skin complications in scleroderma
DESCRIPTION
Skin Complications in Scleroderma Emily L Keimig, MS, MD Clinical Instructor Department of Dermatology Presented at the Scleroderma Patient Education Conference, Saturday, October 19, 2013 at Northwestern Memorial Hospital. Hosted by the Scleroderma Foundation, Greater Chicago Chapter and the Northwestern Scleroderma Program.TRANSCRIPT
Skin Complications in
Scleroderma
Emily L Keimig, MS, MD
Clinical Instructor
Department of Dermatology
Objectives
• To address the various cutaneous complications of scleroderma
• Discuss treatment options for these various complications
• Discuss gentle skin care
Raynaud’s Phenomenon
• First described in 1862 as Raynaud’s Disease
• 40 years later, proposed that ‘phenomenon’ was more appropriate
– Multiple causes of vasospasm
• Today classified as primary or secondary Raynaud’s phenomenon
– Primary
– Secondary
Bakst R et al. Raynaud's phenomenon: pathogenesis and management. J Am Acad Dermatol 2008;59:633-53
Primary Raynaud’s Phenomenon
• Younger age of onset
• Normal nail fold capillaries
– cuticles
• Negative or low titers of auto-antibodies
• All fingers symmetrically affected
• Minimal pain
Bakst R et al. Raynaud's phenomenon: pathogenesis and management. J Am Acad Dermatol 2008;59:633-53
Secondary Raynaud’s Phenomenon
• Associated with autoimmune disease
• Onset >30 years of age
• Frequently attacks are painful
• Asymmetric finger involvement
• Nail fold capillary abnormalities
• Pits and ulcers on the finger tips
• Elevated auto-antibodies
Bakst R et al. Raynaud's phenomenon: pathogenesis and management. J Am Acad Dermatol 2008;59:633-53
N Engl J Med 360;19
Digital Pits
Bolognia J et al. Dermatology, 3rd Edition
Nail fold Capillary Changes
Cause
• Reversible vasospasm
– Vessels have altered responsiveness to vasoconstrictive and vasodilatory stimuli
– Abnormal release of vasoconstricting and vasodilating molecules
– Overactive sympathetic nerve receptors
• Arterial damage
– Thickening of the walls of the arteries
– Obstruction or blockage of the blood vessel
Raynaud’s Phenomenon
• Episodic attacks – Hands, feet, nose, ears – Minutes to hours
• Cold exposure • Emotional stimuli • Tri-color change
– White/Pale – Blue – Red
• Numbness • Re-warming
– Can be painful
Lifestyle Modifications
• Minimize cold exposure – 65F
• Limit time outdoors – Insulated mittens
– Hand/foot warmers
• Dress warmly – Loose-fitting
– Layered clothing
• Thermostat – Few degrees higher
Lifestyle Modifications
• Keep whole body warm
– NOT just hands and feet
• Keep gloves everywhere
– Kitchen
– Car
– Work
• Extra layers of clothing
– Air conditioning can trigger
• Space heater
• Car warmed up
Lifestyle Modifications
• Smoking
– Stop
– Avoidance of secondhand
• Stress modification
– Social support
– Relaxation techniques
Other Things to Avoid
• Cold preparations
– Containing sympathomimetics
– Ephedrine
• Caffeinated beverages
• Ergots (migraine medications)
• Smoking
• Epinephrine
Treatment
• Re-warming
– Warm environment
– Local heat • Warm water
• Warm hair dryer
• Medical intervention
– Medical
– Surgical
Medical Treatment
• Topical therapy
– Nitroglycerin paste
• Calcium channel blockers
• Sildenafil
• Losartan
• Botox injection
• Peripheral digital sympathectomy
Ischemic Ulcerations
• Severe Raynaud’s Phenomenon
• Common complication
• Nail fold changes a risk factor
– Dilatation and dropout
• Due to decreased blood flow
– Leads to decreased oxygenation of skin
Alivernini S et al. Skin ulcers in systemic sclerosis: determinants of presence and predictive factors of healing. J Amer Acad Dermatol. 2009;60:426-35
Prevention
• Avoidance of trauma
• Properly fitting shoes
– ½ inch between front of shoe and toes
– All toes should be extended
– Good heel support
• Avoid medications that cause vasoconstriction
Treatment
• Therapies aimed at improving blood flow and controlling infection
• Wound care
– Hydrocolloid dressings
• Topical nitroglycerin
• Calcium channel blocker
• IV therapies
– Prostanoids
• Bosentan
• Peripheral digital sympathectomy
Alivernini S et al. Skin ulcers in systemic sclerosis: determinants of presence and predictive factors of healing. J Amer Acad Dermatol. 2009;60:426-35
Bakst R et al. Raynaud's phenomenon: pathogenesis and management. J Am Acad Dermatol 2008;59:633-53
Calcinosis Cutis
• Deposits of calcium within the skin
• Result of local tissue damage or abnormalities
• Occurs in various conditions
• 25-40% of patients with limited cutaneous systemic sclerosis
• Local irritation, inflammation, ulceration
• Fingers, forearms, elbows
Reiter N et al. Calcinosis cutis part I: diagnostic pathway. J Amer Acad Dermatol. 2011;65-1-12.
