Non-surgical local treatments of digital ulcers in systemic sclerosis: a systematic literature review

Corrado Campochiaro; Yossra A Suliman; Michael Hughes; Jan W Schoones; Dilia Giuggioli; Pia Moinzadeh; Murray Baron; Lorinda Chung; Laura Ross; Nancy Maltez; Yannick Allanore; Christopher P Denton; Oliver Distler; Tracy Frech; Daniel E Furst; Dinesh Khanna; Thomas Krieg; Masataka Kuwana; Marco Matucci-Cerinic; Janet Pope; Alessia Alunno

doi:10.1016/j.semarthrit.2023.152267

Non-surgical local treatments of digital ulcers in systemic sclerosis: a systematic literature review

Semin Arthritis Rheum. 2023 Dec:63:152267. doi: 10.1016/j.semarthrit.2023.152267. Epub 2023 Sep 26.

Authors

Corrado Campochiaro¹, Yossra A Suliman², Michael Hughes³, Jan W Schoones⁴, Dilia Giuggioli⁵, Pia Moinzadeh⁶, Murray Baron⁷, Lorinda Chung⁸, Laura Ross⁹, Nancy Maltez¹⁰, Yannick Allanore¹¹, Christopher P Denton¹², Oliver Distler¹³, Tracy Frech¹⁴, Daniel E Furst¹⁵, Dinesh Khanna¹⁶, Thomas Krieg¹⁷, Masataka Kuwana¹⁸, Marco Matucci-Cerinic¹⁹, Janet Pope²⁰, Alessia Alunno²¹

Affiliations

¹ Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University. Electronic address: campochiaro.corrado@hsr.it.
² Assiut University Hospital, Egypt.
³ Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.
⁴ Directorate of Research Policy (formerly Walaeus Library), Leiden University Medical Center, Leiden, The Netherlands.
⁵ University of Modena, Italy.
⁶ University Hospital of Cologne, Germany.
⁷ Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
⁸ Stanford University School of Medicine and Palo Alto VA Health Care System, Palo Alto, CA, USA.
⁹ The University of Melbourne, Melbourne, VIC, Australia; St Vincent's Hospital, Melbourne, Australia.
¹⁰ University of Ottawa, Ottawa, ON, Canada.
¹¹ Paris Descartes University, Paris, France.
¹² University College London, London, United Kingdom.
¹³ University of Zurich, Zurich, Switzerland.
¹⁴ University of Utah, Veterans Affairs Medical Center, Salt Lake City, UT, USA.
¹⁵ University of California, Los Angeles, CA, USA.
¹⁶ University of Michigan, Ann Arbor, MI, USA.
¹⁷ Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany.
¹⁸ Nippon Medical School, Tokyo, Japan.
¹⁹ University of Florence, Florence, Italy.
²⁰ Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.
²¹ Department of Life, Health & Environmental Sciences, University of L'Aquila and Internal Medicine and Nephrology Unit and Department of Medicine, ASL Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, L'Aquila, Italy.

PMID: 37778090
DOI: 10.1016/j.semarthrit.2023.152267

Abstract

Introduction: Digital ulcers (DUs) are difficult to treat in patients with systemic sclerosis (SSc) and systemic (i.e., pharmacological) therapy is currently considered the 'standard of care'. Our aim was to examine the safety and efficacy of local, non-surgical treatment for SSc-DUs.

Methods: A systematic literature review (SLR) of original research articles up to August, 29 2022 was performed according to the PICO framework. References were independently screened by two reviewers and risk of bias was assed using validated tools. Due to study heterogeneity narrative summaries are used to present data.

Results: Among 899 retrieved references, 14 articles were included (2 randomised trials (RTs), and 12 observational (OBS) studies). The most frequently studied procedure (5 studies) was botulin A toxin (hand or single finger) injection with a reported healing rate (HR) of 71%-100%. Amniotic and hydrocolloid membranes were examined in one study each and associated with a good HR. Tadalafil 2% cream was studied in a single study with a reduction in the number of DUs. Vitamin E gel was associated with a reduction in ulcer healing time. Low-level light therapy, hydrodissection and corticosteroid injection, extracorporeal shock wave (ESW) and photobiomodulation were evaluated in a single study each and showed a positive trend. Dimethyl sulfoxide was associated with significant local toxicity.

Conclusions: A range of non-surgical, local treatments for SSc-DUs have been explored and showed efficacy to some extent. We have identified methodological flaws that should be avoided in the design of future studies to explore locally-acting treatments for SSc-DUs.

Keywords: Digital ulcers: Management: Non-surgical; Scleroderma; Systemic sclerosis; Topical treatment.

Publication types

Systematic Review
Review

MeSH terms

Fingers
Hand
Humans
Scleroderma, Systemic* / drug therapy
Scleroderma, Systemic* / therapy
Skin Ulcer* / etiology
Skin Ulcer* / therapy

Supplementary concepts

digital ulcers