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Treatments for Digital Ulcers in Scleroderma

Author: Shelley Ensz. Scleroderma is highly variable. See Types of Scleroderma. Read Disclaimer
Overview
Antibiotics
Bosentan/Tracleer
Clinical Trials
Endothelin Rec. Antagonist
Extracorporeal Shock Wave Therapy
Hyperbaric Oxygen
Iloprost
Low Level Light Therapy
N-Acetylcysteine
Quinapril (Do Not Use!)
Riociguat
Stem Cells
Stem Cell Transplant
Surgery
Topical Solutions and Creams
Treprostinil (Remodulin)
Viagra (Sildenafil)
Wound Care Clinics

Overview

The best treatment for digital ulcers is to prevent them from occurring in the first place. Since many digital ulcers are directly related to frequent Raynaud's episodes, it is important to follow the Raynaud's prevention techniques the help to reduce Raynaud's episodes and intensity.

It cannot be emphasized enough that scleroderma finger ulcers are not a do-it-yourself project. Do not attempt any of the ideas listed here (or elsewhere on the Internet) without consulting your doctor first. (Also see Overview of Digital Ulcers, What is Scleroderma? and Types of Scleroderma)

Scleroderma skin ulcers definition, classification and treatment strategies our experience and review of the literature. The recent advancement of knowledge and management strategies of SSc–SU achieved during the last years lead to the clear–cut improvement of patients' quality of life and reduced long–term disability. PubMed, Autoimmun Rev. 2018 Feb;17(2):155-164.

Vasculitic and autoimmune wounds. A multidisciplinary approach with the involvement of rheumatologists allows investigation for underlying systemic disease and improves clinical outcomes for many of these challenging patients. PubMed, J Vasc Surg Venous Lymphat Disord, 2017 Mar;5(2):280-292. (Also see Vasculitis)

Antibiotics

Antibiotics are sometimes necessary for the treatment of infected digital ulcers.

Bosentan, Tracleer, Endothelin Receptor Antagonist (ERA)

Scleroderma Treatments: Tracleer (Bosentan). Digital ulcers in patients with systemic sclerosis (scleroderma) can be prevented and treated with Tracleer (bosentan). ISN.

Overview
Tracleer for Digital Ulcers
Tracleer for Pulmonary Fibrosis
Tracleer for Pulmonary Hypertension
Tracleer for Raynaud's
Tracleer for Scleroderma Renal Crisis
Tracleer for Skin Fibrosis
Also See

Clinical Trials for Digital Ulcers

Macitentan is also known as Opsumit by Actelion. It is a dual endothelin receptor antagonist that was submitted for FDA approval for use in pulmonary hypertension in December 2012.

Effect of Macitentan on the Development of New Ischemic Digital Ulcers in Patients With Systemic Sclerosis. Among patients with systemic sclerosis and active ischemic digital ulcers, treatment with macitentan did not reduce new digital ulcers over 16 weeks. Journal of the American Medical Association, 05/10/16.

Clinical Trial: Macitentan for the Treatment of Digital Ulcers in Systemic Sclerosis Patients (DUAL-2). The primary objective is to demonstrate the effect of macitentan on the reduction of the number of new digital ulcers in patients with systemic sclerosis and ongoing digital ulcers (DU). ClinicalTrials.gov. (Also see Digital Ulcers Research and Scleroderma Clinical Trials)

Endothelin Receptor Antagonist (ERA)

See Tracleer (Bosentan).

Extracorporeal Shock Wave Therapy

Extracorporeal shock wave therapy (ESWT) for digital ulcers associated with systemic sclerosis (SSc). The results of our study suggest that ESWT has the potential to be a novel and efficacious treatment for digital ulcers associated with SSc, and can be added to pharmacological therapy. NCBI, Journal of Scleroderma and Related Disorders, JSRD 2016; 1(2): 181 - 185.

Hyperbaric Oxygen Therapy

Hyperbaric Oxygen Improves Diabetic Ulcers Regardless of Glycemia. Hyperbaric oxygen is increasingly used as an adjunct to antibiotics, debridement, and revascularization for therapy of chronic nonhealing wounds associated with diabetes mellitus. Clinical Endocrinology News. (Also see Diabetes Research)

Iloprost

Practical suggestions on intravenous iloprost in Raynaud's phenomenon and digital ulcer secondary to systemic sclerosis: Systematic literature review and expert consensus. Although these suggestions are supported by this expert group to be used in clinical setting, it will be necessary to formally validate the present suggestions in future clinical trials. PubMed, Semin Arthritis Rheum, 2019 Feb;48(4):686-693. (Also see Raynaud's Treatments: Medications)

Effects of Longterm Treatment with Bosentan and Iloprost on Nailfold Absolute Capillary Number, Fingertip Blood Perfusion, and Clinical Status in Systemic Sclerosis (SSc). The study shows in patients with SSc with up to 4 years of combined therapy a progressive significant recovery in structure and function of microvasculature linked to improved clinical outcomes, independent of disease severity. PubMed, J Rheumatol, 2016 Nov;43(11):2033-2041. (Also see Bosentan)

Low Level Light Therapy

A Feasibility Study of a Novel Low Level Light Therapy (LTTT) for Digital Ulcers (DUs) in Systemic Sclerosis. LTTT for DUs is safe, feasible and well tolerated. There was an early tentative suggestion of treatment efficacy. PubMed, J Dermatolog Treat, 2018 Jun 4:1-30.

