Around 40% of patients with scleroderma develop open sores on their fingertips called digital ulcers. In some patients, this is the major ongoing difficulty whereas in others, digital ulcers are an uncommon and short term complication.
This patient has an ulceration on the tip of her index finger. The other fingers appear unaffected. The scar in her palm is from a previous operation called “selective digital sympathectomy” in an attempt to improved fingertip blood flow.
Digital ulcers occur because of poor blood flow to the fingertips which is in turn related to the narrowing of blood vessels that is the hallmark of all forms of systemic scleroderma.
This is a cross-section of a finger artery from a patient with long-standing scleroderma. The bright blue areas are a special stain for collagen or scar tissue. In this case, the build-up of scar in the center of the blood vessel has severely compromised blood flow.
Digital ulcers are tightly linked with Raynaud phenomenon. They both occur in scleroderma because of narrowed blood vessels. Raynaud attacks occur daily and are clearly worsened by cold weather. Digital ulcers can occur at anytime of the year and in any weather.
The fingertips in scleroderma should be cared for in much the way a patient with diabetes might care for their feet.
- Keep the skin moist and supple. Hand creams rich in lanolin can help.
- Protect the fingertips. Avoid tasks that risk fingertip trauma.
- Treat cuts promptly and thoroughly. Don’t let infection get established.
- Control your Raynaud’s phenomenon more effectively. This requires working closely with your physician to choose the best program of medication.
- Keep your physician involved. Let him or her know when an ulcer has started. The earlier it is treated, the better the outcome.
The scleroderma research community is actively investigating treatments for digital ulcers. In Europe, intravenous iloprost (Ilomedin®) is approved and widely used, although this therapy is not available in the U.S. Recent studies with bosentan (Tracleer®), an agent approved by the FDA for pulmonary hypertension, have suggested an effect in preventing digital ulcers. Other research projects are in early stages of planning.