Scleroderma and evidence based non-pharmaceutical treatment modalities for digital ulcers: a systematic review.
Objective: Digital ulcers are difficult to heal, increasing the chance of infection, gangrene, amputation and limited functional use of hands. They are a complication in scleroderma or systematic sclerosis (SSc) and occur in approximately 50% of patients. This is a systematic review of the evidence supporting the use of non-pharmaceutical therapeutic modalities and their effectiveness to facilitate the healing of chronic digital ulcers in patients with scleroderma.
Method: A comprehensive review of computerised databases from 2000-2013: PubMed/MEDLINE, CINAHL, Pedro, OT Seeker, OT Search, OVID, and Proquest as well as manual review of other resources was completed using the following search terms scleroderma or systemic sclerosis and/or digital ulcers, specific modalities (low level laser therapy, electrical stimulation, intermittent compression, ultrasound, vitamin E, myofascial release, wound dressings, iontophoresis, negative pressure therapy, and exercise), chronic wounds, and wound care. English language studies, from 2000 to January 2013, which used therapeutic modalities to facilitate healing of digital ulcers and use healing of the digital ulcer as an outcome measure were reviewed.
Results: Of the 403 identified articles, only 11 studies addressed non-pharmaceutical treatment modalities to facilitate healing for digital ulcers. Exercise had no direct effect on healing ulcers. The following studies were positive but have limitations in design and sample size:: hyperbaric oxygen therapy (n=2), negative pressure therapy (n=1), intermittent compression (n=27) and acoustic pressure wound healing (n=1). Vitamin E gel showed a significant difference compared to a control group (n=27). Iontophoresis studies have shown that the modality increases blood flow but the results in five different studies are mixed and the application and intensity were inconsistent.
Conclusion: No one modality was proven to be the most effective. Larger efficacy studies on treating digital ulcers are needed in order to develop appropriate care guidelines to improve outcomes, promote function and lower health-care costs. Declaration of interest: There were no external sources of funding for this study. The author has no conflicts of interests to declare.
Localized scleroderma: assessment of the therapeutic response to phototherapy.
Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil.
Scleroderma is a chronic autoimmune disease characterized by progressive connective tissue sclerosis and microcirculatory changes. Localized scleroderma is considered a limited disease. However, in some cases atrophic and deforming lesions may be observed that hinder the normal development. Literature reports indicate phototherapy as a therapeutic modality with favorable response in cutaneous forms of scleroderma.
This study had the purpose of assessing the phototherapy treatment for localized scleroderma.
Patients with localized scleroderma were selected for phototherapy treatment. They were classified according to the type of localized scleroderma and evolutive stage of the lesions. Clinical examination and skin ultrasound were used to demonstrate the results thus obtained.
Some clinical improvement was observed after an average of 10 phototherapeutic sessions. All skin lesions were softer at clinical palpation with scores reduction upon pre and post treatment comparison. The ultrasound showed that most of the assessed lesions presented a decrease in dermal thickness, and only five maintained their previous measure. Treatment response was similar regardless of the type of phototherapeutic treatment employed.
The proposed treatment was effective for all lesions, regardless of the phototherapeutic modality employed. The improvement was observed in all treated skin lesions and confirmed by clinical evaluation and skin ultrasound.
Photomed Laser Surg. 2006 Feb;24(1):17-21.
Effect of linear polarized light irradiation near the stellate ganglion in skin blood flow of fingers in patients with progressive systemic sclerosis.
Lee CH, Chen GS, Yu HS.
Department of Dermatology, Kaohsiung Medical University, Kaohsiung, Taiwan.
OBJECTIVE: The purpose of this study is to evaluate the effect of linear polarized light irradiation near the stellate ganglion area on cutaneous blood flow in fingers of patients with progressive systemic sclerosis.
BACKGROUND DATA: Sympathetic overactivity is known to be present in patients with progressive systemic sclerosis. Recently introduced linear polarized light irradiation is designed to simulate noninvasive stellate ganglion block to decrease sympathetic output.
METHODS: Five patients with progressive systemic sclerosis and three normal healthy controls were studied. Linear polarized light (Super Lizer) was irradiated near the stellate ganglion on the right side of the neck at 358 J/cm(2) for 10 min. Then, laser Doppler flowmetry, laser Doppler imager, and capillary microscopy were used to measure the cutaneous blood flow of the right fourth finger for 30 min.
RESULTS: No significant alternations of the skin blood flow between normal controls and patients with progressive systemic sclerosis after linear polarized light irradiation were detected. The effect of linear polarized light on the microcirculation of patients with progressive systemic sclerosis was minimal and transient.
CONCLUSION: The effect of linear polarized light in treating patients with progressive systemic sclerosis may not result from the improvement of skin blood flow. Therefore, the use of linear polarized light in those patients to increase cutaneous blood flow should not be overemphasized.
Dermatol Surg. 2002 Jul;28(7):615-6.
Use of a 585 nm pulsed dye laser for the treatment of morphea.
Eisen D, Alster TS.
Washington Institute of Dermatologic Laser Surgery, Washington, DC 20037, USA.
INTRODUCTION: The clinical presentation of morphea varies from localized plaques to generalized eruptions. Its cause remains unknown and medical treatments have often proved unsatisfactory. Studies have previously shown that improvement of hypertrophic scars and fibrotic skin can be achieved with the use of a 585 nm pulsed dye laser (PDL). METHODS: A case of plaque-type morphea was treated with 585 nm pulsed dye laser irradiation at an average fluence of 5.0 J/cm2 at bimonthly time intervals. RESULTS: Marked clinical improvement as evidenced by improved pliability and skin coloration was seen after 4 successive PDL treatments. No side effects or complications were encountered. CONCLUSION: Pulsed dye laser therapy is a viable treatment option for morphea. The mechanism of its effect in this condition remains unknown.
Rheum Dis Clin North Am. 2000 Feb;26(1):75-81, viii-ix.
Photopheresis and autoimmune diseases.
Division of Rheumatology, Wayne State University, Detroit, Michigan, USA. firstname.lastname@example.org
Although several case reports and case series suggest efficacy for photopheresis in the treatment of autoimmune diseases, few controlled studies have been conducted to test this hypothesis. After a decade of interest, multiple case reports, open trials, and one controlled study, the role of photopheresis in autoimmune disease remains to be established. Controlled multi-center trials in rheumatoid arthritis, SLE, and scleroderma may be costly but are clearly necessary for proper evaluation of this therapy
Vestn Oftalmol. 1995 Apr-Jun;111(2):10-2.
[Effects of low-intensity laser irradiation on several parameters of microcirculation in the bulbar conjunctiva of patients with scleroderma]
[Article in Russian]
Podelinskaia LV, Polunin GS, Ermakova TM, Rabieva GM.
Computer-aided analytical system of TV images (CASTI) of the anterior segment of the eye revealed an appreciable increase of the level of aggregation gradient in arterioles and venules of the bulbar conjunctiva of 37 children suffering from various forms of scleroderma, as against 18 healthy children. Exposure to low-energy laser of a close infrared band (approximately 890 nm) had a favorable impact on blood aggregation in patients with scleroderma. CASTI of the anterior segment of the eye proved to be an objective and highly informative method for the diagnosis and monitoring of the efficacy of various treatment modalities.