N-Acetylcysteine

Oral N-acetylcysteine (NAC) in the treatment of Raynaud's phenomenon (RP) secondary to systemic sclerosis (SSc): A randomized, double-blind, placebo-controlled clinical trial. NAC orally at a dose of 1800 mg/day showed no vasodilator effect on hands’ microcirculation after four weeks of treatment in patients with RP secondary to SSc. Revista Brasileira de Reumatologia. (Also see Raynaud's Treatments)

Quinapril: Warning, Do Not Use

The routine use of ACE inhibition in treating upper-limb digital ulcers or other vascular manifestations in patients with systemic sclerosis is not advisable.

Riociguat

A multicenter randomized, double-blind, placebo-controlled pilot study to assess the efficacy and safety of riociguat in systemic sclerosis-associated digital ulcers (SSc-DU). In participants with SSc-DU, treatment with riociguat did not reduce the number of DU net burden compared with placebo at 16 weeks. PubMed, Arthritis Res Ther, 2019 Sep 3;21(1):202. (Also see Clinical Trials: Completed, Negative Results)

Stem Cells, Topical Application

A randomised placebo–controlled double–blind trial to assess the safety of intramuscular administration of allogeneic mesenchymal stromal cells (MSCs) for digital ulcers (DUs) in systemic sclerosis (SSc). The Mesenchymal stromal cells for Angiogenesis and Neovascularization in digital Ulcers of Systemic Sclerosis (MANUS) Trial intended to assess the safety and potential efficacy of MSCs for DUs of SSc. PubMed, BMJ Open, 2018 Aug 20;8(8):e020479.

Doctors discover new method to heal painful diabetic ulcers using a jab of 'muffin top' fat. Doctors have discovered an ingenious use for the excess fat — they are using it in injections for painful foot ulcers that are difficult to treat. Mail Online, 12/02/2017. (Also see Treatments for Diabetes)

Stem Cell Transplant

Critical limb ischemia: current challenges and future prospects. In this review, we presented a complete overview about physiopathology, diagnosis and holistic management of CLI. PubMed, Vasc Health Risk Manag, 2018 Apr 26;14:63-74.

Surgery for the Treatment of Digital Ulcers in Systemic Sclerosis Patients

thumb-digital-ulcerSurgery for the Treatment of Digital Ulcers. Digital (finger, toe) ulcers can occur in patients who have either limited or diffuse systemic sclerosis (SSc), which is also known simply as scleroderma (SD) and frequently even abbreviated as "sclero". Surgical treatments include amputation of the affected area, digital sympathectomies, and peripheral arterial bypass grafts. ISN.

Overview
Amputation
Digital Sympathectomy
Peripheral Arterial Bypass
Wound Care Centers

Topical Solutions and Creams

Leg UlcerTopical treatments for digital ulcers in systemic sclerosis include calcium alginate and collagen bandages, Apligraf, Botox, Manuka or MediHoney, Betadine, Dakin's, and Silvadene. Maggot applications may even be useful, especially for large vascular foot/leg ulcers. ISN.

Overview
Botox
Creams and Solutions
Maggots
Manuka Honey/MediHoney
Spray-On Skin Cells
Wound Care Centers

Treprostinil (Remodulin), Oral and Infused by United Therapeutics

Treprostinil (Remodulin) is a treatment for pulmonary arterial hypertension which has also been studied for treating scleroderma digital ulcers. It is made by United Therapeutics. It is available as oral treprostinil and as Remodulin infusions.

Remodulin (Treprostinil Injection). Remodulin prescribing information, for pulmonary arterial hypertension. United Therapeutics. (Also see: Pulmonary Hypertension Treatments)

The prostacyclin analogue treprostinil in the treatment of pulmonary arterial hypertension. We will analyse and discuss results from different clinical trials, comparing treprostinil's four different forms to each other as well as to other drugs targeting the prostacyclin pathway. PubMed, Basic Clin Pharmacol Toxicol, 08/12/2019.

Digital Ischemic Lesions in Scleroderma Treated With Oral Treprostinil Diethanolamine (DISTOL-1). This study will evaluate the effect of treprostinil diethanolamine (UT-15C) sustained release tablets (compared to placebo) on digital ulcers in patients with scleroderma. ClinicalTrials.gov. (Also see Digital Ulcers)

Viagra (Sildenafil)

Viagra Reveals Benefits in Treating Digital Ulcers in Systemic Sclerosis. It was concluded that sildenafil seems to have a clinical benefit in digital ulcer healing in patients with systemic sclerosis. Scleroderma News.

Wound Care

Wound Care Product and Category Index. Treatments can be looked up by type of disease, lesion, or wound. The Wound Care Information Network.

Raynaud's Treatment

Raynaud's Treatments. Mild cases of Raynaud's do not require treatment. Severe attacks which do not respond to the usual treatments, medications, and rewarming procedures may require hospitalization. ISN.

Video Overview
Mild Cases
Amputation
Biofeedback
Botox
Digital Sympathectomy
Ginkgo Biloba
Hypothyroidism
Medications
Nerve Blocks
Nitroglycerine Cream
Raynaud's Prevention
Serotonin Reuptake Inhibitors (SSRI)
Statins
Ineffective Treatments
Research & Clinical Trials
References
Go to Surgical Treatments for Digital Ulcers
 

In Loving Memory of Lorraine Wempner, a donation to tackle scleroderma has been made by Paul Wempner. Posted 11/13/2019. (Also see: ISN News)

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