Pharmacological management of digital ulcers in systemic sclerosis - what is new?

Figures & data

Figure 1. Mobile phone images of (a) the left index ulcer, with the dusky color change and (b) right index ulcers with (c) showing very abnormal nailfold capillaries with enlarged capillaries, avascularity and hemorrhage, consistent with the diagnosis of SSc.

Figure 3. The principles of management of ‘uncomplicated’ RP, and of SSc-related digital vasculopathy, which has progressed to digital ulceration. Reproduced from Herrick AL [20] with permission.

Figure 2. Necrotic, infected ulcer at the tip of the right middle finger (a), and photograph of the left had showing an ulcer at the tip of the index finger, an ulcer overlying the middle finger distal interphalangeal joint, and a dusky colored, critically ischemic ring finger which had an ulcer at the fingertip not seen on this view but demonstrated (one month later) in (c).

Table 1. Summary of current and possible future approaches to blocking the ET-1 pathway, supplementing the NO pathway and supplementing the prostacyclin pathway.

	Blocking ET-1 pathway	Supplementing NO pathway	Supplementing prostacyclin pathway
Current clinical practice	ET-1 receptor antagonist (bosentan)	Systemic nitrate therapy (e.g. by patch), but rarely used	IV prostanoid therapy (e.g. iloprost, epoprostenol)
		PDE5 inhibitor (e.g. sildenafil, tadalafil)
Possible future approaches and/or areas for research		Topical nitrate therapy applied to the digits for local (i.e. not for systemic) effect	Optimisation of IV prostanoid protocols
		Soluble guanylate cyclase stimulation	Re-examination of oral prostanoid therapy
		L-arginine	Possible other routes of delivery e.g. subcutaneous, or topically via iontophoresis

NOTE: ET-1: Endothelin-1. NO: Nitric oxide, IV: Intravenous.

Herrick AL. Raynaud’s phenomenon and digital ulcers: advances in evaluation and management. Curr Opin Rheumatol. 2021;33(6):453–462.

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