Digital Ulcers in Systemic Sclerosis – How to Manage in 2013?
Sevdalina Lambova, Anastas Batalov, Hristo Dobrev, Lyubomir Sapundzhiev and Ulf Müller-Ladner
Affiliation: Medical University – Plovdiv, Department of Propedeutics in Internal Medicine, Clinic of Rheumatology, Plovdiv, Bulgaria, Plovdiv – 4002, 15A “Vasil Aprilov” Blvd, Bulgaria.
Keywords: Digital ulcers, systemic sclerosis, management.
Digital ulcers (DUs) are among the most frequent and disabling vascular complications in patients with
systemic sclerosis (SSc). The etiology and pathogenesis of DUs differs depending on the lesion localization. For this reason
the underlying etiologic and pathogenetic factors will guide the therapeutic decision. The main pathogenic mechanism
that contributes to the development of fingertip DUs is ischemia owing to SSc-related vasculopathy. DUs over bony
prominences are mainly a result of skin fibrosis, epidermal thinning and mechanical friction. At the areas of subcutaneous
calcinosis DUs can develop as a result of mechanical friction and inflammation. Thus, in cases of DUs over bony prominences
and calcinosis, avoidance of trauma and skin care are main measures of primary prophylaxis. In pure ischemic
DUs, a combination of vasodilators (calcium channel blockers (CCBs), intravenous prostanoid, phosphodiesterase
inhibitors) and antiplatelet drugs should be applied. Despite the lack of controlled trials addressing the administration of
antiplatelet agents and anticoagulants in DUs in the context of SSc, the current knowledge about the platelet and coagulation
dysfunction leads to their frequent administration from the leading experts in the field of SSc. In our opinion, as more
powerful agents, anticoagulants should be considered in severe cases of development of digital gangrenes. Analgetics and
antibiotics may be indicated and local treatment is a mandatory care. Currently, the EUSTAR recommendations for the
treatment of RP and DUs in SSc include CCBs, intravenous prostanoids and endothelin receptor antagonists. Although for
the inclusion of other options in the official recommendations, their efficacy should be confirmed by controlled clinical
trials, they are routinely used in the leading scleroderma-centers based on the current knowledge about the pathogenesis of
development of DUs in SSc.
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