosis. Clin Hemorheol Microcirc 2017; 66:117-130. [DOI: 10.3233/ch-150044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Ivone Silva
- Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Multidisciplinar Unit of Biomedical Investigation, Porto, Portugal
| | - Andreia Teixeira
- Department of Health Information and Decision Sciences, Universidade do Porto, CINTESIS - Centre for Research in Health Technologies and Information Systems, Porto, Portugal
| | - José Oliveira
- Department of Clinical Pathology, Clinical Chemistry, Centro Hospitalar do Porto, Porto, Portugal
| | - Rui Almeida
- Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Multidisciplinar Unit of Biomedical Investigation, Porto, Portugal
| | - Carlos Vasconcelos
- Clinical Immunology Unit, Centro Hospitalar do Porto (CHP), Instituto de Ciências Biomédicas Abel Salazar, University of Porto (ICBAS/UP), Multidisciplinar Unit of biomedical investigation (UMIB), Porto, Portugal
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26
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Mouthon L, Carpentier PH, Lok C, Clerson P, Gressin V, Hachulla E, Bérezné A, Diot E, Van Kien AK, Jego P, Agard C, Duval-Modeste AB, Sparsa A, Puzenat E, Richard MA. Controlling the digital ulcerative disease in systemic sclerosis is associated with improved hand function. Semin Arthritis Rheum 2017; 46:759-766. [DOI: 10.1016/j.semarthrit.2017.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 12/20/2016] [Accepted: 01/09/2017] [Indexed: 11/25/2022]
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27
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Souza EJR, Muller CS, Horimoto AMC, Rezende RA, Guimarães I, Mariz HA, Dantas AT, Da Costa IP, Del-Rio APT, Sekiyama J, Kahwage CB, Kayser C. Geographic variation as a risk factor for digital ulcers in systemic sclerosis patients: a multicentre registry. Scand J Rheumatol 2016; 46:288-295. [DOI: 10.1080/03009742.2016.1233994] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- EJR Souza
- Internal Medicine Service, Santa Casa Hospital, Belo Horizonte, Brazil
| | - CS Muller
- Rheumatology Division, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil
| | - AMC Horimoto
- Rheumatology Division, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | - RA Rezende
- Internal Medicine Service, Santa Casa Hospital, Belo Horizonte, Brazil
| | - I Guimarães
- Rheumatology Division, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil
| | - HA Mariz
- Clinics Hospital, Federal University of Pernambuco, Recife, Brazil
| | - AT Dantas
- Clinics Hospital, Federal University of Pernambuco, Recife, Brazil
| | - IP Da Costa
- Rheumatology Division, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | - APT Del-Rio
- School of Medical Sciences, State University of Campinas, Campinas, Brazil
| | - J Sekiyama
- School of Medical Sciences, State University of Campinas, Campinas, Brazil
| | - CB Kahwage
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - C Kayser
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
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Sandqvist G, Wuttge DM, Hesselstrand R. The Modified Hand Mobility in Scleroderma Test and Skin Involvement — A Followup Study. J Rheumatol 2016; 43:1356-62. [DOI: 10.3899/jrheum.151142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2016] [Indexed: 11/22/2022]
Abstract
Objective.To study the change in the modified Hand Mobility in Scleroderma (mHAMIS) test from early to advanced stages of systemic sclerosis (SSc), and the relationship between mHAMIS and skin involvement during followup.Methods.This retrospective study includes 65 patients with baseline disease duration of ≤ 3 years who were assessed with the mHAMIS test at baseline and at 1 or 2 predefined followup points (3.1–5 yrs and 5.1–9 yrs after disease onset). Studied measures were the modified Rodnan skin score (mRSS), mRSS of the hand, serum cartilage oligomeric matrix protein, and digital vascular lesions.Results.The mHAMIS and the mRSS hand changed synchronously during the first 5 years after disease onset (rs = 0.44, p = 0.001). In the group with high mHAMIS at baseline, both mHAMIS and mRSS hand improved significantly at the first followup (p < 0.05), and the improvement sustained during the followup in the mRSS hand. Patients with antitopoisomerase I and anti-RNA polymerase III antibodies had significantly higher mHAMIS at baseline (p = 0.003) and at the second followup (p = 0.030) compared to patients with anticentromere antibodies. Patients with digital vascular lesions at baseline had significantly higher mHAMIS during the followup (p < 0.05) compared to patients without. The mHAMIS improved significantly during the followup in patients with immunosuppressive treatment in early disease (p < 0.05), but not in patients without this treatment.Conclusion.The mHAMIS reflects disease activity in fibrosis in early stages of SSc. In later stages it can be regarded as a measure of damage arising from fibrotic and vascular involvement, making it suitable as an endpoint in followup examinations