Calcinosis Cutis
Bolognia et al. Dermatology. 3rd edition
Treatment Calcinosis Cutis
• Warfarin
• Bisphosphonates
• Antibiotics
– Minocycline
– Decreased inflammation
• Diltiazem
• IVIg
– Decreased inflammation and symptoms
• Surgical Excision
• CO2 laser destruction
Reiter N et al. Calcinosis cutis, part II: treatment options. J Amer Acad Dermatol. 2010;65:15-22
Telangiectasia
• Widened blood vessels
• Hands and face
– But can be anywhere
• Laser treatments
– Target the vessels
– Tend to come back
• Make up to cover
– Dermablend Bolognia et al. Dermatology. 3rd edition
Discoloration
• Diffuse hyperpigmentation
• Overlying pressure points
• ‘salt and pepper’ discoloration
• Increased pigmentation overlying veins
Bolognia et al. Dermatology 3rd edition.
Mobility
• Physical therapy
• Yoga
• Maintaining physical activity
– Low impact exercise
– Stretch
Dry Skin
• Very common
• Decreased sweat glands
• Decreased oil glands
• Itching
Itching = Pruritus
• Almost half of all patients
• Significant impact on quality of life
– Affects ability to fall and stay asleep
– Affects ability to concentrate
– Can lead to anxiety and depression
– Affects daily activities
– Affects personal relationships
– Impacts social functions
Ghassan EB et al. Association of Pruritus with Quality of Life and Disability in Systemic Sclerosis. Arthritis Care & Research. 2010; 62: 1489-95
Itching
• Can result from dry skin and irritation
• Emollients – After bathing
– Locks in moisture
• Gentle skin care
• Medical treatment – Anti-histamines
– Light treatments
– Prescription therapy
Gentle Skin Care
• Bathe at MOST once daily
– Every other day is fine
• Short showers or baths
– 5-10 minutes
• Lukewarm showers
• Do not scrub vigorously
– No brushes, loofahs, sponges
– Gently lather the soap
• Pat the skin dry
Gentle Skin Care
• Avoid rubbing alcohol
• Avoid perfumes
• Rub don’t scratch
• Soothing baths
– Oatmeal baths
– No bubble baths
• Cooling agents
– Sarna (camphor)
– Menthol
Moisturizers
• Oil based
– Petrolatum
• Water in oil products
– Heavier creams as opposed to lotions
• Products containing lipids found in the stratum corneum
– Lipids, ceramides, fatty acids
• Avoidance of fragrances, dyes, perfumes
• Apply to entire body within 2-3 minutes of bathing
References
• Bakst R et al. Raynaud's phenomenon: pathogenesis and management. J Am Acad Dermatol 2008;59:633-53
• Gabrielli A et al. Scleroderma. N Engl J Med. 2009;360:1989-2003.
• Ghassan EB et al. Association of Pruritus with Quality of Life and Disability in Systemic Sclerosis. Arthritis Care & Research. 2010; 62: 1489-95
• Alivernini S et al. Skin ulcers in systemic sclerosis: determinants of presence and predictive factors of healing. J Amer Acad Dermatol. 2009;60:426-35
• Reiter N et al. Calcinosis cutis part I: diagnostic pathway. J Amer Acad Dermatol. 2011;65-1-12.
• Reiter N et al. Calcinosis cutis, part II: treatment options. J Amer Acad Dermatol. 2010;65:15-22