Clinical manifestations of scleroderma at the hand include Raynaud's phenomenon,
calcinosis cutis, sclerodactylia and teleangiectasia. With the progression of the disease, cutaneous and joint contractions,
acro-osteolysis,
necrosis of the finger
tips, and even extensive digital ulceration are likely to occur. These painful and often rapidly advancing lesions cause loss of function and disfigurement and, untreated, often lead to mutilation of the affected hand. Only an interdisciplinary management including the hand surgeon, the rheumatologist, and the physiotherapist can guarantee optimal treatment.
Drug therapy should be included as well as
physical therapy. Both should be made use of before and accompanying surgical treatment. Surgical
therapy consists of treatment of the
infections, excision of
calcinosis,
arthrodesis, in particular of the proximal interphalangeal joints, and
sympathectomy.
Amputation remains a final option, whereas with timely and sufficient treatment,
amputations can be avoided and an improvement of function and an alleviation of the symptoms can be achieved. Among the non-operative treatment options, behavioural training,
calcium antagonists,
prostacyclin derivatives, topical
nitrates as well as plexus
anesthesia and stellatum blocks have proved to be effective. Recent
drug therapies include
endothelin-receptor antagonists for the prevention of digital ulceration and
phosphodiesterase-V antagonists in treatment of Raynaud's phenomenon and induction of
ulcer healing. With reference to several cases seen at our institution, we propose an interdisciplinary treatment concept for acral manifestations of scleroderma.