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29
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Hughes M, Herrick AL. Digital ulcers in systemic sclerosis. Rheumatology (Oxford) 2016; 56:14-25. [PMID: 27094599 DOI: 10.1093/rheumatology/kew047] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/15/2016] [Indexed: 11/14/2022] Open
Abstract
Digital ulcers (DUs) are a common visible manifestation of the progressive vascular disease that characterizes the SSc disease process. DUs not only impact significantly on patients' quality of life and hand function, but are also a biomarker of internal organ involvement and of disease severity. The aetiology of (digital) vascular disease in SSc is multifactorial, and many of these factors are potentially amenable to therapeutic intervention. The management of DU disease in SSc is multifaceted. Patient education and non-pharmacological interventions (e.g. smoking cessation) should not be neglected. There are a number of drug therapies available to prevent (e.g. phosphodiesterase type-5 inhibitors and ET receptor-1 antagonists) and treat (e.g. i.v. iloprost) DUs. DUs are also important for two other reasons: firstly, as a primary end point in SSc-related clinical trials; and secondly, DUs are included in the ACR/EULAR SSc classification criteria. However, the reliability of rheumatologists to grade DUs is poor to moderate at best, and this poses challenges in both clinical practice and research. The purpose of this review is to provide the reader with a description of the spectrum of DU disease in SSc including pathophysiology, epidemiology and clinical burden, all of which inform the multifaceted approach to management.
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Affiliation(s)
- Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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30
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Hunzelmann N, Riemekasten G, Becker M, Moinzadeh P, Kreuter A, Melchers I, Mueller‐Ladner U, Meier F, Worm M, Lee H, Herrgott I, Pfeiffer C, Fierlbeck G, Henes J, Juche A, Zeidler G, Mensing H, Günther C, Sárdy M, Burkhardt H, Koehm M, Kuhr K, Krieg T, Sunderkötter C. The Predict Study: low risk for digital ulcer development in patients with systemic sclerosis with increasing disease duration and lack of topoisomerase‐1 antibodies. Br J Dermatol 2016; 174:1384-7. [DOI: 10.1111/bjd.14367] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- N. Hunzelmann
- Department of Dermatology and Venereology University Hospital of Cologne Kerpener Straße 62 Köln 50937 Germany
| | - G. Riemekasten
- Department of Rheumatology and Clinical Immunology University of Berlin, Charité Berlin Germany
| | - M.O. Becker
- Department of Rheumatology and Clinical Immunology University of Berlin, Charité Berlin Germany
| | - P. Moinzadeh
- Department of Dermatology and Venereology University Hospital of Cologne Kerpener Straße 62 Köln 50937 Germany
| | - A. Kreuter
- Helios St Elisabeth Clinic Dermatology and Venereology Oberhausen Germany
| | - I. Melchers
- University Medical Center Freiburg Clinical Research Unit for Rheumatology Freiburg Germany
| | - U. Mueller‐Ladner
- Justus Liebig University Giessen Kerckhoff Clinic Rheumatology and Clinical Immunology Bad Nauheim Germany
| | - F. Meier
- Justus Liebig University Giessen Kerckhoff Clinic Rheumatology and Clinical Immunology Bad Nauheim Germany
| | - M. Worm
- Department of Dermatology and Venereology University of Berlin, Charité Berlin Germany
| | - H. Lee
- Department of Dermatology and Venereology University of Berlin, Charité Berlin Germany
| | - I. Herrgott
- Department of Dermatology and Department of Translational Dermatoinfectiology University of Muenster Muenster Germany
| | - C. Pfeiffer
- University Hospital Ulm Dermatology Ulm Germany
| | - G. Fierlbeck
- Department of Dermatology University of Tübingen Tübingen Germany
| | - J. Henes
- Department of Rheumatology University of Tübingen Tübingen Germany
| | - A. Juche
- Johanniter Hospital Treuenbrietzen Rheumatology Treuenbrietzen Germany
| | - G. Zeidler
- Johanniter Hospital Treuenbrietzen Rheumatology Treuenbrietzen Germany
| | - H. Mensing
- Hamburg Alstertal Clinic for Dermatology Hamburg Germany
| | - C. Günther
- University Hospital Carl Gustav Carus Dermatology Dresden Germany
| | - M. Sárdy
- Ludwig Maximilian University Dermatology and Allergology Munich Germany
| | - H. Burkhardt
- Goethe‐University Frankfurt & Clinical Research Fraunhofer IME Translational Medicine and Pharmacology (TMP), RheumatologyFrankfurt/Main Germany
| | - M. Koehm
- Goethe‐University Frankfurt & Clinical Research Fraunhofer IME Translational Medicine and Pharmacology (TMP), RheumatologyFrankfurt/Main Germany
| | - K. Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology University Hospital of Cologne Kerpener Straße 62 50937 Köln Germany
| | - T. Krieg
- Department of Dermatology and Venereology University Hospital of Cologne Kerpener Straße 62 Köln 50937 Germany
| | - C. Sunderkötter
- Department of Dermatology and Department of Translational Dermatoinfectiology University of Muenster Muenster Germany
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Ughi N, Crotti C, Ingegnoli F. Effectiveness and safety of oxycodone/naloxone in the management of chronic pain in patients with systemic sclerosis with recurrent digital ulcers: two case reports. Clin Interv Aging 2016; 11:307-11. [PMID: 27042030 PMCID: PMC4798196 DOI: 10.2147/cia.s102577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Digital ulcers (DUs) are a severe and frequent clinical feature of patients with systemic sclerosis (SSc). The presence of DUs may cause severe pain and often lead to impairment of patient’s functional activities and health-related quality of life. Moreover, poor patient cooperation during the wound care procedure due to pain may be associated with a negative outcome of DU healing. Therefore, pain management has a key role in patients with SSc. These two case reports describe the effectiveness and safety of oxycodone/naloxone in patients with SSc complicated by painful chronic DUs. Such a therapy has provided pain relief and consequently an increased compliance during redressing wounds.
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Affiliation(s)
- Nicola Ughi
- Division of Rheumatology, Department of Clinical Sciences and Community Health, Gaetano Pini Institute, The University of Milan, Milan, Italy
| | - Chiara Crotti
- Division of Rheumatology, Department of Clinical Sciences and Community Health, Gaetano Pini Institute, The University of Milan, Milan, Italy
| | - Francesca Ingegnoli
- Division of Rheumatology, Department of Clinical Sciences and Community Health, Gaetano Pini Institute, The University of Milan, Milan, Italy
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32
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Ruaro B, Sulli A, Pizzorni C, Paolino S, Smith V, Cutolo M. Correlations between skin blood perfusion values and nailfold capillaroscopy scores in systemic sclerosis patients. Microvasc Res 2016; 105:119-24. [PMID: 26907637 DOI: 10.1016/j.mvr.2016.02.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/17/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To correlate blood perfusion (BP) values assessed by laser speckle contrast analysis (LASCA) in selected skin areas of hands and face with nailfold capillary damage scores in systemic sclerosis (SSc) patients. METHODS Seventy SSc patients (mean SSc duration 6 ± 5 years) and 70 volunteer healthy subjects were enrolled after informed consent. LASCA was performed at different areas of the face (forehead, tip of nose, zygomas and perioral region) and at dorsal and volar regions of hands. Microvascular damage was assessed and scored by nailfold videocapillaroscopy (NVC) and the microangiopathy evolution score (MES) was calculated. RESULTS SSc patients showed a significantly lower BP than healthy subjects at fingertips, periungual areas and palm of hands (p<0.0001), but not at the level of face and dorsum of hands. A gradual decrease of BP at fingertips, periungual and palm areas, was found in SSc patients with progressive severity of NVC patterns of microangiopathy ("early", "active", or "late") (p<0.01). A negative correlation was observed between MES and BP values, as well as between loss of capillaries and BP, at the same areas (p<0.001 and p<0.01, respectively). Patients with diffuse cutaneous SSc (dcSSc) showed lower BP than those with limited cutaneous SSc (p<0.04). CONCLUSIONS LASCA detects a significant reduction of BP only in those areas usually affected by Raynaud's phenomenon (fingertips, periungual and palm areas), especially in dcSSc patients, and BP values significantly correlate with the nailfold capillaroscopy scores of microangiopathy.
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Affiliation(s)
- B Ruaro
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy
| | - A Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy
| | - C Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy
| | - S Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Ghent University, Belgium
| | - M Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy.
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Cappelli L, Wigley FM. Management of Raynaud Phenomenon and Digital Ulcers in Scleroderma. Rheum Dis Clin North Am 2015. [DOI: 10.1016/j.rdc.2015.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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34
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Hughes M, Ong VH, Anderson ME, Hall F, Moinzadeh P, Griffiths B, Baildam E, Denton CP, Herrick AL. Consensus best practice pathway of the UK Scleroderma Study Group: digital vasculopathy in systemic sclerosis. Rheumatology (Oxford) 2015; 54:2015-24. [DOI: 10.1093/rheumatology/kev201] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Indexed: 01/02/2023] Open
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Camargo CZ, Sekiyama JY, Arismendi MI, Kayser C. Microvascular abnormalities in patients with early systemic sclerosis: less severe morphological changes than in patients with definite disease. Scand J Rheumatol 2014; 44:48-55. [DOI: 10.3109/03009742.2014.926566] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Digital ulcers (DU's) are one of the main symptoms of systemic scleroderma and occur in approximately 60% of all scleroderma patients. Due to possible complications such as infections, gangrene or amputation, they require regular medical attention and a good wound treatment by doctors and nursing staff. A definition of DU's has not yet been established. In 2009 the European League Against Rheumatism (EULAR) published guidelines for the treatment of DU's. An improvement of the healing of active ulcers has been described with Iloprost. Bosentan significantly reduced the frequency of occurrence of new DU's. In some small studies PDE-5 inhibitors appear helpful. Further studies with other therapeutic approaches will follow in the next few years.
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Affiliation(s)
- D Belz
- Klinik und Poliklinik für Dermatologie und Venerologie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland,
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Silva I, Almeida J, Vasconcelos C. A PRISMA-driven systematic review for predictive risk factors of digital ulcers in systemic sclerosis patients. Autoimmun Rev 2014; 14:140-52. [PMID: 25449678 DOI: 10.1016/j.autrev.2014.10.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 10/04/2014] [Indexed: 01/20/2023]
Abstract
Vasculopathy has a major role in the pathogenesis and tissue injury in systemic sclerosis (SSc). Raynaud's phenomenon (RP) is frequently the first clinical manifestation of SSc preceding by years other clinical manifestations. RP in SSc patients is frequent, often very severe and long lasting. The repeated bouts of RP lead to prolonged digital ischemia that may progress to digital ulceration or in extreme to critical digital ischemia with gangrene. Digital ulcers (DU) are a true burden for all patients. They are very painful, with a long and slow healing course, have high risk of infection and are extremely disabling. In adults, up to 40-50% of patients will experience at least one DU in the course of the disease and of these 31-71% will have recurrent ulcers. In order to try to identify predictive risk factors for DU in SSc patients, an extensive literature review was conducted, according to the guidelines proposed at the PRISMA statement. MEDLINE database (PubMed) and Thomson Reuters Web of Knowledge platform were searched for articles published in peer-reviewed journals since 1990 with the last search run on June 2014 and published in English language. The keyword search terms included: digital ulcer/s, systemic sclerosis, scleroderma, digital scars, ischemic complications, autoantibodies, biomarkers, endothelium dysfunction, endothelin-1, vascular endothelial growth factor (VEGF), endostatin, ADMA, endoglin, angiostatin, and capillaroscopy. The following criteria were included: (1) cohorts of SSc patients including patients with DU, (2) endothelium dysfunction and angiogenesis biomarkers compared with a healthy control group, (3) autoantibodies, capillary morphology and distribution, endothelium dysfunction and angiogenesis biomarkers compared between patients with and without digital ulcers, (4) detailed description of the statistical methods used to conclude for predictive factors, and (5) English language. Our search provided a total of 376 citations. Of these, 297 studies were discarded for not meeting the criteria proposed.
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Affiliation(s)
- I Silva
- Angiology and Vascular Surgery and Clinical Imunology Unit, Hospital Santo António, Centro Hospitalar do Porto, Portugal.
| | - J Almeida
- Internal Medicine Service, Centro Hospitalar de Vila Nova de Gaia, Portugal
| | - C Vasconcelos
- Clinical Imunology Unit, Hospital Santo António, Centro Hospitalar do Porto, Portugal; UMIB, ICBAS, Universidade do Porto, Portugal
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Sulli A, Ruaro B, Cutolo M. Evaluation of blood perfusion by laser speckle contrast analysis in different areas of hands and face in patients with systemic sclerosis. Ann Rheum Dis 2014; 73:2059-61. [PMID: 25125696 DOI: 10.1136/annrheumdis-2014-205528] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- A Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - B Ruaro
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - M Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
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39
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Ngcozana T, Ong V, Denton CP. Management of digital vasculopathy in systemic sclerosis: benefits of multiple courses of endothelin-1 receptor antagonists. BMJ Case Rep 2014; 2014:bcr-2013-203174. [PMID: 24682137 DOI: 10.1136/bcr-2013-203174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Two patients with scleroderma and recurrent digital ulcers (DUs) were treated with bosentan for 6 months. Treatment was associated with a reduction in the number of new DUs; however, DUs recurred on treatment discontinuation. This case report illustrates the positive response of digital vasculopathy to bosentan and describes the benefits of multiple bosentan treatment courses in these patients.
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40
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Hughes M, Herrick AL. Treatment options in Raynaud's phenomenon. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.883314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Herrick AL, Murray AK, Ruck A, Rouru J, Moore TL, Whiteside J, Hakulinen P, Wigley F, Snapir A. A double-blind, randomized, placebo-controlled crossover trial of the α2C-adrenoceptor antagonist ORM-12741 for prevention of cold-induced vasospasm in patients with systemic sclerosis. Rheumatology (Oxford) 2014; 53:948-52. [PMID: 24489014 DOI: 10.1093/rheumatology/ket421] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Our primary purpose was to evaluate the efficacy of the high-potency α2C-adrenoceptor antagonist ORM-12741 in the attenuation of a cold-induced reduction in finger blood flow and temperature in patients with RP secondary to SSc. Secondary objectives were to assess safety and tolerability. METHODS This was a phase IIa, randomized, double-blind, crossover, single-dose, placebo-controlled, single-centre study. Patients attended five times: initial screening, treatment visits 1-3 (each at least 1 week apart) and 1-2 weeks after the last treatment. At each treatment visit, each subject received a single oral dose of 30 mg or 100 mg of ORM-12741 or placebo. Thirty minutes later the subject underwent a cold challenge. Blood flow to the fingers was assessed by three methods [temperature by probe, laser Doppler imaging (LDI) and infrared thermography] performed before, during and after the cold challenge. RESULTS Twelve patients (10 female, mean age 58 years) were included. The area under the rewarming curve (LDI) of the right index finger (arbitrary flux units × time) was lower for both 30 mg (P = 0.043) and 100 mg (P = 0.025) of ORM-12741 compared with placebo, indicating delayed reperfusion. The time to 70% temperature recovery (middle finger probe) was longer with active than placebo treatment: mean (s.d.) values for placebo, 30 mg of ORM-12741 and 100 mg of ORM-12741 were 21.4 min (12.4), 25.7 min (12.2) and 26.9 min (13.9), respectively. Overall ORM-12741 was well tolerated. CONCLUSION ORM-12741 did not expedite recovery from a cold challenge in the fingers of patients with SSc. TRIAL REGISTRATION https://www.clinicaltrialsregister.eu/; no. 2010-024005-13.
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Affiliation(s)
- Ariane L Herrick
- Clinical Sciences Building, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK.
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